First metatarsal distraction lengthening without arthrodesis after failed first metatarsal phalangeal joint replacement

Lorenzo Monti; Fabrizio De Marchi; Luigi Lovisetti; Ilaria Alice Crippa; Maurizio A Catagni

doi:10.4103/jllr.jllr_8_22

CASE REPORT

Year : 2022 | Volume : 8 | Issue : 1 | Page : 88-90

First metatarsal distraction lengthening without arthrodesis after failed first metatarsal phalangeal joint replacement

Lorenzo Monti¹, Fabrizio De Marchi¹, Luigi Lovisetti¹, Ilaria Alice Crippa², Maurizio A Catagni³
¹ Department of Orthopaedics, San Donato Group, Villa Aprica Clinical Institute, Como, Italy
² Department of Anaesthesiology and Critical Care, San Donato Group, San Marco Hospital, Zingonia, Italy
³ Department of Orthopaedics, Ilizarov Unit, Mangioni Hospital, Lecco, Italy

Date of Submission	29-Mar-2022
Date of Decision	25-May-2022
Date of Acceptance	26-May-2022
Date of Web Publication	30-Jun-2022

Correspondence Address:
Lorenzo Monti
Department of Orthopaedics, San Donato Group, Villa Aprica Clinical Institute, Via Castelcarnasino 10, Como
Italy

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jllr.jllr_8_22

Abstract

Arthrodesis is the most common salvage procedure for failed first metatarsophalangeal joint replacement arthroplasty. However, such procedure is not without limitations. Hereafter, we present the first case of replacement arthroplasty by distraction lengthening without associated arthrodesis as a salvage procedure for a failed first metatarsophalangeal joint replacement arthroplasty.

Keywords: External fixation, hallux valgus, Ilizarov, metatarsophalangeal joint, short ray

How to cite this article:
Monti L, De Marchi F, Lovisetti L, Crippa IA, Catagni MA. First metatarsal distraction lengthening without arthrodesis after failed first metatarsal phalangeal joint replacement. J Limb Lengthen Reconstr 2022;8:88-90

How to cite this URL:
Monti L, De Marchi F, Lovisetti L, Crippa IA, Catagni MA. First metatarsal distraction lengthening without arthrodesis after failed first metatarsal phalangeal joint replacement. J Limb Lengthen Reconstr [serial online] 2022 [cited 2023 Mar 27];8:88-90. Available from: https://www.jlimblengthrecon.org/text.asp?2022/8/1/88/349424

Introduction

Case Report

A 48-year-old woman came to consultation due to pain and deformity in her left hallux. She had a replacement of the first metatarsal-phalangeal (MTP) joint for hallux rigidus 5 years before in another hospital [radiological evaluation before surgery is reported in [Figure 1]]. Clinical examination upon presentation showed markedly shortened and laterally deviated first ray [Figure 2]. Swelling and weight-bearing pain made it impossible to the patient to wear closed shoes. Radiographs showed displaced implants, signs of osteolysis, and significant bone loss [Figure 3]. Surgery was performed with a dorsal-medial incision over the first ray. The implants were removed; no signs of infection were noted. Bone ends were debrided. A customized external fixator prepared by one of the authors (MAC) was applied using 1.8-mm and 2.0-mm Kirschner wire as half pins [Figure 4]. Osteotomy was performed with an osteotome after predrilling to minimize heat damage. A 1.8-mm Kirschner wire was inserted axially up to the medial cuneiform to prevent subluxation of the metatarsophalangeal interval during lengthening. The axial Kirschner wire was inserted so to allow plantar flexion of the distal fragment, fundamental to ensure a normal weight transfer in the forefoot. During subsequent frequent follow-up consultation, gradual lengthening of the external fixator was performed at 0.5 mm per day. Distraction was stopped once the distal end of the first metatarsal reached the normal parabola, resulting in a total lengthening of 20 mm after 90 days. The external fixator was removed 3 months postoperatively. At the same time, a transmetatarsal Kirschner wire was inserted on the first and second ray to prevent the collapse of the newly lengthened metatarsal and removed 4 months postoperatively [Figure 5]. Twelve months after surgery, no rest or weight-bearing pain was reported and the patient was able to wear closed shoes. Active MTP joint dorsiflexion was 45° and plantar flexion was 15°. Upon examination, the first ray was shorted and distally Dorsiflexed due to the shortening of the proximal phalanx [Figure 6]. The American College of Foot and Ankle Universal Evaluation Score (module 1 MPJ) was 89. The patient had returned to work as a bartender and was satisfied with the surgical outcome. The patient had follow-up consultations up to 4 years postoperatively. At the last follow-up, the patient was extremely satisfied with the surgical results and referred that she had started jogging on a regular basis.

