Long-term outcome of first metatarsophalangeal joint fusion in the treatment of severe hallux rigidus. Int Orthop. 2016;40:2401-2408. [PMID: 27542800 DOI: 10.1007/s00264-016-3277-1]

Percutaneous hallux fusion with calcaneus bone autograft: a retrospective cohort study of clinical and radiographic outcomes

BACKGROUND

In the case of end-stage hallux rigidus, first metatarsophalangeal (MTP) joint arthrodesis is the gold-standard and is traditionally performed via an open approach. However, complications such as nonunion have been reported to be as high as 30%. Recently, there have been reports demonstrating a percutaneous approach to be effective and safe.

METHODS

Forty-nine patients with end-stage hallux rigidus underwent percutaneous first MTP joint arthrodesis with calcaneus autograft performed by a single surgeon. Each patient underwent a minimum of 24 month clinical and radiographic follow up, including 3 month post operative computed tomography scans. Clinical outcomes were assessed using the Visual Analog Scale (VAS) and Foot Function Index (FFI) preoperatively and at final follow-up.

RESULTS

Mean follow-up was 27.3 months. Bone union was observed in 46 patients (93.9%). Mean time to union was 3.1 months. Nonunion rate was 6.1%. Overall complication rate was 12.2%. Mean pre- and postoperative VAS scores were 7.5 and 0.2, respectively (P < .0001). Mean pre- and postoperative total FFI values were 56.3 and 15.7 (P < .0001), respectively. Patient satisfaction after the procedure was 93.9%.

CONCLUSION

Observed union rate is comparable to the average fusion rate previously reported for open and minimally invasive procedure union rates. Mean time to union was observed to be comparable to open procedures union time. Observed overall complication rate is similar to those reported for open techniques as well. Patient reported outcomes demonstrated a significant reduction in postoperative VAS and FFI for the percutaneous metatarsophalangeal arthrodesis with calcaneus bone autograft. Patient satisfaction rates compared favorably to those reported following open surgery.

LEVEL OF EVIDENCE

LEVEL IV

The Outcome of the Use of Continuous Action Compression Device for the First Metatarsophalangeal Joint Fusion

INTRODUCTION

First metatarsophalangeal (MTP) joint fusion is a widely accepted surgical intervention for treating severe arthritis, deformities, and instability of the first MTP joint. This paper provides a review of a single surgeon's experience with continuous compression implants (CCI), which offer a notable advantage by providing uniform compression across a larger surface area of the fusion site compared to plate and screw constructs. This design potentially reduces soft tissue irritation and, consequently, the need for subsequent implant removal. It also saves on cost and has the potential to reduce the length of surgery.

METHODS

 A retrospective review was conducted on 27 patients (n=36 feet) who underwent primary first metatarsophalangeal joint (MTPJ) fusion using continuous compression implants (CCI) between March 2020 and April 2024 at Bradford Royal Infirmary. Patient data were collected from the surgeon's logbook and medical records. The outcomes analyzed included the fusion rate and complications. Statistical analysis was performed using SPSS version 22.0, with p<0.05 considered significant.

RESULTS

 The mean age of the cohort was 60.24 years (range 41-90), with 88.88% female. The ratio of left to right was 70%. The mean follow-up duration was 27 months (range 6-48 months). Complete fusion of the first MTPJ was achieved in 34 out of 36 feet (94.4%). Nonunion occurred in one patient, while delayed union was observed in another. Clinically, 35 out of 36 patients (97.3%) reported satisfaction with the procedure, with one patient requiring metalwork removal and revision due to loosening.

CONCLUSION

Early results show that the rate of fusion achieved by using the CCI for the first MTPJ arthrodesis in our series was comparable to that of other devices quoted in the literature.

Effect of Prior Cheilectomy on Outcomes of First Metatarsophalangeal Joint Fusion

Cheilectomy, a joint-conserving procedure, is often a first-line choice for treating early stages of hallux rigidus. Recent evidence has revealed its efficacy in treating more advanced stages. However, when degeneration is profound, first metatarsophalangeal (MTP) fusion remains the most appropriate strategy. Nevertheless, it is common for surgeons to proceed initially with cheilectomy, reserving joint fusion for subsequent considerations if cheilectomy fails. This article will explore the relationship between the 2 procedures and evaluate the research surrounding the effect of prior cheilectomy on first MTP joint arthrodesis.

Sagittal Plane Alignment for First Metatarsal Phalangeal Arthrodesis Correlated with Postoperative Function: What is the Optimal Position?

There have been many reports describing the proposed alignment of a first metatarsal phalangeal arthrodesis to obtain optimum function. Most of these recommendations are based upon historical and anecdotal evidence. Furthermore, there are few reports directly comparing alignment to patient reported function. We studied radiographic sagittal plane alignment in a group of 60 patients (80 feet) who had undergone a first metatarsal phalangeal joint arthrodesis (20 of the 60 had bilateral arthrodesis) to better understand how this component of the arthrodesis position translates to real world function. The patients in this study had completed a functional survey in 2022 at a mean of 28.4 (median 27.8; range 13.2-45.7) months with very high satisfaction for return to activities of daily living and recreational sports. We measured the sagittal plane position of the first metatarsal relative to the proximal phalanx in this cohort with known post operative activity data. We found that a mean (standard of deviation) sagittal plane angle (angle between the anatomic axis of the first metatarsal and the proximal phalanx) of 15.4 (SD 7.4) degrees and a proximal phalanx head to ground height of 12.7 (SD 3.3) mm was present in this group. Comparing the functional and positional results we conclude that this sagittal plane position provides a good recommendation for alignment.

Arthrodesis for Hallux Rigidus

First metatarsophalangeal (MTP) joint fusion, or arthrodesis, has been a cornerstone treatment for advanced joint degeneration since the 1950s, benefiting not only older patients but also younger individuals. The procedure boasts favorable long-term outcomes and a low rate of revision when fusion is successful. However, complications such as interphalangeal arthritis may occur, and nonunion or malunion can necessitate revision. While the first MTP fusion provides significant relief, its applicability varies, underscoring the need for careful patient selection.

