Metatarsophalangeal Arthroplasty Research Articles

Preoperative Risk Factors for Primary Metatarsophalangeal Arthroplasty Revision to MTP Arthrodesis for Hallux Rigidus

Revision or conversion to arthrodesis following metatarsophalangeal (MTP) joint arthroplasty are salvage procedures to manage complications of MTP joint arthroplasty. The purpose of this study is to use a national administrative database to characterize nationwide trends of patients undergoing hallux MTP arthrodesis vs arthroplasty for hallux rigidus. Additionally, the authors sought to evaluate demographic trends and evaluate influence of patient-related risk factors in those undergoing MTP arthroplasty revision to arthrodesis. Patients who underwent MTP arthroplasty for diagnosis of hallux rigidus from 2010 to 2019 were identified in the Mariner subset of the PearlDiver database. Patients were included if they had undergone MTP arthroplasty for the diagnosis of hallux rigidus. Notably, the database lacks resolution about critical features of the arthroplasty design and materials. The revision cohort encompassed patients who underwent subsequent ipsilateral MTP arthrodesis or arthroplasty within 2 years of index arthroplasty procedure. Demographic characteristics and medical comorbidities were examined as potential patient-related risk factors for arthroplasty revision or revision to fusion. Univariate analyses were performed to analyze differences in patient demographics, comorbidities, and risk factors. A multivariate regression analysis was subsequently conducted to control for confounding variables. 2750 patients underwent primary MTP arthroplasty for diagnosis of hallux rigidus. Of these, 44 (1.6%) underwent revision arthroplasty and 188 patients (6.8%) were revised to arthrodesis within the first 2 years after the index procedure. Multivariate regression analysis indicates that obesity (odds ratio [OR] 1.48, 95% CI 1.05-2.09), depression (OR 1.59, 95% CI 1.15-2.20), and steroid use (OR 2.94, 95% CI 1.30-6.65) were associated with a statistically significant increase in revision to arthrodesis from primary arthroplasty. Revision arthrodesis following primary MTP arthroplasty for hallux rigidus within 2 years was found to be a relatively common occurrence in this national insurance database study. Risk factors for revision arthroplasty to arthrodesis within 2 years of primary arthroplasty include obesity, depression, and steroid use. Level III, case-control study.

Деформации стоп у пациентов с синдромом диабетической стопы (обзор литературы)

The objective was to review the orthopaedic literature on treatments of diabetic foot disease. Material and methods PubMed, CyberLeninka, Google Scholar, Scopus, Medline, eLIBRARY were searched. Studies in English and in Russian that reported foot deformities in the pathogenesis of diabetic foot disease and orthopaedic correction methods in the complex treatment of this late complication of diabetes mellitus were included for review. All study designs were considered. The search was produced using the following terms: diabetes mellitus, foot deformities, diabetic foot syndrome, orthopaedic treatment, osteotomy, metatarsophalangeal arthroplasty, achilles tendon lengthening. Literature sources reporting methods of orthopaedic correction of foot deformities in isolation from the diabetic foot syndrome and literary sources reporting manifestations of the diabetic foot syndrome without description orthopedic methods of treatment (surgery for purulent complications, vascular surgery, hypoglycemic therapy) were excluded from the study. Results The literature review allowed us to evaluate the role of orthopaedic treatment of foot deformities in patients with diabetic foot syndrome to be addressed either conservatively or surgically. The effectiveness of conservative methods has long been reported in studies with higher degree of evidence. Surgical correction of DFS through orthopaedic interventions has not been covered in such detail. Conclusion The literature review focused on the topical issue at the junction of various medical specialties. The results of treatment reported by Russian and foreign authors were analyzed. "Blind spots" in the literature were explored, goals for subsequent research delineated.

Revision First Metatarsophalangeal Joint Fusion for Non-Union, Implant Failures, and Failed Hallux Valgus Correction: Does the Indication Matter?

