ARTICLE IN PRESS The Journal of Foot & Ankle Surgery 000 (2019) 1−4
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Case Reports and Series
Conversion of First Metatarsophalangeal Joint Arthrodesis to Interpositional Arthroplasty With Acellular Dermal Matrix for First Ray Ulceration: A Case Report Jonathan Lee, DPM1, Eric So, DPM, AACFAS2, Daniel B. Logan, DPM, FACFAS2,3 1
Resident Physician, Grant Medical Center, Columbus, OH Member, Ohio Innovation Group, Columbus, OH 3 Director, FASCO Reconstructive Foot & Ankle Surgery Fellowship. Chairman, Podiatric Medicine & Surgery, Grant Medical Center, Columbus, OH 2
A R T I C L E
I N F O
Level of Clinical Evidence: 4 Keywords: first metatarsophalangeal joint arthrodesis fusion hallux disorders interpositional arthroplasty revision ulceration
A B S T R A C T
The purpose of this study is to report the outcome of the conversion of a first metatarsophalangeal (MTP) joint arthrodesis to an interpositional arthroplasty with an acellular dermal matrix for a chronic nonhealing first ray wound. To our knowledge, this is the first case report converting a first ray arthrodesis to an interpositional arthroplasty to heal a chronic ulceration. A 78-year-old female developed a chronic neuropathic ulceration under the first metatarsal head and hallux after a first MTP joint arthrodesis. The patient failed local wound care and underwent gastrocnemius recession, hallux interphalangeal joint fusion, and an interpositional arthroplasty with the use of an acellular dermal matrix. Bone tunnels were placed proximal to the metatarsal neck, where absorbable sutures affixed to the dermal matrix were passed from plantar to dorsal, and the graft was secured to the reamed metatarsal head and associated capsule. Postoperative radiographs revealed improved alignment of the first MTP joint. Complete reepithelialization of the plantar ulceration occurred within 2 weeks postoperatively. At the 16-month follow-up, the patient was ambulating without restriction and continued to be free of first ray ulceration and infection. This case study details the use of an acellular dermal matrix in an interpositional arthroplasty to offload a chronic nonhealing ulceration secondary to elevated first ray pressure associated with first MTP joint arthrodesis. The goal of this treatment is to reduce pain, heal the ulceration, and prevent its recurrence. © 2019 by the American College of Foot and Ankle Surgeons. All rights reserved.
First metatarsophalangeal (MTP) joint arthrodesis has been used in the treatment of many forefoot disorders, including severe or recurrent hallux valgus and varus deformities, rheumatoid arthritis, and osteoarthritis (1−3). The main purpose for this procedure is to realign the first ray into an anatomic position and to improve pain and function. Many methods of first MTP joint arthrodesis have been described; however, despite reproducible outcomes, complications continue to include nonunion, malunion, infection, ulcer formation, osteomyelitis, hallux interphalangeal joint (IPJ) arthritis, and wound dehiscence (4). Hallux ulcerations account for nearly one third of all diabetic foot ulcerations and can be attributed to the biomechanical abnormalities, structural deformities, or systemic complications of diabetes (5,6). Progressive thickening of collagen-containing tissues results in thickened skin and possible limited joint motion and microvascular compromise (7). Diabetic skin changes and neuropathy coupled with limited joint
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Jonathan Lee, DPM, Grant Medical Center, 285 E. State Street, Suite 670, Columbus, OH 43215. E-mail address:
[email protected] (J. Lee).
