The dowel technique for first metatarso-phalangeal joint arthrodesis in revision surgery with bone loss

An Innovative Application of a Computer Aided Design and Manufacture Implant for First Metatarsal Phalangeal Joint Arthrodesis: A Case Report

The definitive treatment to correct the deformity of hallux abducto valgus involves surgical fixation. This pathological condition focuses on combined abnormalities of the first metatarsal phalangeal joint (MPJ), medial progression of the first metatarsal, and lateral deviation of the hallux. In most known literature described to date, a computer aided design/manufacture implant has not yet been reported as a viable salvage tool used as an inter-positional structural implant for a first MPJ arthrodesis. The fundamentals of this salvage procedure are to restore anatomical length of the first ray, furnish continuity to the forefoot parabola, administer a robust inter-positional implant^TM (Additive Orthopaedics, Little Silver, NJ) of optimal strength, and provide biomechanical reclamation of the tripod foot. This case study describes a procedural technique that required a 2-stage surgical approach consisting of primary external fixation with a SideKick^TMCoreTrack^TM (Wright Medical, Memphis, TN) tube fixator monorail to expand soft tissues for approximately 1 month.  Followed by a secondary procedure utilizing BioCUE® (Biomet Orthopaedics, Warsaw, Indiana) Bone Marrow Aspiration Concentration system, Augment® Injectable (Wright Medical, Memphis, TN), and custom GAME PLAN^TM (Additive Orthopaedics, Little Silver, NJ) Technology with computer assisted design/manufacture first MPJ inter-positional caged implant^TM arthrodesis.  We present the case of a 46-y-old active female who suffered avascular necrosis of her left foot first metatarsal head from a previous Austin bunionectomy correctional procedure.

First Metatarsal Phalangeal Joint Arthrodesis without the Use of Hardware after Failed Arthroplasty: A Case Report

Introduction

First metatarsal phalangeal joint (MTPJ) arthroplasty has a high failure rate due to aseptic loosening, which leads to bone loss. The salvage procedure is conversion to an arthrodesis, but bone loss can make obtaining screw fixation difficult. Herein, we report a unique case of revision first-metatarsal arthrodesis without the use of hardware after a failed arthroplasty.

Case Report

A 60-year-old women presented to us with first MTPJ pain in the setting of failed arthroplasty. We performed an arthrodesis; however, intraoperatively, hardware fixation could not be obtained due to bone loss. We utilized allograft bone struts to maintain first ray length and to hold the correct hallux position during arthrodesis maturation.

Conclusion

Bone loss is a frequently encountered problem in revision surgery to a first MTPJ arthrodesis. An arthrodesis can be obtained without the use of hardware in scenarios where bone loss precludes screw fixation.

Revision surgeries for failed hallux valgus correction: A systematic review

BACKGROUND

Failure of hallux valgus (HV) correction is not uncommon, and its management can be challenging. The available literature is not exhaustive. Therefore, we conducted a systematic review to investigate the current evidence on the role of revision surgery for failed HV correction, including clinical presentation, indications, surgical strategies and outcomes.

MATERIAL AND METHODS

The present systematic review was performed according to the PRISMA guidelines. Pubmed, EMBASE, Google Scholar and Scopus online databases were accessed in November 2020. All the clinical studies on revision for failed HV correction were analysed, and only studies reporting quantitative data under the outcomes of interest were considered for inclusion.

RESULTS

Data from 20 studies (586 procedures) were retrieved. The HV angle, the intermetatarsal angle and the distal metatarsal articular angle were reduced of 17.8° (P < 0.001), 3.3° (P = 0.05) and 7.3° (P < 0.001) respectively. The American Orthopaedic Foot & Ankle Society score improved of 24.7% (P < 0.001). The visual analogue scale improved by 40.8% (P < 0.001). Dorsiflexion and plantar flexion of the first metatarso-phalangeal joint remained similar to their preoperative values (P = 0.2 and P = 0.4, respectively). After revision surgery the following complications were further detected: recurrences 5.1% (30 of 586 patients), non-unions 4.1% (24/586), additional surgical procedures 8.7% (51 of 586 patients).

CONCLUSION

Revision surgery for failed primary HV correction can yield satisfying results. Accurate preoperative planning is necessary to try and identify the causes of failure, and address them appropriately.