Category:Midfoot/Forefoot; BunionIntroduction/Purpose:The most common indications for revision of 1st Metatarsophalangeal (MTP) joint surgery are symptomatic failures of prior fusion, failed hallux valgus correction, and failed MTP arthroplasty implants. The outcome of revision 1st MTP fusion has rarely been studied. The purpose of this study was to compare the clinical, radiographic, and patient-reported outcomes of revision MTP fusion for different indications.Methods:A retrospective chart review was performed for patients who underwent revision 1st MTP fusion between January 2015 and December 2019 in a single-center, by 4 fellowship-trained foot and ankle surgeons. The complication, revision, and non- union rates as well as VAS and PROMIS scores and pre-operative and post-operative radiographs were analyzed and compared between the different indication groups. Univariate and multivariate analysis and logistic regression models were used to obtain odds ratio of the explanatory variables for outcome measures.Results:A total of 79 cases of revision MTP fusion were included. Thirty-eight cases of hallux valgus corrections salvage, 22 failed MTP arthroplasty implants, 6 failed polyvinyl alcohol hydrogel implants, 13 prior MTP fusion non-unions. The mean follow-up time was 350 days (Median 226, SD 306). Seven cases (8.9%) required structural iliac-crest bone graft during the revision. Seven cases (8.9%) required allograft augmentation. The overall complication rate was 40.7%. Fifteen patients (18.5%) were classified as Clavien-Dindo grade 3, which represents a complication that may require a revision surgery (i.e. non-union, deep infection, loss of correction). Eventually, 7 cases (8.9%) underwent further revision surgery. The logistic regression model demonstrated that indication for revision was not significantly related to union rate (p=0.280). Visual-Analogue-Scale significantly improved at 6 weeks, 3 months, and at last follow-up in all indications for revision (p=0.001). PROMIS-10 Physical and PROMIS-10 Mental did not change significantly during follow-up (p=0.860, p=0.589).Conclusion:Treatment of 1st MTP joint surgery failures is a clinical challenge in orthopaedic surgery. In our study, revision of 1st MTP joint surgery with MTP fusion had higher non-union rates and higher overall complication rates compared to primary 1st MTP fusion. Nevertheless, revision rates remained comparable to primary 1st MTP fusion. Complication rates and patient- reported outcomes were similar between the different indications for revision groups. Visual-analogue-scale improved significantly during follow-up in all groups. Diabetes mellitus had a significant impact on non-union rates and overall complication rates.

Five-Year Prospective Roentgen Stereophotogrammetric and Clinical Outcomes of the BioPro MTP-1 Hemiarthroplasty.

Mixed results for functional outcomes and long-term fixation have been reported for first metatarsophalangeal arthroplasty. This prospective study was designed to evaluate the migration of the BioPro metatarsophalangeal-1 (MTP-1) joint hemiprosthesis with Roentgen stereophotogrammetric analysis (RSA). Migration patterns of the prosthesis, prosthesis-induced erosion of the metatarsal bone, and clinical outcomes were evaluated sequentially to 5 years postoperation (PO). Eleven female patients received the BioPro-1 hemiprosthesis. Prosthesis translation and metatarsal erosion were measured with RSA at immediately PO, 6 weeks, and 3, 6, 12, 36, and 60 months postoperatively. Clinical assessment was done by patient questionnaires. RSA data of 9 patients were available for analysis. Median (range) number of markers used in RSA analysis, condition number, and mean error of markers around the prosthesis were 4 (3-7), 320 (208-862), and 0.13 (0.02-0.28), respectively. Progressive subsidence was seen up to 3 years PO (mean 2.1 mm, SE 0.32). Progressive metatarsal erosion was found from 1 year PO (mean 0.49 mm, SE 0.15). Pain, function, and quality scores improved after surgery and did not deteriorate at later follow-up moments. Model-based RSA of the BioPro-1 prosthesis shows nonstabilizing medial and distal translation and metatarsal erosion. Despite the measured migration and erosion, clinical outcomes improved and remained similar up to 5 years postoperation. Level II, prospective analysis of MTP-1 hemiprosthesis.