mobility, especially at the first MTP joint or ankle, creates a setting for repetitive injury at the hallux which, when unnoticed, may progress to ulceration. To counter the effects of limited motion within the first MTP joint, conservative therapies aimed at offloading the first MTP joint or distributing the forces throughout the forefoot should be used. With recalcitrant ulcerations underlying the hallux, surgical intervention to improve limited joint motion with motion-sparing arthroplasties, such as Keller arthroplasty, have been described (8−10). Keller arthroplasty was originally described for the treatment of hallux valgus and has been shown to improve first MTP joint range of motion directed toward a patient population with less active lifestyles or as a salvage procedure (8). However, Keller arthroplasty is plagued by a high rate of complications such as transfer metatarsalgia, decreased toe strength, cock-up deformity, and hallux malleus (11). Thus, as Mackey et al (11) have stated, modifications were made to this procedure to include an interpositional arthroplasty that would minimize complications, maintain range of motion at the first MTP joint, and provide a more predictable outcome. The resection of the proximal phalangeal base, and in some modifications the addition of an interpositional substance, aims to improve motion within the first MTP joint. This can be observed with the increased postoperative range of motion
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at the first MTP joint after the procedure, indicating successful offloading of the hallux (10,11). Thus, Keller arthroplasty may be useful in the treatment of diabetic pressure ulcerations by providing mechanical offloading (11). The current report describes the first known case of conversion of a first MTP joint arthrodesis to an interpositional arthroplasty for surgical offloading of a great toe neuropathic ulceration. Case A 73-year-old white female patient initially presented to the office with a severe hallux valgus deformity that caused intermittent pain with ambulation as well as superficial wounds at the plantar medial first MTP joint secondary to the medial prominence. Her medical history included hypertension, peripheral neuropathy, hypercholesterolemia, and degenerative joint disease; she also confirmed a surgical history including a total knee replacement, hysterectomy, and a tooth extraction. After failing conservative therapy, the patient underwent arthrodesis of the first MTP joint and experienced an uneventful postoperative recovery with resolution of pain and deformity, as well as the intermittent wounds. Postoperative weightbearing radiographs revealed adequate positioning of the proximal phalanx at the level of the first MTP joint (Fig. 1A, B). However, 4 years after her first MTP joint arthrodesis, she returned to the clinic with complaints of a full thickness plantar first MTP ulceration with a hyperkeratotic rim and associated local mild erythema and edema. There were no signs of a sinus tract or drainage, and the ulceration did not probe to bone. The first MTP joint was noted to be in a fixed, fused position, and the ankle was noted to be in equinus with −3° dorsiflexion with the knee extended.
Fig. 1. (A) Anteroposterior view of right foot with first MTP joint fusion and fixation intact. (B) Lateral view of right foot with first MTP joint fusion in a neutral hallux position.
Conservative measures, which involved silver alginate dressings, sharp debridement, topical/oral antibiotics, and offloading inserts, were attempted over the course of several months. During this time, a second superficial ulceration formed on the plantar aspect of the hallux with no signs of acute infection. A combination of the gastrocnemius equinus and the rigid lever arm of the first ray likely perpetuated the chronic, nonhealing nature of these wounds. Hardware removal, first MTP joint interpositional arthroplasty with acellular dermal matrix application, hallux IPJ arthrodesis, and gastrocnemius recession were performed to provide surgical offloading of the wound. The patient received a regional blockade before transport to the operating room. General anesthesia was obtained, and a well-padded pneumatic thigh tourniquet was applied. A modified Strayer technique was performed to address the equinus deformity (12). The first MTP joint hardware was removed without complication. A sagittal saw was used to perform a bone block resection from the head of the first metatarsal to the base of the proximal phalanx. A conical reamer was applied to the first metatarsal head to provide a more anatomic shape and eliminate any jagged bony prominences. A 5 by 5-cm GRAFTJACKET matrix (Wright Medical Technology) was placed into the arthroplasty site and wrapped around the first metatarsal head (Fig. 2). This was maintained and secured into the surrounding capsular tissue with absorbable suture using a technique previously described by Hyer et al (13). Next, the incision was carried distally, where the hallux IPJ was exposed. Planal wedge resection was performed to correct the valgus deformity of the hallux IPJ. Once the wedge was removed, the hallux was able to be realigned. Two 2.5-mm headless DART-Fire screws (Wright Medical Technology) were placed across the arthrodesis site, using the recommended manufacturer’s technique. Headless screws were selected to minimize the risk of pressure ulceration at the distal tuft of the hallux. Deep and superficial subcutaneous closure was obtained with absorbable suture, and skin was closed with nonabsorbable suture. A well-padded short leg posterior splint was applied to the operative extremity, and the patient was discharged home postoperatively. At the first postoperative appointment, the patient was found to have a wound dehiscence overlying the dorsal-distal first metatarsal with concerns for local infection. Wound cultures were obtained, and the patient was prescribed 875 mg Augmentin (amoxicillin and clavulanate potassium) and instructed to perform daily dressing changes consisting of silver alginate dressings until the next appointment. The wound cultures were found to be positive for methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa, and treatment was initiated consisting of intravenous daptomycin 400 mg daily as well as
Fig. 2. Intraoperative image of the acellular dermal matrix overlying the first metatarsal head.
