This patient had marked 1st MTPJ pain that had been recalcitrant to conservative care, including various orthotics. Her range of motion was mildly reduced; however, she had crepitus present. The radiograph was reported to have only mild degenerative disease in the joint; however, there are some subtle changes in the position of the joint that can allow us to suspect the cartilage damage may be worse.
Remember, you cannot see cartilage in X-rays. If you compare the 1st MTPJ to the lesser MTPJs, you can see the loss of congruency and, in particular, the base of the proximal phalanx is slightly shifted laterally on the head of the 1st metatarsal. A healthy joint cannot function in this position as every motion at the joint will lead to grinding of the joint.
Also, note subchondral sclerosis, joint space narrowing and a small loose body noted medially. An MRI would have allowed us to see this better. However, the patient was in marked pain, conservative care had not produced the desired results, and the patient was keen for surgical intervention; therefore, the expense of an MRI was deemed unnecessary.
A capsular interpositional arthroplasty was planned and, sure enough, on surgical inspection approximately 60% of the cartilage was missing, with a large flap of cartilage noted centrally.
The joint was remodelled, and the thickened capsule was interposed, which should allow long-term pain-free motion in the joint.
Also read:
1st MTPJ cartilage damage
Motion following hallux limitus surgery
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