Primary Isolated Arthrodesis of the First Metatarsophalangeal Joint for Hallux Rigidus: Clinical, Radiologic, and Pedobarographic Evaluation

Background

Arthrodesis of the first metatarsophalangeal joint is an effective treatment of advanced hallux rigidus. Numerous options have been described for performing this intervention. The aim of this study was to evaluate the outcomes following a consistent surgical technique of joint preparation with hand tools and fixation with 2 crossed screws and a dorsal compression plate.

Methods

Thirteen patients (16 feet) who underwent primary isolated arthrodesis of the first metatarsophalangeal joint between March 2019 and June 2021 were available for clinical, radiologic, and pedobarographic evaluation at a minimum of 12 months after surgery. American Orthopaedic Foot & Ankle Society scores, numerical pain rating scale, the radiologic hallux valgus and intermetatarsal 1-2 angles as well as the distribution of plantar pressure during gait were compared between the pre- and postoperative conditions.

Results

After an average follow-up period of 26 months, union was achieved in all cases and the mean AOFAS score raised significantly by 39 points. All the patients were satisfied with the result. Only 1 patient complained of mild residual pain at walk. Hardware removal was performed in 2 cases. The mean hallux valgus angle dropped from 12.3 to 6.3 degrees. The mean postoperative dorsiflexion angle was 21.6 degrees. After the procedure, peak pressure was significantly higher beneath the first metatarsal head and heel, whereas pressure-time integral was significantly lower beneath the hallux and medial lesser toes.

Conclusion

Arthrodesis of the first metatarsophalangeal joint with 2 crossed screws and a dorsal compression plate is a safe and effective treatment of advanced hallux rigidus. This procedure provides adequate pain relief and functional improvement of gait.

Level of Evidence

Level IV, therapeutic, retrospective case series.

Arthrodesis vs arthroplasty for moderate and severe Hallux rigidus: Systematic review

Hallux rigidus is the most frequent arthritis of the foot, due to multiple factors. Arthrodesis and interposition arthroplasty are treatments considered in advanced stages of the disease, when conservative treatment has failed. Although arthrodesis may be considered the technique recommended by multiple authors, for patients in whom joint mobility is to be preserved, arthroplasty could represent a reliable alternative. The purpose of this systematic review is to investigate and compare the clinical outcomes and complications of arthrodesis and interposition arthroplasty for moderate and severe stages of hallux rigidus.

METHODS

For this systematic review we searched COCHRANE, EMBASE, PUBMED databases. Twenty-six research papers were obtained, with a total of 1348 feet, which were included for qualitative analysis. The following groups were included: Cartiva hemiarthroplasty (286), double stem silicone arthroplasty (276), total metallic arthroplasty (394) and arthrodesis (392).

RESULTS

In the arthrodesis group, the AOFAS-HMI score was the most used, ranging from 36 to 45 in the preoperative period and from 79 to 89 in the postoperative period. The greatest improvement in the VAS PAIN score was from 86 to 4. The fusion rate was 98.6% of the total number of cases, the most frequent complication was pain due to material discomfort. In the total metallic arthroplasty group, the ROTO-GLIDE system reported an AOFAS score of 95 points, with low complication rates; but, with the TOEFIT-PLUS and BIOMED-MERCK systems, despite the good postoperative value, they report 37% and 15% revision due to aseptic loosening in the series with the longest follow-up, respectively. The Cartiva group showed a significative increase in FAAM ADL and FAAM SPORT from 59.4 to 90.4 and from 60.9 to 89.7, respectively; similarly, 20.5% implant removal and conversion to arthrodesis were reported. Finally, the double stem silicone arthroplasty group, in the series with the longest follow-up, it manages to improve the MOXFQ score from 78.1 to 11.0, with an average range of mobility of 22.3 degrees. Lysis was reported in 10% of cases.

CONCLUSIONS

Arthrodesis has proven to be the best option for the treatment of advanced hallux rigidus. Arthroplasty can be a valid option for patients who demand to maintain the range of mobility of the joint; however, it is important to inform about the complications that may arise in the short and medium term.

LEVEL OF CLINICAL EVIDENCE

II.

Ten-Year Minimum Follow-up Study of First Metatarsophalangeal Joint Fusion in Young vs Old Patients

BACKGROUND

Painful degenerative joint disease (DJD) of the first metatarsophalangeal joint (MTP I), or hallux rigidus, mainly occurs in later stages of life. For end-stage hallux rigidus, MTP I arthrodesis is considered the gold standard. As young and active patients are affected considerably less frequently, it currently remains unclear, whether they benefit to the same extent. We hypothesized that MTP I arthrodesis in younger patients would lead to an inferior outcome with decreased rates of overall with lower rates of patient postoperative pain and function compared to an older cohort.

METHODS

All patients aged <50 years who underwent MTP I arthrodesis at our institution between 1995 and 2012 were included in this study. This group was then matched and compared with a group of patients aged >60 years. Minimum follow-up was 10 years. Outcome measures were Tegner activity score (TAS), a "Virtual Tegner activity score" (VTAS), the visual analog scale (VAS), and the Foot Function index (FFI).

RESULTS

Sixty-one MTP I fusions (n = 28 young, n = 33 old) in 46 patients were included in our study at an average of 14 years after surgery. Younger patients experienced significantly more pain relief as reflected by changes in VAS and FFI Pain subscale scores. No difference in functional outcomes was found with change in the FFI function subscale or in the ability to have desired functional outcomes using the ratio of TAS to VTAS. Revision rate did not differ between the two groups apart from hardware removal, which was significantly more likely in the younger group.

CONCLUSION

In patients below the age of 50 years with end-stage DJD of the first metatarsal joint, MTP I arthrodesis not only yielded highly satisfactory postoperative results at least equal outcome compared to an older cohort of patients aged >60 years at an average 14 years' follow-up. Based on these findings, we consider first metatarsal joint fusion even for young patients is a valid option to treat end-stage hallux rigidus.

LEVEL OF EVIDENCE

Level III, a case-control study.

Patient Satisfaction Following Hallux Rigidus Treatment With a Synthetic Cartilage Implant

BACKGROUND

There remains no clear consensus on patient satisfaction and functional outcomes following synthetic cartilage implant (SCI) implantation for hallux rigidus. The purpose of this study was to review our experience at a single academic institution using an SCI for treatment of hallux rigidus.