Utilizing Cost and Quality Measures to Guide Fixation of MTP Arthritis

Category: Midfoot/Forefoot Introduction/Purpose: Severe hallux rigidus is the 2nd most common disorder of the 1st metatarsophalangeal (MTP) joint and is present on more than 44% of radiographs taken in those over 80 years of age. Arthrodesis has been the proposed method of fixation for 1st MTP pathology. However, joint preserving alternatives to fusion have also been proposed to maintain joint motion and due to the relatively high nonunion rate (5.4%). However, few reports have investigated if the risk of complications from a fusion impact daily activities and functional outcomes. As such, we investigated the cost and quality associated with treatment of severe MTP arthritis to determine the optimal surgical intervention. Methods: This was a retrospective review of 384 patients from a prospectively collected foot and ankle platform registry in a payor-provider healthcare system. Patients who underwent surgical intervention from July 2015 to November 2017 were identified by CPT codes for MPT arthrodesis (28750) and arthroplasty (28293) as well as key words “hallux” and “rigidus”. Patient reported outcome scores were extracted from the medical records including SF12-M, SF12-P, FAAM, and a binary PASS score. Exclusion criteria included poly-trauma, neurological impairment, and revision procedures. The Mann-Whitney test was performed using Minitab 18 to compare procedure groups for the small samples without a normal distribution, and chi squared analysis was used to analyze the PASS score. Significance was defined by a p-value of <0.05. Additionally, cost data was gathered across the institution based on the previously mentioned CPT codes at the same institution, although statistical analysis was limited by reporting of average numbers. Results: A total of 35 patients met inclusion criteria, with 26 arthrodesis and 9 arthroplasty patients. The arthrodesis group had an average age of 63.4 and the arthroplasty group had an average age of 60.1. The arthrodesis group had higher post op scores in measures including SF12-M, SF12-P, FAAM, and PASS. The arthrodesis group also had greater increase in postoperative SF12-P, and FAAM compared to pre-op scores, with the arthroplasty having higher increase in SF12-M. Of these, the differences in PASS score (p=0.02) and the change in SF12-P were significant (p=0.05). Analysis of cost identified 25 logs of MTP arthroplasty with an average cost of $6,538 per case and 79 logs of MTP arthrodesis with an average cost of $5,086. Conclusion: This study suggests that patients treated with arthrodesis for 1st MTP arthritis have improved outcomes with greater cost containment. Although the PASS and SF-12 scores showed significant differences, all of the results including pain scores revealed greater improvement with arthrodesis, with the exception of the SF12 mental. The small cohorts in this study are a limitation, but these, results are consistent with the current literature. However, with both higher outcome scores and lower cost, arthrodesis appears to have significant advantages compared to arthroplasty and further studies can help guide clinical decision making in this patient population.

Early results of Roto-glide joint arthroplasty for treatment of hallux rigidus

BackgroundTraditionally severe hallux rigidus is treated with arthrodesis. Recently arthroplasty has been used in order to retain motion at the metatarsophalangeal joint. AimTo assess the early to mid-term functional and radiological outcomes in patients undergoing first metatarsophalangeal arthroplasty using the Rotoglide implant. Materials and methodsA prospective review was undertaken to assess functional and radiological outcomes of all patients undergoing an un-cemented three-component first metatarsophalangeal arthroplasty for hallux rigidus. Thirty four implants were performed in 28 patients over a 2-year period. Mean age was 60.5 years (range 45–77 years). Mean follow-up was 27.7 months (range 7–44 months). ResultsMean AOFAS score improved from 41.2 pre-operatively to 89.1 at final follow-up (47.9; 95% CI=43.6–54.3; p<0.0001). The mean metatarsophalangeal (MTP) range of motion improved from 29.5° pre-operatively to 68.2° post-operatively (38.7; 95% CI=35.1–42.2; p<0.0001). The mean AOFAS pain scores improved from 8.8 preoperatively to 35.0 postoperatively (26.2; 95% CI=22.4–29.9; p<0.0001).Three patients required revision surgery. No radiological complications were observed in any other patients. ConclusionsThis un-cemented prosthesis provides pain relief, while maintaining range of motion of the joint. The authors have observed clinically and statistically significant improvement in functional outcomes, with a low early complication rate and high patient satisfaction levels.

Clinical study of Ludloff osteotomy and artificial metatarsophalangeal arthroplasty in the treatment for severe hallux valgus

