Review Question - QID 211913

This patient has hallux valgus with degenerative joint disease and underwent 1st MTP joint fusion. Aggressive bone resection at the time of surgery may lead to transfer metatarsalgia.

Hallux valgus causes valgus deviation of phalanx which promotes varus positioning of the metatarsal, causing the sesamoid complex to laterally and rotationally translate relative to the metatarsal head. First MTP joint arthrodesis is indicated in cerebral palsy, Down's syndrome, rheumatoid arthritis, gout, severe DJD, and Ehler-Danlos. Aggressive bone resection leads to shortening of the first metatarsal which may result in transfer metatarsalgia. First MTP joint arthrodesis has demonstrated superior clinical outcomes compared with metallic hemiarthroplasty.

Rammelt et al. reviewed first metatarsophalangeal (MTP) joint fusion for end-stage arthritis. They report that complications include infection, osteonecrosis, implant protrusion or failure, nonunion, and malunion. They concluded that the medium-term results of first MTP joint fusion indicate mostly good functional results with success rates of approximately 90%.

Raikin et al. compared the long-term clinical and radiographic outcomes of a metallic hemiarthroplasty with those of arthrodesis for the treatment of severe arthritis of the first metatarsophalangeal joint. They report that 24% of the hemiarthroplasties failed, whereas all of the arthrodeses achieved fusion, and no revisions were required. They concluded that arthrodesis is more predictable than a metallic hemiarthroplasty for alleviating symptoms and restoring function in patients with severe osteoarthritis of the first metatarsophalangeal joint.

Figure A is the radiograph of the foot demonstrating hallux valgus with degenerative joint disease of the 1st MTP joint. Illustration A demonstrates transfer metatarsalgia following MTP joint fusion with excessive shortening.

Incorrect Answers:
Answer 1: Although rare, osteonecrosis of the metatarsal head can occur and is classically linked to distal Chevron osteotomy
Answer 2: A cock-up toe deformity occurs due to injury of FHL and is the most severe complication with a Keller resection
Answer 3: Painful incisional neuromas after bunion surgery frequently involve the medial dorsal cutaneous nerve (a terminal branch of the superficial peroneal nerve). It is most commonly injured during the medial approach for capsular imbrication or metatarsal osteotomy.
Answer 4: Recurrence is much more common with other surgical procedures for hallux valgus as opposed to 1st MTP joint arthrodesis