METHODS

A retrospective review was performed of patients who underwent the SCI procedure for treatment of hallux rigidus between January 2017 and May 2019. Functional outcomes were evaluated using Patient-Reported Outcome Measures Informational System (PROMIS)-10 scores as well as a survey investigating patient satisfaction, self-reported clinical improvement, and changes in sporting ability. Patients were divided into satisfied versus unsatisfied subgroups, and between-group differences in preoperative variables and complications were reviewed. A total of 90 patients (96 implants) were included in this study. The mean follow-up time was 26.4 months.

RESULTS

In all, 81.2% of patients reported that their foot was "much improved" (55.2%) or "improved" (26.0%) since undergoing the SCI procedure, whereas a slightly lower percentage, 74.0%, stated that they were "extremely satisfied" (41.7%) or "satisfied" (32.3%) at final follow-up. Patients were able to tolerate higher impact sporting activities after the procedure, and 75.0% of patients stated they would have the same surgery again. PROMIS-10 T-scores averaged 54.2 points for physical health and 57.4 points for mental health. Only 2.1% of patients required conversion to arthrodesis. Significant differences between the satisfied versus unsatisfied subgroups were found in preoperative corticosteroid injection use (21.1% vs 41.1%, respectively; P = .029) and preoperative VAS pain score (8.2 vs 7.1, respectively; P = .036).

CONCLUSION

The SCI procedure can be a viable option for treating hallux rigidus with high satisfaction overall, increased sport activity levels, and a very low revision rate. However, maximizing patient satisfaction may require more careful consideration of preoperative prognosticators and extensive patient counseling to ensure realistic expectations for recovery time and individual outcome.

LEVEL OF EVIDENCE

Level IV: Retrospective case series.

Gait and dynamic pedobarographic analyses in hallux rigidus patients treated with Keller's arthroplasty, arthrodesis or cheilectomy 22 years after surgery

Background

Keller's arthroplasty, arthrodesis and cheilectomy are well-known surgical interventions for hallux rigidus. This study aimed to evaluate the effects of these surgical interventions on gait, plantar pressure distribution and clinical outcome in patients treated for hallux rigidus 22 years after surgery.

Methods

Spatio-temporal gait parameters and plantar pressure distribution, determined as pressure time integrals (PTIs) and peak pressures (PPs), were analyzed using a 7-foot tone analysis model. Patient-reported outcome was assessed using the Manchester-Oxford Foot Questionnaire (MOXFQ). Of the 73 patients (89 feet) from the original study, 27 patients (33 feet) and 13 healthy controls (26 feet) were available for evaluation 22 years after hallux rigidus surgery.

Results

Spatio-temporal gait parameters were comparable between all groups and were in line with healthy controls (P > 0.05). No differences (P > 0.05) in PTIs and PPs were found in the seven plantar zones between groups and as compared to healthy controls. MOXFQ scores in all domains (walking/standing, range 21.4-24.1; pain, range 16.5-22.2 and social interaction, range 23.8-35.4) were not clinically and statistically different (P > 0.05) between the three different surgical interventions.

Conclusion

These results suggest no long-term functional and biomechanical differences after these surgical interventions for hallux rigidus correction. The interventions seem to be appropriate treatment options for a selective group of patients with symptomatic hallux rigidus.

Evaluating the Biomechanical Integrity of Various Constructs Utilized for First Metatarsophalangeal Joint Arthrodesis: A Systematic Review

The first metatarsophalangeal (MTP) joint is a frequently loaded joint, handling loads up to 90% of bodyweight. First MTP arthrodesis is a frequently performed procedure designed to improve pain in patients with degenerative MTP joint disease. There are a wide variety of fixation constructs for this procedure without consensus on the most effective method. The purpose of this study was to compare the biomechanical integrity of various constructs utilized for first MTP arthrodesis. A systematic review of the literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, CINAHL, MEDLINE, and Web of Science databases were searched from inception to 18 June 2023. Articles discussing the biomechanics of first MTP arthrodesis constructs were included. A total of 168 articles were retrieved. A total of 20 articles involving 446 cadaveric and synthetic bone constructs were included in the final review. Of the six articles comparing dorsal plating with compression screws to crossed interfragmentary screws, five found that dorsal plating had significantly higher stiffness. All three studies assessing shape-memory staples found them to be significantly less stable than crossed screws or dorsal plates alone. Both studies evaluating fully threaded screws found them to be stronger than crossed cancellous screws. Wedge resections have been shown to be 10 times stronger than standard planar or conical excision. Dorsal plating with compression screws is the gold standard for MTP arthrodesis. However, more research into newer methods such as fully threaded screws and wedge resections with an increased focus on translation to clinical outcomes is needed.

Association of First Metatarsal Phalangeal Joint Fusion for Hallux Rigidus With Patient-Reported Pain and Mental Health Outcomes in Patients Taking Psychotropic Medications

Background:

Limited literature examines the relationship between surgical outcomes in chronic foot and ankle conditions and concurrent psychiatric care. The present study aimed to investigate patient-reported and surgical outcomes of patients treated for a psychiatric disorder undergoing first metatarsophalangeal (MTP) fusion for hallux rigidus. We hypothesized that patients on psychotropic medications would have greater subjective pain preoperatively and less improvement in physical and mental functionality postoperatively when compared with nonmedicated patients.

Methods:

A single-center, retrospective review of prospectively collected data was conducted on 92 patients undergoing first MTP fusion with a preoperative diagnosis of hallux rigidus from 2015 to 2019. At their preoperative, 6-month postoperative, and 1-year postoperative visits, patients were administered visual analog pain scale (VAS) and 36-Item Short Form Health Survey (SF-36) functionality surveys. Patients were subsequently identified by chronic use of psychotropic medication preoperatively and grouped for analysis (MED, n = 42; NO MED, n = 50).

Results:

Postoperative mean VAS pain scores were lower for all studied patients at 6 months (VAS = 1.6 ± 2.3) and 1 year postoperatively (VAS = 1.1± 1.8) relative to the preoperative visit (VAS = 4.7 ± 2.8) (P ≤ .0001 and P ≤ .0001, respectively). No differences in mean VAS pain scores nor SF-36 physical component summary scores were detected at preoperative, 6-month, or 1-year visits between NO MED and MED groups. Mean SF-36 mental component summary scores for those in the MED group were lower at preoperative (NO MED = 83.8, MED = 71.8, P = .006) and 6-month postoperative (NO MED = 86.1, MED = 72.7, P = .037) visits than those in the NO MED group, a trend not observed at the 1-year postoperative mark (NO MED = 84.1, MED = 76.8, P = .228). There were no observed differences in operative time (P = .219), tourniquet time (P = .359), nor time to full weightbearing (P = .512) between MED and NO MED groups. Additionally, no differences in postoperative complication rates were observed between groups.

