Allograft Interposition Bone Graft for First Metatarsal Phalangeal Arthrodesis: Salvage after Bone Loss and Shortening of the First Ray

CATEGORY: Bunion; Midfoot/Forefoot; Other INTRODUCTION/PURPOSE: Previous studies have demonstrated success in using autogenous bone graft for arthrodesis in patients with previously failed surgeries of the hallux. These patients have several causes for pain and dysfunction preoperatively, including shortened first ray, nonunions, and poor hallux alignment. In this study, a consecutive series of 36 patients (38 procedures) were treated with a patellar wedge interposition structural allograft to salvage bone loss from great toe arthrodesis malunion, painful joint replacement, failed osteotomy, or infection of the great toe metatarsophalangeal (MP) joint with shortening of the first ray. The goals of the surgery were to restore length to the first ray and provide a stable MP joint fusion to relieve pain. METHODS: The 38 treated toes were followed for at least one year and were evaluated for preoperative and postoperative American Orthopaedic Foot & Ankle Society (AOFAS) MP scores, subjective patient outcome scores, and clinically successful fusion of the hallux. RESULTS: At a minimum one-year follow-up, all but two feet healed with a solid fusion, and all patients reported good or excellent outcomes. AOFAS MP scores averaged 43.5 preoperatively and 77.2 postoperatively. Three patients with infection as cause for nonunion of the initial procedure were treated with staged procedures, including the use of a temporary antibiotic spacer and mini external fixator; all three healed without recurrent infection. One patient had a fracture of her allograft following her interposition arthrodesis, but fused successfully after a second interposition arthrodesis surgery. Two patients developed a nonunion of the revision arthrodesis. CONCLUSION: In conclusion, the use of an interposition patellar wedge allograft can restore length to the first ray and provide successful salvage of arthrodesis nonunions and bone loss from failed hemi and total joint implants of the great toe MP joint.