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
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.
GENERAL: No apparent distress. VSS
— 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.
— 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
— 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
— 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
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.
Pre Op X-rays:
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.