Conclusion:

In patients treated with psychotropically active medications with hallux rigidus, MTP Fusion appears to be a reasonable treatment choice with similar outcomes for patients requiring psychotropically active medications to the outcomes of those patients not requiring psychotropically active medications.

Level of Evidence:

Level III, retrospective comparative study.

First metatarsophalangeal arthrodesis outcomes for hallux rigidus versus hallux valgus

BACKGROUND

This study compared radiographic and functional patient outcomes of 1st MTP arthrodesis between hallux rigidus (HR) and hallux valgus (HV) cohorts.

METHODS

A retrospective review was conducted at an academic medical center on patients who underwent 1st MTP arthrodesis during 2009-2021. In total, 136 patients (148 feet: HR=57, HV=47, combined=44) met the inclusion criteria of minimum three-month follow-up (mean=1.25 years, range=0.25-6.14 years). Data collection included patient-reported outcome measures (PROMs), radiographic markers, and complication and reoperation rates.

RESULTS

PROMs improved overall, with HV patients significantly improving the least. The HR group had a significantly smaller improvement in HV angle (HR=-3.6, HV=-17, Combined=-15 p < .001), intermetatarsal angle (H=-0.16, HV=-2.8, Combined=-2.6 p < .001), and 1st-5th metatarsal width (HR=-0.98, HV=-4.6, Combined=-4.6, p < .001). Complication and reoperation rates did not differ by group.

CONCLUSION

Outcomes of 1st MTP arthrodesis does not appear to differ between diagnostic indications of hallux rigidus, hallux valgus, or both.

LEVEL OF EVIDENCE

Level III, Retrospective cohort study.

Interposition arthroplasty with bovine collagenous membrane for hallux rigidus: A long-term results retrospective study

BACKGROUND

Hallux rigidus (HR) is a degenerative arthritis of the first metatarsophalangeal joint (MTP1) with progressive loss of range of movement (ROM). Interposition arthroplasty (IA) is a technique widely used for the treatment of HR;however, few studies reported long-term clinical results. This study aims to report the clinical results of IA using a bovine pericardium collagen matrix for HR with a minimum 10-years follow-up.

METHODS

Thirty patients (31 feet) who underwent IA using a bovine pericardium collagen matrix from 2001 to 2009 were retrospectively evaluated with a mean follow up of 154.1 ± 28.6 (range 124-218) months. All HR ranged from grade II to grade III, according to Regnauld classification. All patients were clinically assessed with the American Orthopedic Foot and Ankle Society Hallux Metatarsophalangeal- Interphalangeal Scale, a pain Visual Analog Scale, and the Foot and Ankle Disability Index. Scores before and after treatment, respectively achieved from clinical records and clinical evaluation at final follow-up were compared.

RESULTS

At final follow-up, an improvement of all the considered scores (p < 0.01) was recorded. The overall rate of unsatisfying results was 16.1 %. Two (6.4 %) patients complained discomfort due to first ray shortening and 3 (9.7 %) cases of persistent metatarsal pain. There was one (3.2 %) case of Complex Regional Pain Syndrome (CPRS). No revision surgeries, infection, or other adverse events were reported.

CONCLUSION

Interposition arthroplasty using bovine collagenous membrane is a reliable solution for high-grade HR with durable results over 10 years in more than 80 % of patients.

Retrospective Comparison of Two Different Fixation Methods for First Metatarsophalangeal Joint Arthrodesis

Background and Purpose: Arthrosis of the first MTP joint is a common condition. Among the available arthrodesis methods, plate/screw and screw methods are the current treatment methods of choice. In this study, we investigate whether there is a difference between these two methods. Methods: Thirty-four toes of 32 patients with advanced arthrosis were included in the study. Eighteen toes were fixed with plates/screws and 16 with cross-screws. In the radiological evaluations, malunion and nonunion were examined. Clinical evaluation was made according to AOFAS-HMI scoring. Results: The mean age of the patients was 57.74 years and the mean follow-up period was 22.21 months. There was no statistically significant difference in clinical scores or union times between the two groups. As complications, superficial skin problems developed in 2 (5.9%) cases, deep infection in 3 (8.8%) cases, and nonunion in 3 (8.8%) cases. There was no statistically significant difference between the two groups in this regard. Conclusion: Plate/screw and cross-screw techniques give similar clinical and radiological results in cases of arthrodesis of the first MTP joint. The cross-screw technique, which can be performed more easily and has lower costs, should be the first choice.

Clinical and Radiologic Outcome of First Metatarsophalangeal Joint Arthrodesis Using a Human Allogeneic Cortical Bone Screw

Background:

Different fixation techniques are established for first metatarsophalangeal joint (MTPJ) arthrodesis, including compression screws, plates, Kirschner wires, metal- and bioabsorbable screws as well as staples. The purpose of this study was to investigate and present first clinical and radiologic results using a novel human, allogeneic cortical bone screw for arthrodesis of the first MTPJ.

Methods:

Arthrodesis of the first MTPJ was performed in 31 patients with hallux rigidus. Percentage union and time to union were the first outcomes; visual analog scale for pain, hallux valgus angle (HVA), intermetatarsal angle, and American Orthopaedic Foot & Ankle Society (AOFAS) hallux score were secondary outcomes.

Results:

Median time to union was 89 days, and union was observed in all patients. There were 4 complications (2 osteolysis margin, 1 cystic brightening, and 1 severe swelling at the first follow-up) all of that resolved at last follow-up. Pain significantly decreased from visual analog scale 8.0 to 0.2 points ( P < .0001). The HVA decreased from 30.4 to 10.2 degrees in the patient group with deformities. The total AOFAS score increased significantly from 48 to 87 ( P < .0001).

Conclusion:

Primary and revision arthrodesis of hallux rigidus with the human, allogeneic cortical bone screw reveals satisfying results similar to clinical and radiologic outcomes of other surgical techniques. Within 1 year, the human, allogeneic cortical bone screw is fully remodeled to host bone.

