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Year |
2001 |
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Question Number |
216. |
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Category |
Select |
Question
A 36-year-old man has pain in the metatarsophalangeal (MTP) joint of the great toe with all weight-bearing activities, and management consisting of shoe modification and an insert has failed to provide relief. Examination reveals a painful 10° arc of motion. Radiographs show degenerative changes with dorsal and medial osteophytes and joint narrowing. Treatment should now consist of
1- excision of the osteophytes and the dorsal third of the metatarsal head.
2- a dorsiflexion osteotomy of the metatarsal head.
3- resection arthroplasty of the MTP joint.
4- a Silastic implant of the MTP joint.
5- arthrodesis of the MTP joint.
Figures
Answer (click for answer)
Preferred Response: (5). This patient meets all of the criteria for a 1st MTP arthrodesis, choice 5: young patient, pain with weightbearing, painful & limited ROM, and joint DJD. This is the only procedure of those listed that will give this active, young patient a painless durable result. A cheilectomy, choice 1, addresses the osteophytes but does not address the arthritic joint. Choice 2 is more appropriate in the situation of a prominent metatarsal head with pressure sore problems. Resection arthroplasty, choice 3, decompresses the first MTP joint by removal of one third to half of the proximal phalanx and is recommended only for elderly or inactive patients. Long-term complications include cock-up deformity of the first toe, weakness in push off, instability, excessive shortening, valgus drift, and transverse metatarsalgia. Choice 4, silastic implant, does not give durable long-term results and can cause problems with silicone synovitis.
Reference: Mizel MS, MiUer RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 151-161.