Objective To analyze the clinical outcomes of Ludloff osteotomy and artificial metatarsophalangeal arthroplasty in the patients with severe hallux valgus and metatarsophalangeal joint osteoarthritis. Methods From Apr. 2013 to Aug. 2015, 120 feet with severe hallux valgus were treated by operation in Beijing Friendship Hospital, Capital Medical University. Before operation, measured some angles, such as hallux valgus angle, intermetatarsal angle, proximal articular surficial intrinsic angle and so on in the two groups. And evaluated the patients condition by Maryland scale at the same time. Through the date, we make sure that there was no significant difference between the two groups before operation. According to the order of hospitalization, all patients were randomly divided into experimental group (n=60) and control group (n=60). The cases of experimental group were treated by Ludloff osteotomy and artificial joint replacement. The cases of control group were treated by Ludloff osteotomy and Akin osteotomy. We used the visual analogue scale, the core quality of life scale-36 and Maryland scale to record the date, such as pain, the range of motion and appearance of the metatarsophalangeal joint and the ability of daily life and sports before and after operation. Compared above categorical variables using paired T-test between before and after operation and using T-test between the two groups. Compared the rate of operative complications by Fisher′s exact test between the two groups. Results Through the Maryland scale, the total excellent rate of the experimental group (91.7%) was higher than the total excellent rate of the control group (75.0%), with statistically significant (P 0.05). The scores of quality of life of the experimental group after treatment were significantly higher than those of the control group, with statistically significant (P<0.05). The visual analogue scale pain score (1.61±0.12) of the experimental group was significantly lower than the control group (3.68±0.58), with statistically significant (P<0.05). Conclusion The clinical outcomes of Ludloff osteotomy and artificial metatarsophalangeal arthroplasty in patients with severe hallux valgus and metatarsophalangeal joint osteoarthritis is better, high safety, less trauma and faster recovery. It is worthy of promotion and use. Key words: Hallux valgus; Ludloff osteotomy; Replacement of artificial metatarsophalangeal joint; Treatment outcome; Comparative effectiveness research

First metatarsophalangeal joint fusion combined with metatarsophalangeal arthroplasty from the second to the fifth toe to treatment forefoot deformities caused by rheumatoid arthritis

Objective To explore the effect of the treatment of forefoot deformities caused by rheumatoid arthritis by the method of the first metatarsophalangeal joint fusion combined with metatarsophalangeal arthroplasty from the second to the fifth toe.Methods The data of 19 patients with forefoot deformities caused by rheumatoid arthritis was retrospectively studied after receiving the treatment by the method of the first metatarsophalangeal joint fusion combined with metatarsophalangeal arthroplasty from the second to the fifth toe from June 2007 to October 2010.There were 17 females (31 feet) and 2 males (4 feet) with an average age of 56 years (range,33-73 years).The American Orthopaedic Foot and Ankle Society (AOFAS),visual analogue scale (VAS) were applied.Hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured to investigate the changes in forefoot deformity preoperatively and postoperatively respectively.Results In 17 cases,the appearances of forefoot were improved in different degrees.The metatarsalgia disappeared completely in 29 feet.In other 3 feet,the fifth metatarsal metastatic metatarsalgia appeared and the pain was relieved after the forefoot decompression pad treatment.The distal end of hallux was excised due to necrosis.Forming joint have different degrees of anchylosis.The AOFAS improved from 46.82±6.13 preoperative to 84.25±2.87 postoperative,while the VAS,HVA,IMA decreased from 9.03±1.82,38.96°±10.13° and 15.87°±3.43° to 2.12±0.67,15.84°±5.12° and 10.35°±1.67° respectively.Conclusion The effect of the treatment for forefoot deformities caused by rheumatoid arthritis by the first metatarsophalangeal joint fusion combined with metatarsophalangeal arthroplasty from the second to the fifth toe is excellent. Key words: Arthritis, rheumatoid; Foot deformities, acquired; Metatarsophalangeal joint; Arthrodesis

MOJE Ceramic Metatarsophalangeal Arthroplasty: Disappointing Clinical Results at Two to Eight Years

Among the surgical treatment options for osteoarthritis of the first metatarsophalangeal joint (MTPJ) are a number of different designs of total arthroplasty, including the MOJE, a ceramic press fit arthroplasty. We present a 2- to 8-year followup of 31 procedures. Thirty-two MOJE arthroplasties were undertaken for painful hallux rigidus in 30 patients (nine male, 21 female) over 6 years (mean age 61.9; range, 37 to 76). At followup patients' symptoms, levels of function and radiographs were scored using SF-36, modified Kitaoka and AOFAS systems. Followup rate was 97%, with mean followup time 58 months (range, 28 to 97). Mean scores were: Kitaoka 53.8 (15 to 75), AOFAS 61.3/100 (range, 18 to 100), SF-36 physical combined 48.6 (27.6 to 58.7) SF-36 mental score 52.2 (19.5 to 62.2). Sixteen showed radiological evidence of component loosening (either lucency, subsidence or both) and one radiograph revealed component fracture. Eight implants have been revised. In patients who had not undergone subsequent fusion, 15 had less than 36 degrees of movement, nine had 36 to 45 degrees, four were in the 46 to 60 range, and only one had more than 60 degrees. There were no infections. Although previous studies have suggested favorable initial outcomes with the MOJE prosthesis, all have focused only on the early results. In our series, the reoperation rate of 26% at up to 8 years is worryingly high, especially given that 16 (52%) showed loosening. Although there appears to be a cohort of patients who have satisfactory outcomes with the MOJE, we would suggest the continued use of this implant.