Level of Evidence:

Level IV, retrospective case series without control group.

Complications of Hallux Rigidus Surgery

Hallux rigidus can be treated with a variety of surgical procedures, including joint preserving techniques, arthrodesis, and arthroplasty. The most commonly reported complications for joint preserving techniques consist of progression of arthritis, continued pain, and transfer metatarsalgia. Although good outcomes have been reported for arthrodesis overall, careful attention must be paid to technique and positioning of the toe to avoid nonunion or malunion. Arthroplasty preserves motion but in the case of failure can present the additional challenge of bone loss. In these scenarios, the authors recommend distraction bone block arthrodesis with structural autograft.

Metallic hemiarthroplasty or arthrodesis of the first metatarsophalangeal joint as treatment for hallux rigidus: A systematic review and meta-analysis

BACKGROUND

Arthrodesis and metallic hemiarthroplasty are two surgical interventions for the treatment of end-stage osteoarthritis of the first metatarsophalangeal (MTP1) joint. This systematic review and meta-analysis aims to compare the two operations with regards to patient-reported outcomes, pain reduction, complications and revision rates.

METHODS

A systematic literature search identified all relevant studies. The methodological quality was assessed using two validated tools. Data of interest were derived and presented. For non-comparative studies, data was assessed for trends, while for comparative studies pooling statistics were performed.

RESULTS

A total of 33 studies were included for analysis. The majority of studies (>75%) reported an AOFAS-HMI score greater than 80 points after both metallic hemiarthroplasty and arthrodesis. The lowest VAS pain score was observed after arthrodesis (weighted mean difference -1.58, 95% confidence interval (CI) -2.16 to -1.00 P< 0.00001). Comparable numbers of complications (odds radio 1.48, 95% CI 0.81 to 2.73, P = 0.21, favoring: hemiarthroplasty) and revisions (odds ratio 1.16, 95% CI 0.62 to 2.15 P = 0.64, favoring: hemiarthroplasty) were observed after both interventions. The included non-comparative studies seem to confirm these findings of the comparative studies.

CONCLUSION

Metallic hemiarthroplasty and arthrodesis have excellent clinical outcomes and acceptable complication- and revision rates. Arthrodesis seems to be superior in pain reduction, while metallic hemiarthroplasty is a suitable alternative for patients performing activities that requires motion in the first metatarsophalangeal joint.

Crossed Screw Fixation Versus Dorsal Plating for First Metatarsophalangeal Joint Arthrodesis: A Retrospective Cohort Study

Multiple fixation techniques for first metatarsophalangeal joint arthrodesis have been described with an average fusion rate of 93.5%. This retrospective cohort study assesses the association between crossed screws (vs dorsal plating) and medical comorbidities and the outcome radiographic union. Bivariate tests of association and multivariable logistic regression were employed to assess differences across fixation type and outcomes. We identified 305 patients who underwent a first metatarsophalangeal joint arthrodesis during the study period. Crossed screw fixation was used in 158 (51.8%) patients while dorsal plating (tubular or anatomic locking plate) was used in 147 (48.2%) patients. Dorsal plating was utilized more often in patients with rheumatoid arthritis (p = .019) and history of smoking (p = .044). At 12 weeks post-operatively there were no significant differences in fusion rates between the two groups (crossed screw group = 95.3% vs dorsal plate group (referent) = 93.5%, Adjusted odds ratio (AOR) 1.39, 95% confidence interval [CI] 0.45-4.26). Not smoking was associated with a greater odds of fusion at 12 weeks (96.2% for nonsmokers vs 75.0% for smokers (referent), AOR 0.07, 95% CI 0.02-0.28). Lower body mass index was associated with a greater odds of fusion at 12 weeks (AOR 0.90, 95% CI 0.82-0.99). Surgeons allowed weightbearing earlier with dorsal plate fixation (2 weeks (interquartile range [IQR] 2.6) versus 5 weeks (IQR 2.6) for crossed screw fixation, p = .001). Patients with multiple medical comorbidities were more likely to require revision surgery than patients having 0-1 comorbidities (p < .05). Crossed screws can provide an inexpensive yet effective option for first metatarsophalangeal joint arthrodesis.

Management of Periprosthetic Polyvinyl Alcohol Synthetic Cartilage Implant Infection with Staged First Metatarsophalangeal Joint Arthrodesis

Surgical management of hallux rigidus using a polyvinyl alcohol synthetic cartilage implant has gained popularity among foot and ankle surgeons. Although uncommon, appropriate diagnosis and management of a periprosthetic implant infection is critical in limiting morbidity. We present a case report and staged technique for converting a first metatarsal synthetic cartilage hemiarthroplasty to arthrodesis in the setting of a periprosthetic joint infection.

A systematic review of total arthroplasty and arthrodesis for end-stage hallux rigidus: A biomechanical perspective

BACKGROUND

Both arthrodesis and total arthroplasty are acceptable surgical options for end stage hallux rigidus without significant angular deformity. Total arthroplasty preserves first metatarsophalangeal joint (MTPJ) motion, which may help restore a more physiological gait pattern.

RESEARCH QUESTION

Is there a difference in the findings of gait studies after 1st MTPJ total arthroplasty or arthrodesis for end-stage hallux rigidus?

METHODS

PRISMA guidelines were followed to conduct a systematic review of literature for studies reporting gait analysis after the above procedures. Predetermined criteria were used to select papers and evaluated the findings of kinematic (spatial-temporal and dynamic motion), kinetic and foot pressure (pedobarographic) studies.

RESULTS

12 titles were short-listed for synthesis. There was 1 randomized controlled trial comparing the two procedures. Among the remaining cohort studies, 5 reported on total arthroplasty and 6 on arthrodesis of the 1st MTPJ. Due to significant heterogeneity, a narrative synthesis was undertaken. No studies in the arthroplasty group reported spatial-temporal or kinetic parameters. Only 2 papers, 1 in each group, recorded motion within the foot. One of them showed preserved dynamic motion at the 1st MTPJ after total arthroplasty. Pedobarographic studies had discordant findings in studies within both groups regarding restoration of weight bearing through the medial forefoot and the pulp of the great toe during gait.

