Failed First Metatarsophalangeal Arthroplasty Salvaged by Hamstring Interposition Arthroplasty: Metallic Debris From Grommets
Kurt V. Voellmicke, MD, Manjula Bansal, MD, and Martin J. O’Malley, MD
Dr. Voellmicke is in private practice, Mount Kisco Medical Group, P.C., Mount Kisco, NY.
Dr. Bansal is Attending Pathologist, Hospital for Special Surgery, and Dr. O’Malley is Attending Surgeon, Foot and Ankle Service, Hospital for Special Surgery, New York, New York.
Abstract not available. Introduction provided instead.
Implant arthroplasty of the first metatarsophalangeal joint (MTPJ) was first developed in 1967 to address inadequacies of Keller resection arthroplasty.1 Implant arthroplasty, though still a joint ablative procedure, maintains length and alignment and preserves function. As with implant arthroplasty in other joints, the implants are subject to wear and therefore are usually advocated for older, less active patients.2,3
Synovitis secondary to particulate silicone debris is well established.4-8 The inflammatory response initiated by silicone debris not only produces pain and swelling and compromises motion, but it also contributes to bone destruction and gross implant failure.4-8 To prevent or decrease production of silicone debris at the implant–bone interface, titanium grommets were introduced.
Use of circumferential titanium grommets in MTPJ arthroplasty began in 1985 in an attempt to reduce silicone wear by shielding the midsection of the flexible silicone hinge.1 Reduction of silicone debris and synovitis through use of grommets has led to increased implant durability and fewer complications.1,9-11 Swanson and
colleagues1 reported an overall complication rate of 11% related to sharp bone edges, implant fracture, and reactive synovitis after flexible hinge arthroplasty without grommets and noted that grommets essentially eliminated these problems.
Production of particulate titanium debris with associated cellular response is a well-established entity in total hip arthroplasty,12-14 but up until now there have been no reports of titanium debris with respect to arthroplasty of the first MTPJ. Indeed, the literature suggests the opposite, that grommets themselves behave fairly inertly and significantly reduce the amount of particulate silicone produced
and its associated problems.1,9-11
To our knowledge, this is the first published report of metallic debris secondary to use of grommets in first MTPJ implant arthroplasty. In addition, salvage of a failed prosthesis has historically consisted of arthrodesis or resection15-17 or revision to another implant system.18 To our knowledge, this is also the first reported case of interposition arthroplasty used as a salvage technique.