History: 56 y.o. African American with Cc of painful big toes on both feet.
The patient states that he has had pain for approximately 10 years which is
progressively worsening, causing pain with shoe wear and ambulation. His
pain is on a daily basis and has affected his daily activities. He has no
history of trauma to the feet. His only other foot complaint is that he has
pain and an inability to bend his big toes.
PMH: Controlled hypertension
Meds: Norvasc 5mg po daily
Allergies: denies
PSH: hernia 5 years ago without complications
Social Hx: denies nicotine, alcohol and drug use
ROS: Non-contributory
Physical Examination:
Vascular: palpable pedal pulses 2/4 B/L; CFT 3-5 seconds
Neurological: all sensations intact, DTR B/L and symmetrical
Dermatological: Dystrophic toenails; mild hyperkeratosis plantar IPJ crease B/L
Hallux; mild xerosis B/L heels
Orthopedic: Muscle strength 5/5 in all 4 planes at the ankle;
ROM: Ankle 10 DF, 40 PF without crepitus or pain.
STJ and MTJ WNL without pain or crepitus, 1st MPJ 5 DF, 20 PF on Right, < 5 DF, 10 PF on the Left.
With pain on end ROM. Palpable painful dorsal exostosis.
1st metatarsal B/L. Abnormal increase DF ROM B/L IPJ hallux.
X-Ray B/L feet:
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Figure 1: AP View: Normal IM angle B/L, with 1st MPJ joint narrowing with lateral lipping
Eburnation B/L 1st MPJ, mild increase hallux interphalangeous angle
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Figure 2:
Lateral View: Normal calcaneal inclination angle, elevated 1st ray B/L
Severe dorsal bone flag (exostosis) B/L left > right |
Proposed treatment options:
Conservative: Oral NSAIDS, joint steroid injections, shoe modifications
Surgical: Joint replacement arthroplasty
Treatment: Joint replacement arthroplasty with BioPro Hemi-implant Left foot. Severe degeneration noted intra-operatively, with large dorsal exostosis 1st metatarsal head.
Intra-operative pictures:
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Figure 3: Pre-op range of motion limited |
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Figure 4: Intra-op dorsal exostosis |
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Figure 5: Resection with inserton of BioPro hemi-implant |
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Figure 6: Post-op increased range of motion after resection and joint replacement |
Post-op X-rays:
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Figure 7: AP View: resection of prox phalanx base with insertion of Bio-Pro hemi-implant in excellent alignment |
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Figure 8: Lateral View: Complete resection of dorsal spur 1st metatarsal with remodeling of head. Bio-Pro implant in excellent placement in base of the proximal phalanx |
Post-Op Care:
Immobilization dressing changed once a week for three weeks. Begin ROM exercises and return to normal shoe gear in 4 to 6 weeks.
ROM went from 5 degrees DF 10 degrees PF pre-op to 30 degrees DF, 50 degrees PF post-op without pain or stiffness.
Patient progress:
Weekly dressing changes for 3 weeks with passive ROM in bandage. Patient returned in soft shoes at 4 weeks. After 1 month in Physical Therapy, the patient was ambulating in regular shoes without discomfort.
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