SLR - December 2017 - Rosabel Loya

Bone-Block Arthrodesis Procedure in Failures of First Metatarsophalangeal Joint Replacement

Reference: Usuelli FG, Tamini J, Maccario C, Grassi M, Tan EW. Bone-Block Arthrodesis Procedure In Failures Of First Metatarsophalangeal Joint Replacement. European Foot and Ankle Surgery. 2017 Mar; (23): 163–167.

Scientific Literature Review

Reviewed By: Rosabel Loya, DPM
Residency Program: Southern Arizona VA Health Care System, Tucson, AZ

Podiatric Relevance: First MTPJ implant arthroplasties preserve range of motion in end-stage arthritis as opposed to the gold standard, first MTPJ arthrodesis. Standard protocol for correcting first MTPJ implant complications is not usually reported. This article proposes a revision approach, bone-block arthrodesis using ipsilateral calcaneus bone graft as an alternative to tibial or iliac crest options. The goal was to maintain and/or restore the hallux length. This is the first study with standardized technique using autograft calcaneus bone block for hallux arthrodesis in joint arthroplasty revision.     

Methods: The study group included 12 patients with diagnosis of hallux MTPJ prosthesis failure. Symptoms included localized pain and decreased range of motion of first MTPJ. Patients had no prior surgical intervention. Average time between prosthetic implant and revision was 15 months. Eight of the 12 patients had aseptic loosening of prosthesis, and one patient had septic loosening. Treatment consisted of removal of prosthesis in 11 of 12 patients followed by autologous bone graft from ipsilateral calcaneus by lateral incision to NWB area. The graft was secured with dorsal plate and locking screws. The patient with septic loosening underwent a staged revision, allowing placement of antibiotic spacer for two months prior to calcaneal graft. Procedures were performed by the same surgeon and technique. Postoperative care consisted of NWB and immobilization for four weeks. After five weeks, progressive WB in postop shoe. FADI, VAS and AOFAS-HMI were clinically evaluated. Postoperatively CT scans obtained for patients with suspected nonunion to confirm diagnosis. Radiographs were evaluated for first IM angle, hallux valgus angle and first ray length.  

Results: All patients were female right feet with a mean age of 58.4 years. Average bone block used was 14.3 mm. Average consolidation was at 11 weeks. All patients returned to their daily activities except for one awaiting revision. Postoperative nonunion was found in three patients. The two asymptomatic patients had hardware removed at six and eight months postoperatively, and the symptomatic patient is awaiting revision surgery. Average VAS, FADI and AOFAS-HMI scores improved significantly from 8.5, 41.8 and 50.7 preoperatively to two, 84.6 and 73.8 postoperatively (p<0.05). Radiographically findings preoperatively included average: IM angle, hallux valgus angle and first ray length as follows: 9.5°, 19.7° and 10.4 cm. Postoperative radiographic findings are: 8.4°, 14.3° and 10.3 cm. IM angle was significantly decreased at final follow up (p<0.05), and average hallux length did not show significant change (P-0.42).

Conclusion: This study demonstrates clinical and radiographic improvement as well as preservation of hallux length after revision of a failed first MTPJ implant arthroplasty. First MTPJ arthrodesis is gold standard for end-stage arthritis and revision. This study presented 12 cases of revision with an autologous bone graft from ipsilateral calcaneus, providing an alternative option from where a podiatrist may harvest bone. Results are similar to previous literature, and nonunion is the most common complication. Increased incidence of nonunion may be secondary to small sample size and patient age. Further research with a larger sample size and different techniques may aid in discovering the procedure of choice.

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