Case Report
Osteochondral Cylinder Transplantation of First Metatarsal Head Secondary to Behçet's Disease (Delayed Radiographic Changes): A Case Report
Mahbod Arefi*
Department of Podiatric Surgery, University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH 45219, USA
*Corresponding author: Mahbod Arefi, Department of Podiatric Surgery, University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH 45219, USA
Published: 20 Apr, 2017
Cite this article as: Arefi M. Osteochondral Cylinder
Transplantation of First Metatarsal
Head Secondary to Behçet's Disease
(Delayed Radiographic Changes): A
Case Report. Clin Surg. 2017; 2: 1415.
Abstract
Behçet's disease (BD) is a multisystem disease with typically non deforming articular manifestations.
Erosive arthropathy is an uncommon condition in patients with BD. Radiographic studies alone,
could be misguiding in early stages of the disease.
An osteochondral defect of the first metatarsal head is a rare clinical finding leading to osteochondral
dissecans. The majority of case series studies reported in the medical literature regarding
osteochondral auto/allo-grafting deals with chondral lesions of the knee, shoulder and the ankle.
We report such a case, where a calcium sulfate implant was used for the first metatarsal head lesion
in a patient with Behçet's disease.
Introduction
An osteochondral defect of the first metatarsal head is a rare clinical finding leading to osteochondral dissecans. The majority of case series studies reported in the medical literature regarding osteochondral auto/allo-grafting deals with chondral lesions of the knee, shoulder and the ankle. We report such a case, where a calcium sulfate implant was used for the first metatarsal head lesion in a patient with Behçet's disease.
Case Presentation
A 36-year-old female patient presented with left foot first metatarsophalangeal joint pain. Upon
initial examination and radiographic study no fracture or dislocation was noted. At that time the
primary diagnosis was thought to be rheumatoid arthritis, which she was treated conservatively
without any benefit. The patient was suffering from long lasting Behçet's disease that has developed
recurrent oral ulcerations during the onset of the left foot symptoms. Clinical symptoms included:
mono-articular pain, decreased range of motion of the left 1st metatarsophalangeal joint, localized
edema. Initial radiographic study of the foot revealed no erosive and destructive changes in the 1st
metatarsophalangeal (Figure 1).
However, subsequent MRI study revealed osteochondral erosion over the first metatarsal head at its central portion with marrow edema measuring 1.5 cm × 1.0 cm × 0.5 cm (Figure 2).
The patient was treated conservatively for a few months with
no improvement. Decision was made for surgical treatment to
relief symptomatic pain in daily activities. Patient was taken to
the operating room for excision of the osteochondral defect and
implantation of cartilaginous graft for osteochondral damage of the
first metatarsal head. Upon careful dissection of the sub periosteum
a circular osteochondral lesion was identified in the central aspect
of the first metatarsal bone. The lesion was then reamed and the
damaged cartilage was removed and replaced with a calcium sulfate
implant (Figure 3 and 4).
The patient tolerated the procedure well and followed up as an
outpatient. Post operatively radiographic study showed a sharply
marginated, focal and tubular appearing defect in the central portion
of the first metatarsal distal articular surface.
Patient was partial heel weight bearing with post- operative shoe.
No soft tissue or osseous complications were encountered. Physical
therapy for increased range of motion of the first MTPJ started 12
weeks postoperatively. At 12 months follow up, the patient had
a functional metatarsophalangeal joint pain free range of motion
(Figure 5).
Figure 1
Figure 2
Figure 2
Osteochondral erosion over the first metatarsal head at its central
portion with marrow edema.
Figure 3 and 4
Figure 5
Discussion
Behçet's disease (BD) is a multisystem disease with typically
non deforming articular manifestations. Erosive arthropathy is an
uncommon condition in patients with BD. It was believed that there
were no abnormal radiographic changes in patients with Behçet’s
disease [1], especially in the foot. Joint manifestations are common
in patients with Behçet’s disease, but destructive arthritis is rare,
even though one has been reported in calcareous and in metatarsal
bone [2]. Radiographic studies alone could be misguiding in early
stages of the disease [2,3]. Articular cartilage defects that do not
penetrate subchondral bone (partial thickness defects) usually do
not heal spontaneously [3,4]. Full thickness defects have an intrinsic repair response which results in fibro cartilaginous scar tissue [5].
Fibrocartilaginous repair tissue is a poor substitute for hyaline
cartilage [6]. This type of intrinsic repair will eventually degenerate
with time and result in further degeneration of the articular surface [7].
OATS® (Osteochondral cylinder transplantation) procedure
involves use of a single plug that usually fills the entire defect. This
procedure may provide favorable results in some cases, but some
complications have also been reported which include fracture of
the osteochondral plug, postoperative hematoma, risk of surface
incongruity and instability of the graft [5,8].
Few clinical studies are available that compare the results of
osteochondral allo/autografting with other established therapies. The
medical literature suggests OATS procedure might be appropriate for
moderate lesions, between 1.1 and 2.5 cm2 [9]. The improvement of
symptoms appears to be time dependent. Clinical and radiographic
results of medium term follow up seem promising.
References
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- Al-Shaikh RA, Chou LB, Mann JA, Dreeben SM, Prieskorn D. Autologous osteochondral grafting for talar cartilage defects. Foot Ankle Int. 2002;23(5):381-9.
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- Thomas AP, Dwyer NS. Osteochondral defects of the first metatarsal head in adolescence: a stage in the development of hallux rigidus. J Pediatr Orthop. 1989;9(2):236-9.