2007 OITE Question 9

Question

A sedentary 65-year-old woman has pain and swelling localized to the first metatarsophalangeal joint for the past 12 months. She underwent a Silastic implant arthroplasty for hallux rigidus 12 years ago. Examination reveals that the first metatarsophalangeal joint is swollen and warm and has less than 20° of total motion. The overall alignment and length of the great toe are acceptable, and she has no transfer lesions. Most of her erythema resolves with elevation. She is afebrile, and her C-reactive protein level and erythrocyte sedimentation rate are within normal limits. What is the most appropriate surgical treatment for this patient?

1- Implant removal and joint debridement

2- Dorsiflexion phalangeal osteotomy

3- First metatarsal shortening osteotomy

4- First metatarsophalangeal joint fusion with bone block autograft

5- Revision Silastic arthroplasty

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Answer (click for answer)

The correct answer is 1 – Implant removal and joint debridement

This patient has a diagnosis of silastic synovitis. Silastic arthroplasty has a reputation for high wear, loosening, silastic synovitis, lymphadenitis, and failure; over 10% are revised at 10 years, and overall clinical failure is 25-35%. Although her joint is swollen and warm, infection is ruled out by a normal ESR/CRP and decreased erythema on elevation. Although joint fusion with autograft (choice 4) is the most biomechanically sound, the first step in salvage of a failed first MTP joint implant arthroplasty, especially for this older, more sedentary patient, is implant removal/synovectomy. Therefore, the correct answer is 1. It is important to note that the patient does not have any transfer lesions which would make choice 4 the more appropriate answer.

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