When A Metal Allergy Affects Reconstruction Efforts

(Co-authored by Yashraj A. Chauhan, DPM)

A 58-year-old man previously had a Evans calcaneal osteotomy, a calcaneonavicular joint coalition resection and endoscopic plantar fasciotomy in February 2013 to the left foot with another surgeon. This surgeon also removed hardware from the left foot and performed an open plantar fasciotomy in January 2014. In the interval between the procedures, this patient continued to have significant pain and redness to the surgical site. Given the patient’s symptoms, he got a referral to an immunologist, who diagnosed the patient with a true nickel allergy. 

Shortly afterward, the patient presented to our office with persistent, debilitating lateral column pain. Radiographs and magnetic resonance imaging (MRI) revealed significant arthritic changes to the calcaneocuboid joint and peroneus tendinopathy with split tears of both peroneal tendons. In August 2014, we performed the following surgical procedures to the patient’s left lower extremity: calcaneocuboid joint arthrodesis (utilizing an external fixator with hydroxyapatite-coated Schanz pins); peroneal tendon repair; and sural neurectomy with burial into the calcaneus. Transecting the nerve and creating a small tunnel in the calcaneus to bury the nerve in helps prevent stump neuroma formation.

Subsequently, we removed the external fixator at the eight-week mark despite incomplete radiographic consolidation evident across the calcaneocuboid joint.

Despite bone stimulator application and prolonged immobilization, a computed tomography (CT) scan demonstrated only 25 to 30 percent consolidation across the fusion site. At this point, the patient had an ultrasound-guided injection to the proximal sural nerve (which provided no relief) and we recasted him for custom-molded orthotics (which also provided no relief). Subsequently, a repeat MRI obtained in October 2017 showed pseudarthrosis across the calcaneocuboid joint with articular surface irregularity, subchondral bone marrow edema and osteophyte formation. Furthermore, no evidence of avascular necrosis was present.

Since multiple conservative options had failed, we decided to perform revision surgery. This entailed the use of Bone Marrow Aspirate Concentrate (BMAC, Harvest Technologies) for the left tibia and a calcaneocuboid joint distraction arthrodesis with a 10 mm graft (Calc-Cuboid Arthrodesis Lengthening Graft, Paragon 28) in the left foot.

The patient knew of a family member who had an autogenous graft taken from the hip and wanted to avoid this “painful surgery” at all cost. Since the patient was allergic to metallic fixation, we fixated the calcaneocuboid joint distraction fusion site with a bioabsorbable implant, namely the ReUnite four-hole plate with 2.5 mm locking screws (Zimmer Biomet). We soaked the graft in the aforementioned bone marrow aspirate concentrate and inserted it into the pseudarthrosis resection site. This restored the lateral column length and we verified the lateral column position as excellent. The patient is just a few weeks post-operative at this point.

Since this is a somewhat rare case, there could be several surgical approaches. Please provide your thoughts and experience with this type of patient (if any). Perioperative pearls are helpful to share as well.