Case Review #1 Failed First MPJ Arthroplasty to Revisional Arthrodesis

Case Review #1

HPI: This is a case of a 72 year old male who presented for evaluation of a painful right first MPJ. This had been present for four years and has progressively worsened over time. He had a first MPJ implant arthroplasty performed from a different provider 4 years ago. His pain is located at the dorsal first MPJ and is described as aching in nature. His VAS is rated as a 7/10. His pain is aggravated with ROM of the first MPJ and with pressure over the dorsal first MPJ forcing him to wear shoes with a deeper and wider toe box.

PMHX: DM 2; HTN; Tuberculosis and Malaria

MEDs: Atorvastatin; Lisinopril; Metformin; Insulin; Hydrocholorothiazide

Allergies: None

SURGHX: Coronary Artery Stent; Right first mpj implant arthroplasty 4 years ago

SOHX: Lives at home with wife and is currently retired. Denies current or previous tobacco use. Does not drink alcohol.

PHYSICAL EXAMINATION:

GENERAL:  No apparent distress. VSS

LOWER EXTREMITIES:

VASCULAR:

— Palpable pedal pulses, dorsalis pedis and posterior tibial arteries.

— Capillary refill time less than 3 seconds in all digits of lower extremity.

—  Foot is warm to warm proximal to distal.

NEUROLOGICAL:

— Gross tactile sensation absent to light touch distal to midfoot bilaterally

— Sensation via 10 g monofilament: diminished

— Achilles reflexes:  normal

— Vibratory sensation diminished via tuning fork to great toes, bilaterally

DERMATOLOGICAL:

— No open lesions, erythema or edema.

— Interdigital spaces: clean, dry and intact

— Hyperkeratotic lesions:  none

— Dorsal osseous prominence over 1st MPJ, right pronounced with minor erythema localized to dorsum

— Well healed surgical incision over 1st MPJ right

MUSCULOSKELETAL:

— Foot type:  normal arch with rectus forefoot to rearfoot

— 5/5 muscle strength to all groups: dorsiflexors, plantarflexors, evertors, invertors

— Pain with ROM to: metatarsophalangeal

— Pain to palpation Dorsal boney prominence of 1st MPJ

— 1st MPJ ROM: 2 degrees plantarflexion, 2 dorsiflexion, painful throughout

— Hammertoe deformity:  2,3,4,5 toes bilaterally

ASSESSMENT/PLAN:

S/p 1st MPJ total arthroplasty implant with hypertrophic bone formation

Hallux Rigidus, right foot

Proposed procedure:  Right 1st MPJ hardware removal, 1st MPJ arthrodesis with plate fixation, calcaneal autograft harvesting and allograft for arthrodesis site.

Imaging:

Pre Op X-rays: 

 

Intra Op

4 Months Post Op:

  

At this time the patient’s assessment is the following: 1. Cellulitis with possible foreign body reaction due to the plate and screw fixation 2. Non-union right 1st MPJ

Please feel free to give your feedback on how the patient treatment plan should proceed from here. Suggestions/questions can be left in the comment section.

 

Case Review

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One thought on “<span class="entry-title-primary">Case Review #1</span> <span class="entry-subtitle">Failed First MPJ Arthroplasty to Revisional Arthrodesis </span>”

  1. Is the possibility of bone infection considered? He is Diabetic (unsure of how well controlled he is). Is that an open wound?

    Swelling seems significant based on image. May need incision and drainage, remove hardware, antibiotic beads. Also have him tested for metal allergy, while waiting for infection to resolve, since re-fusion of 1st MPJ can be an option once infection has resolved.

    Is MRI possible? If yes, then consider that to check for extent of bone infection vs non-union.

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