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Fig. 3. Status post right foot interpositional arthroplasty. (A) Anteroposterior view. (B) Medial oblique view. (C) Lateral view.
oral ciprofloxacin 500 mg twice a day for 10 days. The patient developed hives after initiating the ciprofloxacin treatment, so this medication was consequently converted to intravenous Rocephin (ceftriaxone) 1 g daily. At the next follow-up appointment, Infectious Disease was consulted to discuss extended antibiotic therapy, and the patient initiated treatment at a local wound care center for the wound dehiscence, as the plantar wounds had already reepithealized by the second postoperative week. The patient’s antibiotic regimen was converted to intravenous vancomycin 1.25 g daily and intravenous ceftazidime 1 g twice a day for the next 6 weeks. Wound care consisted of serial wound debridements and Dakin’s solution dressings until complete
healing at 18 weeks postoperatively. Radiographs were obtained at 16 weeks postoperatively during a routine follow-up appointment, which revealed an open first MTP joint with sufficient bony apposition at the first IPJ (Fig. 3A−C). Ultimately, at 16 months postoperatively, the patient presented without evidence of preulcerative or full-thickness lesions, nonunion to the IPJ, or recurrence of the hallux abductovalgus deformity. Final first MTP joint and ankle joint range of motion were recorded as 60° and 10° of dorsiflexion, respectively. No further complications were encountered, and the patient resumed regular diabetic foot care, free from recurrent ulceration (Fig. 4A, B).
Fig. 4. (A) Postoperative image of healed plantar hallux wounds. (B) Postoperative image of healed dorsal wound.
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Discussion Ulcerations healed on the plantar aspect of the first MTP joint and hallux IPJ may be present due to a host of etiologies including structural “foot deformities, limited joint mobility, peripheral neuropathy, presence of callus, and soft tissue thickness” (14), which ultimately result in increased plantar pressure and a poor environment for soft tissue healing. Because of the overall function of the hallux and the first MTP joint, both areas are at higher risk of ulcer formation. The hallux and first MTP joint are crucial during the push-off phase of gait, when the ground reactive forces transfer from the lateral forefoot to medial forefoot and first ray (15). This places significant force to the plantar hallux and first MTP joint and, coupled with neuropathy or vascular compromise, may result in a breakdown of soft tissues in the aforementioned areas. Hyer et al (13) performed an interpositional arthroplasty with an acellular dermal matrix in advanced hallux rigidus patients and reported an increase in the American Orthopaedic Foot & Ankle Society score from an average preoperative score of 38 to a postoperative average of 65.8. They concluded that their method allowed for “continued pain relief and preserved function at a follow-up of more than 5 years” (13). Also using an acellular dermal matrix as an interpositional material, Khoury et al (16) presented a case study reporting the successful salvage of a hallux after a failed total first MTP joint arthroplasty by interposing this dermal matrix between the first distal phalanx and metatarsal. Magnetic resonance imaging findings at 6 months demonstrated the incorporation of this matrix with the surrounding soft tissues, with the patient retaining a rectus, plantigrade hallux with “adequate propulsion at the first MTP joint during gait” (16). Other studies have used Keller arthroplasty to improve hallux range of motion, thereby decreasing plantar pressures and shear forces (15). Armstrong et al (9) used Keller arthroplasty as a curative procedure for hallux interphalangeal ulcerations and found improved healing times and reduced rates of recurrence in their case control study. Similarly, Lin et al (10) compared Keller arthroplasty to total contact casting and found an improved time to healing. In the present case, the authors’ revisional procedure used an acellular regenerative tissue matrix along with a takedown arthroplasty of a previously performed arthrodesis in order to achieve similar results to the aforementioned studies. The tissue matrix provided a smooth surface on the distal first metatarsal to allow for an unrestricted gliding motion of the proximal phalanx in response to ground reactive forces during gait. With further healing, this matrix would transition to a tissue resembling the joint capsule and surrounding soft tissue to allow increased joint mobility when compared to a fused first MTP joint. Although the patient sustained a postoperative infection causing dehiscence of the dorsal incision that took considerable time to heal, the plantar ulcerations healed rapidly owing to the biomechanical