Resultados preliminares da prótese total metatarsofalângica METIS-Newdeal®

OBJETIVO: Avaliar os resultados preliminares da prótese METIS-Newdeal® como tratamento de hallux rigidus grau III/IV. MÉTODOS: Estudo prospectivo de oito próteses MTF colocadas em seis pacientes entre nov/2007 e jul/2009. A idade média foi de 55 anos e o tempo de seguimento após a cirurgia de 50 semanas. Na avaliação dos resultados foi utilizado o escore AOFAS-MTF e controle imageológico por radiografia. RESULTADOS: Verificou-se um aumento pontual significativo do escore AOFAS-MTF que passou de 42p pré-operatório para 82p após a cirurgia (↑1,95x), tendo sido ao nível da função o maior ganho. Radiologicamente não se identificaram intercorrências. Dos cinco pacientes operados, apenas um se mostrou descontente com a cirurgia, após o surgimento de infecção precoce no local cirúrgico, sendo que corresponde à única complicação pós-op encontrada. CONCLUSÃO: A artroplastia total metatarsofalângica METIS-Newdeal® apresenta resultados promissores no curto prazo. No entanto, é necessário avaliar um maior número de casos com um tempo de seguimento mais longo para que se possa obter conclusões mais consistentes.

PRELIMINARY RESULTS FROM THE METIS-NEWDEAL® TOTAL METATARSOPHALANGEAL PROSTHESIS

Objective: To evaluate the preliminary results from the METIS-Newdeal® metatarsophalangeal prosthesis for treating hallux rigidus grade III/IV. Methods: This was a prospective study on eight metatarsophalangeal prostheses that were placed in six patients between November 2007 and July 2009. The patients' mean age was 55 years and the mean follow-up after the surgery was 50 weeks. The results were evaluated using the AOFAS-MTP score and x-ray images as controls. Results: The AOFAS-MTP score increased significantly from 42p before the surgery to 82p after the surgery (↑ 1.95x), mainly due to improvement in the functional level. No intercurrences were identified radiologically. Among the five patients who underwent operations, only one expressed dissatisfaction with the surgery: this was expressed after early infection appeared at the surgical site, and it was the only postoperative complication found. Conclusion: Total metatarsophalangeal arthroplasty using METIS-Newdeal® presented promising short-term results. However, evaluations on a larger number of cases with a longer follow-up are needed in order to draw more consistent conclusions.

Opening first metatarsal osteotomy and resection arthroplasty of the first MPJ in the treatment of first ray insufficiency associated with degenerative hallux valgus

Opening wedge proximal metatarsal osteotomy combined with first metatarsophalangeal arthroplasty can be used to correct first metatarsus primus varus with a high intermetatarsal angle and a short first metatarsal. 147 feet in 138 patients with degenerative first metatarsophalangeal arthrosis, >or=15 degrees of metatarsus primus varus and, a short first metatarsal were included. Preoperative and postoperative clinical, radiographic, and subjective outcome measurements were taken (Scale AOFAS). The mean first intermetatarsal angle decrease was 7.79+/-1.43 degrees and the mean increase in first metatarsal length was 2.88+/-0.45 mm. The pre-intervention mean values were 52.6 points in the AOFAS scale, and an overall result of 92.95 obtained after surgery (P<0.001). The opening proximal first metatarsal osteotomy without internal fixation and with first metatarsophalangeal resection arthroplasty can correct severe hallux valgus with an intermetatarsal angle >or=15 degrees and a short first metatarsal, achieving low rate of complications.