CONCLUSION

Currently available studies are heterogenous and report inconsistent findings, which do not convincingly answer our research question. Prospective comparative studies with a large sample size, using standardized methodology in accredited laboratories with detailed reporting of kinetic, kinematic and pedobarographic components of gait analysis are required in order to draw concrete conclusions.

Risk Factors for Nonunion After First Metatarsophalangeal Joint Arthrodesis With a Dorsal Locking Plate and Compression Screw Construct: Correction of Hallux Valgus Is Key

First metatarsophalangeal joint (MTPJ) arthrodesis is currently the gold standard technique for advanced hallux rigidus. This retrospective study aimed to identify the risk factors for nonunion after first MTPJ arthrodesis with a dorsal locking plate and compression screw construct. Between April 2014 and April 2019, 165 consecutive patients (28 men and 137 women; mean age, 60 (range, 28-84) years) who underwent 178 primary first MTPJ arthrodeses were retrospectively reviewed. All arthrodeses were performed using either a dorsal locking plate with an integrated compression screw (Anchorage CP plate, Stryker, n = 97) or a dorsal locking plate (Anchorage V2 plate, Stryker, n = 81) with a separate compression screw (4 mm cannulated ACE screw). Union was defined as bone bridging across the fusion site on at least 2 of the 3 standard foot radiographs (anteroposterior, lateral, oblique) and no MTPJ movement or pain during clinical examination. Potential risk factors for nonunion were analyzed with the use of univariate and multivariate analyses. The overall nonunion rate was 6.2% (11 of 178 cases). The risk factors identified in the univariate analysis included preoperative hallux valgus deformity, postoperative residual hallux valgus deformity, and diabetes (p < .05). Multivariate analysis confirmed that postoperative residual hallux valgus deformity (odds ratio 6.5; p= .015) and diabetes (odds ratio 7.4; p = .019) are independent risk factors for nonunion after first MTPJ arthrodesis. Diabetes is the most important independent risk factor for nonunion after first MTPJ arthrodesis with a dorsal locking plate and compression screw construct. A residual postoperative hallux valgus deformity is associated with a significantly increased risk for nonunion. It is therefore crucial to correct the hallux valgus deformity to a hallux valgus angle of less than 20°.

Modern approaches to the treatment of hallux rigidus

The number of patients with degenerative joint pathology is steadily increasing. Arthrosis of the 1st metatarsophalangeal joint (hallux rigidus) is no exception, it occurs in 20-35 % of young and working people who lead a mobile lifestyle and is manifested by a symptom complex, including pain and a significant restriction of the function of the entire lower limb. The leading cause of the pathology development is degenerative-dystrophic changes in the joint, leading to pain syndrome and restriction of movement. Today, there are a large number of treatment options, both conservative and surgical. The choice of a specific surgical intervention from the entire variety of options is a difficult task, it is strictly individual and requires consideration of various clinical manifestations of the disease and a number of other factors. So, if 10 years ago arthrodesis was considered a gold standard for the HR treatment, today most authors recommend organ-sparing treatment, in particular, shortening osteotomies of the metatarsal bone with a possible use of scaffolds for the regeneration of articular cartilage. The article analyzes the main results of the HR surgical treatment presented in the publications of national and foreign specialists. In some cases, our own recommendations on the choice of the method are suggested.

Complications Associated with the Surgical Management of Hallux Rigidus

Hallux rigidus is the most common arthritic pathology of the foot. This review article discusses the pathophysiology and common clinical presentation of hallux rigidus. Furthermore, we discuss multiple classification systems that categorize the arthritic process and guide management. Surgical interventions include cheilectomy, Moberg osteotomy, synthetic cartilage implants, interpositional arthroplasty, and arthrodesis. The common complications are reviewed, and the rates of these complications highlighted. Surgical options for hallux rigidus globally have successful outcomes with low rates of complications when done on appropriate patients.

Surgery Performed by Supervised Trainees Does not Affect Outcome in First Metatarsophalangeal Joint (MTPJ) Arthrodesis

First metatarsophalangeal joint (MTPJ) arthrodesis is an index procedure for orthopedic trainees in the United Kingdom. There is an absence of evidence as to the outcome of surgery when performed by supervised trainees. The aim of this study is to compare the incidence of fusion, complication rate and radiographic outcomes in first MTPJ arthrodesis performed by supervised orthopedic trainees with consultants. This is a retrospective cohort study of 117 patients undergoing first MTPJ arthrodesis from August 2015 to December 2017 in our institute for hallux valgus (HV) deformity with first MPTJ arthrosis or for hallux rigidus. Patients were followed to a minimum of 1-year postsurgery and were given an open appointment thereafter. In the hallux rigidus group, there was no significant difference between the complication rate (p = .477), incidence of fusion (p = .663), postoperatively HVA (p = .763), and postoperative intermetatarsal angle (p = .539) between trainees and consultants. There was a significant difference in mean tourniquet time (p = .563) between trainees and consultants. In the hallux valgus group, there was no significant difference in the complication rate (p = .519), incidence of fusion (p = .786), tourniquet time (p = .075), postoperative HVA (p = .423), and postoperative intermetatarsal angle (p = .143) between the trainees and consultants. This is the first MTPJ fusion series that demonstrates good results can be achieved by supervised trainees performing the procedure. This would suggest that first MTPJ arthrodesis remains an opportunity for trainees to continue learning to perform under supervision whilst ensuring no change in outcome for the patient.

Does the length of the plate affect the failure rate of hallux MTP joint arthrodesis for severe hallux valgus?

PURPOSE

The purpose of this study was to investigate the effect of the length of the dorsal locking plate on the failure rate of first MTP joint arthrodesis for severe hallux valgus deformities.

METHODS

A retrospective review was conducted for all patients who underwent first MTP joint arthrodesis using solely a specific locked plating system (Depuy-Synthes, Raynham, MA) for severe hallux valgus deformities between January 2014 to June 2017. Patients were divided into subgroups according to the length of the plate and the failure rate was investigated. Furthermore, radiographic parameters including intermetatarsal angle (IMA) and hallux valgus angle (HVA) were evaluated in weightbearing AP foot radiographs.