benefit from the procedure. Furthermore, the authors acknowledge the effects that a gastrocnemius recession may have on plantar forefoot pressures. This procedure was performed in conjunction with the modified interpositional arthroplasty to revise the first MTP joint arthrodesis after biomechanical evaluation to sufficiently relieve forefoot pressures. Although this adjunct procedure likely aided the favorable outcomes of this case report, the authors conclude that the interpositional arthroplasty was the main driver for this intervention’s success. In conclusion, the current report describes the outcome of a novel revisional approach to a chronic first ray ulceration in the setting of a first MTP joint arthrodesis. To our knowledge, this is the first reported case of the performance of this procedure. The modified interpositional arthroplasty was found to have favorable outcomes, with resolution and complete healing of the first ray ulceration without recurrence. References 1. Roukis TS. First metatarsal-phalangeal joint arthrodesis: primary, revision, and salvage of complications. Clin Podiatr Med Surg 2017;34:301–314. 2. Hamilton GA, Ford LA, Patel S. First metatarsophalangeal joint arthrodesis and revision arthrodesis. Clin Podiatr Med Surg 2009;26:459–473. 3. Coughlin MJ. Rheumatoid forefoot reconstruction. A long-term follow-up study. J Bone Joint Surg Am 2000;82:322–341. 4. Grimes JS, Coughlin MJ. First metatarsophalangeal joint arthrodesis as a treatment for failed hallux valgus surgery. Foot Ankle Int 2006;27:887–893. 5. Ahmed ME, Tamimi AO, Mahadi SI, Widatalla AH, Shawer MA. Hallux ulceration in diabetic patients. J Foot Ankle Surg 2010;49:2–7. 6. Boffeli TJ, Bean JK, Natwick JR. Biomechanical abnormalities and ulcers of the great toe in patients with diabetes. J Foot Ankle Surg 2002;41:359–364. 7. Zimny S, Schatz H, Pfohl M. The role of limited joint mobility in diabetic patients with an at-risk foot. Diabetes Care 2004;27:942–946. 8. Tamir E, Tamir J, Beer Y, Kosashvili Y, Finestone AS. Resection arthroplasty for resistant ulcers underlying the hallux in insensate diabetics. Foot Ankle Int 2015;36: 969–975. 9. Armstrong DG, Lavery LA, Vazquez JR, Short B, Kimbriel HR, Nixon BP, Boulton AJ. Clinical efficacy of the first metatarsophalangeal joint arthroplasty as a curative procedure for hallux interphalangeal joint wounds in patients with diabetes. Diabetes Care 2003;26:3284–3287. 10. Lin SS, Bono CM, Lee TH. Total contact casting and Keller arthoplasty for diabetic great toe ulceration under the interphalangeal joint. Foot Ankle Int 2000;21:588–593. 11. Mackey RB, Thomson AB, Kwon O, Mueller MJ, Johnson JE. The modified oblique Keller capsular interpositional arthroplasty for hallux rigidus. J Bone Joint Surg Am 2010;92:1938–1946. 12. Pinney SJ, Sangeorzan BJ, Hansen ST Jr. Surgical anatomy of the gastrocnemius recession (Strayer procedure). Foot Ankle Int 2004;25:247–250. 13. Hyer CF, Granata JD, Berlet GC, Lee TH. Interpositional arthroplasty of the first metatarsophalangeal joint using a regenerative tissue matrix for the treatment of advanced hallux rigidus: 5-year case series follow-up. Foot Ankle Spec 2012;5: 249–252. 14. Barn R, Waaijman R, Nollet F, Woodburn J, Bus SA. Predictors of barefoot plantar pressure during walking in patients with diabetes, peripheral neuropathy and a history of ulceration. PLoS One 2015;10:e0117443. 15. Downs DM, Jacobs RL. Treatment of resistant ulcers on the plantar surface of the great toe in diabetics. J Bone Joint Surg Am 1982;64:930–933. 16. Khoury W, Fahim R, Sciulli J, Ehredt DJ Jr.. Management of failed and infected 1st MPJ total joint implant arthroplasty with an acellular dermal matrix. J Foot Ankle Surg 2012;51:669–674.