A Novel Approach to an Infected First Metatarsophalangeal Joint Implant

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Raymond Lee, DPM:
I'm Raymond Lee, I am a podiatrist practicing out of Union, New Jersey. I graduated from the New York College of Podiatric Medicine, and then afterwards I completed a three-year residency at the Morristown Memorial Medical Center in Morristown, New Jersey. I am now a active faculty member at the Morristown Residency Program.

It was a case report on a 65-year-old female patient that presented to us with a diabetic foot ulceration. What was unique about her case was that she actually had an infected first metatarsophalangeal joint implant in there. It was a silicone implant that was placed about a month prior to her surgery. And so what happened was basically the wound probed straight down to the level of the implant. It probes down to the bone, acute osteomyelitis was confirmed and we were kind of talking about the different types of treatment plans for her.

So really, she was looking at possibly a primary amputation, partial first ray amputation, versus some type of multi-stage reconstructive surgery, and she ultimately opted for reconstructive care. And so we staged it for a two-stage procedure.

The first stage was basically almost like a masquelet technique. We excised the implant. We also excised the first metatarsophalangeal joint to clean margins. We put in an antibiotic spacer. We placed a unilateral mono external fixator and then I actually put in a wound graft. So we placed in the antibiotic spacer and then I used a dehydrated amnion/chorion tissue graft to cover up the soft tissue defect on the plantar aspect of the wound. And then the plan was after the soft tissue defect was resolved, then we would take her back in for a secondary procedure for a primary orthosis at that point.

What was really unique about the DHAC was that for the most part, the plan was to get some type of soft tissue envelope so that I can perform a first MPJ fusion with no exposure to the underlying hardware. Usually in these situations, I would say on average I would probably be about six to eight weeks for a soft tissue envelope to resolve. And in the diabetic population, that usually turns upwards to about 8 to 12 weeks. What was unique about her case was that when I used the DHAC, I got full closure technically in four weeks. I waited an extra week just to make sure everything was completely closed, and so we got full closure in five weeks. And so I think that really expedited the course of a treatment to allow us to move on to the secondary procedure of the primary orthosis at that point.

Sure. So she is about, I believe a year and a half now since her second procedure. Since then, she follows up every 6 to 12 months for just follow preventative care. She hasn't had a recurring ulceration. She's with her family and playing with her grandchildren and everything.

What I would like to hope is more DPMs would expand on the literature on these types of cases. I think the literature regarding first metatarsophalangeal joint implants is relatively low, compared with a lot of the other types of joints that the literature is kind of supports. And I think we use a lot of the similar techniques to resolve a lot of these problems, but we don't really report it. And so if anything, I would hope that this would, number one, expand the literature and just have different practitioners say, "Hey, I have a case very similar to this, or cases similar to this. Let me kind of talk about the way that I could treat it." But also I kind of hope that this would give practitioners different mindsets on how to treat some things like this.