RESULTS

A total of 25 patients were included in this study. There were 16 (64%) patients in the medium-sized plate cohort and 9 (36%) patients in the small-sized plate cohort. We found a significant difference in the failure rate between the two groups; only 1 (6.25%) failure case occurred in the medium-sized plate cohort while 4 (44.44%) failure cases occurred in the small-sized plate cohort (P = .040, Odds ratio (OR) = 12.000, 95% Confidence Interval (CI) = 1.074, 134.110). The mean postoperative IMA and HVA were significantly improved in both cohorts. However, significant differences were found between the two cohorts in final follow-up IMA and HVA (P = .002 and P < .001, respectively).

CONCLUSIONS

For severe hallux valgus deformities, the use of longer plates to gain additional purchase in the diaphyseal bone may help mitigate the increased stresses placed on the fixation constructs for first MTP joint arthrodesis and decrease failure rate.

LEVEL OF EVIDENCE

Level III, case control study.

First Metatarsophalangeal Arthrodesis After Failed Distal Chevron Osteotomy for Hallux Valgus

BACKGROUND

The purpose of this study was to compare the clinical outcomes after first metatarsophalangeal (MTP) joint arthrodesis for hallux rigidus between patients who underwent primary arthrodesis and those who had had a prior surgery for hallux valgus.

METHODS

Our design was a retrospective cohort study comparing 29 patients who underwent primary arthrodesis (primary group) and 34 patients with hallux rigidus after hallux valgus surgery (secondary group). The clinical assessment included the American Orthopaedic Foot & Ankle Society (AOFAS) score and a visual analog scale (VAS) for pain. Radiological evaluation was also performed. Overall, the mean postoperative follow-up was 3.4 (range, 2-5) years.

RESULTS

At final follow-up, AOFAS and VAS pain scores significantly improved in both groups (P = .001). However, the mean AOFAS (P = .001) and VAS pain (P = .008) scores were significantly better in the primary group than in the secondary group. Radiologically, there were no significant differences between the groups in any angle after arthrodesis. Revision surgeries were not required in the primary group. In the secondary group, there was 1 revision due to deep infection, and 3 other patients required dorsal plate removal. Excluding plate removal, the Kaplan-Meier survival at 3 years was not significantly different between groups (P = .775).

CONCLUSION

Although arthrodesis of the first MTP joint was an effective procedure for hallux rigidus, the clinical outcomes in patients who had prior hallux valgus surgery were worse than those for patients who underwent primary surgery for hallux rigidus.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Clinical and radiological outcomes after arthrodesis of the first metatarsophalangeal joint

PURPOSE

The main aim of this study was to investigate the correlation between radiographic findings and clinical outcomes following the first metatarsophalangeal (MTP) joint arthrodesis.

METHODS

In a comparative retrospective study, on 46 patients (48 ft), the correlation between post-operative radiographic findings including hallux valgus angle (HVA) and first MTP dorsiflexion angle (MTPDA) and clinical outcomes including VAS pain, modified AOFAS hallux score, and FFI questionnaire were evaluated. Moreover, clinical outcomes were compared between cases with pre-operative diagnosis of first MTP inflammatory arthritis, hallux valgus, hallux varus, and grade 3 and 4 of hallux rigidus. The effect of first MTP arthrodesis on Meary's angle and intermetatarsal angle (IMA) were found out.

RESULTS

The mean age of the patients was 56.3 ± 9.1 (range, 29-69) years, including 42 (91.3%) females and 4 (8.7%) males. We had fusion rate of 97.9%, one asymptomatic nonunion case (2.1%). Totally, mean scores of modified AOFAS hallux score, FFI percentage, and VAS pain were 88.9 ± 12.6, 9.4 ± 16.5, and 1.23 ± 2.24, respectively. Hallux varus was associated with the most favourable outcomes; whereas, patients with first MTP arthritis got the worst outcome. Regression analysis test between clinical outcomes and HVA > 15° and first MTPDA >15° showed correlation coefficient of almost zero. No statistically significant differences were found between the clinical outcomes of grade 3 and 4 of hallux rigidus (p value of modified AOFAS hallux score, FFI percentage, and VAS pain: 0.879, 0.906, and 0.298, respectively). Mean of HVA and IMA reduction in 15 hallux valgus underwent first MTP fusion were 34.4° and 8.4°, respectively. Meary's angle increased about 4° with statistically significant difference (p value 0.001).

CONCLUSION

Patients with first MTP fusion > 15° in coronal and transverse plans could have acceptable clinical outcomes. The clinical outcome of first MTP arthrodesis for grade 3 hallux rigidus is comparable with grade 4. First MTP fusion would have positive effect on IMA and Meary's angle.

Outcomes of bilateral simultaneous hallux MTPJ fusion

BACKGROUND

Arthrodesis of the first metatarsophalangeal joint (MTPJ) is a frequently performed surgical procedure. Many patients have bilateral hallux MTPJ pathology requiring bilateral arthrodesis. There are concerns that bilateral simultaneous hallux surgery, under one anaesthetic, results in the patient being severely incapacitated in the early post-operative period. We hypothesize that bilateral simultaneous hallux MTPJ fusions does not compromise outcomes or the patients' post-operative comfort and rehabilitation and is cost and time effective.

METHODS

In this retrospective study, 16 patients who underwent bilateral simultaneous first MTPJ arthrodesis were compared to 16 patients who had unilateral MTPJ arthrodesis with regards to outcome, tolerance, cost and time effectiveness. Outcome measures were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux score and the Self-Reported Foot and Ankle questionnaire (SEFAS).

RESULTS

There was a significant improvement in the AOFAS scores post surgery in the bilateral group and according to the SEFAS grading, 14 patients (87.5%) had good or excellent outcome scores with 13 (81.25%) of these patients having excellent scores. This was comparable to the outcome scores in the unilateral group. Two patients developed non-unions bilaterally compared to one in the unilateral group. There is also a notable general cost saving and less time off work when bilateral fusions are done at the same setting.

CONCLUSION

Bilateral simultaneous hallux MTPJ arthrodesis is an effective, convenient and cost effective option for patients requiring MTPJ fusions for bilateral hallux pathology.

LEVEL OF EVIDENCE

Level 4.

Minimally invasive arthrodesis of the first metatarsophalangeal joint: A systematic literature review

AIM

Currently, cohort studies reported the use of minimally invasive arthrodesis of the first metatarsophalangeal joint (MTP I). The aim of this systematic literature review was to analyse clinical, radiological outcome and complications with this technique.