Figure 1: X-rays performed before first MTP joint replacement showing bilateral severe first MTP joint valgus and advanced arthrosis of the left foot. MTP: Metatarsal-phalangeal

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Figure 2: Clinical presentation after first MTP joint replacement was characterized by severe first MTP joint valgus, with superposition of the second finger. The patient had severe functional limitations and weight-bearing pain and could not wear closed-toe shoes. MTP: Metatarsal-phalangeal

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Figure 3: Loosen MTPJ implants. MTPJ: Metatarsal-phalangeal joint

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Figure 4: Clinical and radiographic appearance of the custom-made external fixator at the end of the surgical procedure. The custom-made external fixator was progressively extended to allow first metatarsal lengthening after the first metatarsal osteotomy

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Figure 5: Clinical and radiological follow-up 3 months after surgery showing no signs of infection and proper consolidation of the bone gap

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Figure 6: Clinical and radiological follow-up 12 months after surgery. The patients had no weight-bearing pain and the first ray was only slightly shortened

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Discussion

MTP joint replacement arthroplasty was introduced in the late 60s in an attempt to address the complications of Keller arthroplasty and is nowadays widely applied to hallux rigidus. However, such a procedure shows uncertain surgical outcomes and lacks favorable long-term results. Synovitis and implant failure secondary to the use of silicone implants have been described. In a recent retrospective study of the long-term outcomes of Silastic implant arthroplasty of the first MTP joint, osteolysis was radiographically diagnosed in 23% of patients. Furthermore, in case of failure of the procedure, excessive bone loss, shortening of the first ray, deformity, and poor bone quality may complicate the subsequent salvage procedure. A previously published randomized controlled trial showed that arthrodesis leads to better outcomes in terms of pain, function, patients' satisfaction, and complications compared to replacement arthroplasty.^[1] In a retrospective study, there was no difference in the subjective outcomes between arthrodesis, hemi-metallic joint implant, and resection arthroplasty as surgical treatment of end-stage hallux rigidus.^[2] Furthermore, a systematic review concluded that arthrodesis may achieve a better functional outcome than total joint replacement in case of hallux rigidus.^[3] Arthrodesis with bone grafting had been the most commonly performed salvage procedure for failed MTP joint replacement arthroplasty.^[4],[5] However, such a procedure has potential complications such as skin necrosis and hardware intolerance.^[4],[5] Furthermore, arthrodesis with bone grafting showed variable rate of successful union with high reoperative rate[6], and this procedure allows a limited lengthening due to possibility of soft-tissue tension and vascular distress. Other techniques, such as removal of implants and synovectomy, hamstring interposition arthroplasty, and change to another implant system have been described. Distraction osteogenesis by Ilizarov is a technique that allows gradual soft-tissue distraction and bone lengthening, correcting deformities through osteogenesis stimulation. The use of distraction osteogenesis in the metatarsals has been widely documented in the literature for the treatment of congenital brachymetatarsia in children and adolescents.^[6] In adults, surgeries to the hallux are often complicated with metatarsal shortening,^[7] with subsequent risk of metatarsalgia. In 2018, Da Cunha et al. described a case series of three failed first MTP joint arthroplasty that were treated with first metatarsal lengthening combined with first MTP joint arthrodesis.^[8] The authors reported superficial pin site infection in one patient and premature consolidation in one other patient, although they reported an ultimate good functional result. Our approach differed substantially from the one described in that we did not alter MTP joint functionality. Indeed, joint arthrodesis often determines alteration in the gait cycle, while our approach preserved the functionality of the first MTP joint and physiological gait cycle. However, we cannot exclude future development of pain or inflammation, and the need for a joint arthrodesis in future. We reported the first successful use of distraction osteogenesis by Ilizarov with preserved MTP joint functionality on a case of metatarsal shortening due to hallux rigidus surgery. Distraction osteogenesis is a successful alternative to arthrodesis in case of failed first MTP joint replacement.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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