1st MPJ fusion v chilectomy v tarsometatarsal fusion

Members do not see these Ads. Sign Up.

hoping photos of x-ray imaging attached viewable
dx hallus rigidis, severe arthritis in big toe joint , limited mobility, suspect secondary to first metatarsal significantly elevated
debate as to best procedure given age (33) active life style .
if fusion of tarsometarasal with plantar flexión of 1st metatarsal to better align and restore healthy range of motion, save joint from further wear (MRI shows significant wearing of cartilage )
MPJ fusion 1st metatarsal to address pain and most predictable outcome
chilectomy , some providers believe this will automatically reduce elevated 1st metatarsal and increase range of motion though if doesn’t address structural issue may increase pain
thoughts on procedure recommendations, factoring in quality of life outcomes for active individual.
leaning towards MPJ fusion since likely necessary down the line even if able to manage pain now by limiting activity - fusion of tarsometarsal risks if doesn’t work and need MPJ fusion down the line entire plain of foot will be locked
mobility wise
last do you drink the “cool aid” that chilectomy will address severe elevation of 1st metatarsal and will possible further aggravate pain due to trauma of surgery and increasing range of motion to that joint that already has severe degenerative arthritis

 

Not sure what you are observing, but this certainly does NOT look like "severe" arthritis of the 1st MTP joint by any stretch of the imagination. There doesn't appear to be any spurring of either the 1st metatarsal head nor the base of the proximal phalanx.

This appears as a markedly dorsiflexed 1st ray, leading to jamming of the 1st MTP joint during walking...and hence the pain. Would recommend examining peroneal strength as the first part of the exam. If inhibited, as I would expect, then manipulating the ankle should be effective to restore normal facilitation. Other joints of the foot are also restricted, most likely the calcaneal cuboid and talo-navicular joints. Mobilizing these would also be most helpful.

Would then prescribe a very neutral orthotic with a 1st ray cutout. Give it a couple of months and patient should be much improved. Considering fusion in a 33 year old would be a terrible course of action.

Howard Dananberg

 

Hi Dana @Dananberg , I think the MRI and functional exam shows more clearly the moderate to severe arthritis, in addition to my debilitating pain - which is why doctors are leaning towards MPJ fusion. can you say more why an MPJ would be a terrible course of action ?(assuming I am not able to improve symptoms with orthotic and other conservative measures)

 

Todd,

Your toe joint may be painful, but plain x-rays are sufficient to demonstrate whether or not there is destruction of the joint space. In the films provided, there is clearly none. Depending on age, fusion of this joint is a fairly irreversible option. There are many others ways to approach hallux limitus. At least try an orthotic with a 1st ray cutout to see if that does not eliminate the jamming of the joint and begins to reverse the pain. Good luck.

Howard Dananberg