Radiographic Analysis of Transverse Plane Digital Alignment After Surgical Repair of the Second Metatarsophalangeal Joint

We undertook a retrospective cohort study of 51 feet in 49 patients with surgically managed second metatarsophalangeal joint instability, including repair of the crossover second toe deformity. The fundamental intervention consisted of proximal interphalangeal joint arthrodesis combined with second metatarsophalangeal joint relocation and Kirschner-wire transfixation, and this was performed alone or in combination with one of the following additional surgical maneuvers: flexor tendon transfer or flexor set release, flexor plate repair, placement of a plantar-lateral retention suture, extensor tendon transfer, metatarsophalangeal arthroplasty, metatarsal osteotomy, or second-to-third syndactyly. The outcome of interest was the presence of a transverse plane second metatarsophalangeal joint angle of 0 degrees to 15 degrees measured on the late postoperative follow-up radiograph. Overall, the median angular correction for all second metatarsophalangeal joint interventions was 8 degrees , and second-to-third syndactyly yielded the most long-term correction followed by, in descending order of the amount of angular correction, use of the fundamental intervention in combination with metatarsophalangeal joint arthroplasty, placement of a plantar-lateral anchor suture in the flexor plate, metatarsal osteotomy, flexor tendon transfer, flexor plate repair, extensor tendon transfer, and the fundamental intervention as a solitary procedure. A sensitivity analysis indicated that our results were resistant to the influence that an unmeasured variable would impart on the data. The results of this investigation should aid surgeons treating patients with unstable second metatarsophalangeal joints, and can be used in the development of future clinical trials and observational studies that focus on the management of this common deformity.

Second MTP Joint Capsular Instability With Clawing Deformity: Metatarsal Osteotomy, Flexor Transfer with Biotenodesis, Hammer Toe Repair, and MTP Arthroplasty Without the Need for Plantar Incisions

Capsular instability of the second metatarsophalangeal (MTP) joint (crossover second toe deformity) is a common source of forefoot pain and often but is not always associated with deformity. Various methods of surgical treatment have been described, each with its own success and limitations. A biomechanical approach to stabilization of the second metatarsophalangeal joint often includes a flexor tendon transfer, and the results of treatment with this method have been well documented. Persistent pain after stabilization in a patient without inflammatory arthritis may be indicative of concurrent interdigital neuroma, persistent joint-related symptoms, residual tenderness related to the plantar incisions, or a combination. When the deformity is obvious (fixed clawing or hammering, MTP subluxation, and tender plantar callous), a combination of procedures is considered to provide relief of symptoms and realignment of the joint and digit. The purpose of this paper is to describe a rational approach to treatment based on the deformity while minimizing potentially painful incisions and dissection. A combination of second metatarsal capital oblique osteotomy, MTP joint arthroplasty with extensor lengthening and ligamentous/capsular repair, open hammer-toe repair, and flexor tendon transfer with biotenodesis screw fixation in the proximal phalanx is described.

Silastic metatarsophalangeal arthroplasty: Very long-term results of single-stem implants in degenerative joint disease

Concern over long-term outcomes in patients with silastic metatarsophalangeal (MTP) implants prompted an assessment of such patients. We reviewed 21 single-stemmed silastic metatarsophalangeal arthroplasties in 18 patients with a mean follow-up of 18 years 9 months. Eight operations were performed for hallux valgus (HV) and 13 for hallux rigidus (HR). Patients were assessed by clinical scoring, patient satisfaction and radiographic grading. Patients treated for HR achieved higher clinical scores than those treated for HV. This difference was statistically significant. There was no correlation between radiographic appearance and clinical score, patient satisfaction or time since implantation. Long-term changes to the bone stock did not cause clinical detriment, and in no case was late revision surgery necessary. Very long-term results have not previously been reported and in our review outcomes were surprisingly good particularly in the surgical treatment of HR in the over 50 age group.

Infection after Total Joint Arthroplasty from Distal Extremity Sepsis

At the UCLA Medical Center in three patients treated for hematogenous infection after total joint arthroplasty, the source was apparently an infection in the extremities at a site distal to the joint arthroplasty. In a 72-year-old woman with rheumatoid arthritis infection developed in the right hip after total hip arthroplasty following a Staphylococcus aureus infection at the site of a left metatarsophalangeal arthroplasty. In a 64-year-old man with osteoarthritis the staphylococcal infection that developed after right total hip arthroplasty was seeded from a pyarthrosis of the right knee. In a 61-year-old woman with rheumatoid arthritis the sites of bilateral knee arthroplasties were seeded from a soft tissue infection of the left foot. These cases illustrate the potential for infection from local wound sepsis distal to joint arthroplasty. Such infections, particularly in patients with rheumatoid arthritis, should be treated aggressively to avoid seeding of the more proximal total joint arthroplasty site.