METHODS

A systemic literature search of the databases Google Scholar, PubMed, Scopus, EMBASE and Cochrane to identify studies reporting on clinical, radiological outcome or complications of minimally invasive MTP I arthrodesis was conducted.

RESULTS

A total of 6 studies (1 Level V, 5 Level IV) reporting on 109 minimally invasive MTP arthrodesis in 105 patients were included. Validated scores were reported in 103 cases. Clinical outcome improved in 57 cases from a mean of 36.9 to 82.6 points American Orthopedic Foot and Ankle Score (AOFAS) and in 46 cases from 38.7 to 18.4 points Manchester Oxford Foot Questionnaire (MOXFQ). Radiological fusion rate was 87% (n = 94 out of 109) achieved after 6-12 weeks. Overall complication rate was 11.9% (13 cases) leading to revision surgeries in 5.5% (6 cases). Most common complications Most common complications were symptomatic non-union (n = 6, 5.5%), asymptomatic non-union (n = 2, 1.8%) and subsequent interphalangeal joint arthritis (n = 2, 1.8%).

CONCLUSION

Minimally invasive MTP I arthrodesis is a promising technique with comparable clinical, radiological outcome and complication rates to open surgery in hallux rigidus and rigido-valgus. Future studies are needed providing higher level of evidence to prove the potential benefit of minimally invasive compared to open MTP I arthrodesis.

Analysis of the effects of arthrodesis of the hallux metatarsophalangeal joint on gait cycle: results of a GAITRite® treadmill test

INTRODUCTION

Approximately 80% of patients are satisfied with the outcome of arthrodesis of the hallux metatarsophalangeal (MTP) joint. The hypothesis of this study was that MTP arthrodesis does not influence the walking cycle. The aim of this study was to evaluate the effect of MTP arthrodesis on gait cycle and to measure the functional outcome of MTP arthrodesis after a minimum of two year follow-up.

METHOD

This was an observational prospective cohort study performed at a single centre that included 26 patients (32 ft) who underwent unilateral or bilateral MTP arthrodesis during the period 2004-2014. An X-ray assessment based on the American Orthopaedic Foot and Ankle Society score was performed pre-operatively and at the last follow-up (average follow-up duration 8.3 years). The walking cycle was analysed at the final follow-up using a GAITRite^® treadmill test.

RESULTS

Twenty unilateral and six bilateral MTP arthrodeses were included in this study. The average age of the patients was 70 years. No significant difference was found in the walking cycle between the operated and non-operated sides for unilaterally MTP arthrodesis. However, we observed a non-significant increase in the percentage of contact time after MTP arthrodesis (65% on the operated side vs. 63% on the non-operated side). We also observed a significant decrease in the average walking rate, and a decrease in walking speed, in cases of bilateral MTP arthrodesis compared with normal walking cycle data from a laboratory study.

CONCLUSIONS

MTP joint arthrodesis does not appear to have any effect on the walking cycle, but reduced patient pain and increased the walking distance. The patients reported satisfaction with the surgical outcomes and would recommend it to a relative with the same pathology.

Long-term Effects of Cheilectomy, Keller's Arthroplasty, and Arthrodesis for Symptomatic Hallux Rigidus on Patient-Reported and Radiologic Outcome

BACKGROUND

Several operative interventions are available to alleviate pain in hallux rigidus, and the optimal operative technique is still a topic of debate among surgeons. Three of these are arthrodesis, cheilectomy, and Keller's arthroplasty. Currently, it is unclear which intervention yields the best long-term result. The aim of this study was to assess which of these interventions performed best in terms of patient-reported outcome, pain scores, and disease recurrence at long-term follow-up.

METHODS

These data are the follow-up to the initial study published in 2006. In the original study, 73 patients (n = 89 toes) with symptomatic hallux rigidus were recruited and underwent first metatarsophalangeal joint arthrodesis (n = 33 toes), cheilectomy (n = 28 toes), or Keller's arthroplasty (n = 28 toes). Outcome measures were AOFAS hallux metatarsophalangeal-interphalangeal (HMI) score, and pain was assessed with a visual analog scale (VAS) at a mean follow-up period of 7 years. Patients of the original study were identified and invited to participate in the current study. Data were collected in the form of AOFAS-HMI score, VAS pain score, Manchester-Oxford Foot Questionnaire (MOXFQ), and Forgotten Joint Score (FJS-12). In addition, a clinical examination was performed and radiographs were obtained. Data were available for 37 patients (45 toes), with a mean follow-up period over 22 years.

RESULTS

AOFAS-HMI and VAS pain score improved during follow-up only in arthrodesis patients. Furthermore, no statistically significant differences in clinical and patient-reported outcome were detected between groups based on AOFAS-HMI, VAS pain, MOXFQ, or FJS-12. However, clinically important differences in patient-reported outcomes and pain scores were detected, favoring arthrodesis. Radiographic disease progression was more evident after cheilectomy compared with Keller's arthroplasty.

CONCLUSION

Arthrodesis, cheilectomy, and Keller's arthroplasty are 3 sucessful operative interventions to treat symptomatic hallux rigidus. Because clinically important differences were detected and symptoms still diminish many years after surgery, a slight preference was evident for arthrodesis.

LEVEL OF EVIDENCE

Level III, comparative study.

Is adjunction of advanced platelet-rich fibrin (A-PRF) useful in first metatarsophalangeal joint arthrodesis? A retrospective cohort study

PURPOSE

First metatarsophalangeal (MTPJ1) fusion represents the gold standard treatment for end-stage hallux rigidus (HR). The aim of this study was to assess efficacy and safety of A-PRF in promoting union after MTPJ1 arthrodesis. Our hypothesis was that the use of A-PRF may reduce the non-union rate and the time to fusion in the treatment of HR.

METHODS

14 patients that had undergone MTPJ1 arthrodesis with A-PRF adjunction with 21 standard MTPJ1 fusions were retrospectively reviewed. The fusion rate and time to fusion (clinically and radiographically) were assessed at 6, 12 weeks and at the longest follow-up; the clinical status at final follow-up through forefoot AOFAS, EQ5d, SEFAS and VAS-pain scores; the complication rate.

RESULTS

At 6-weeks, bony union was achieved in 100% of patients in the A-PRF group compared to 70% in the control group, but this difference was not statistically significant (p=0.22). At final follow-up (41 months), union rate in the control group reached 92% (one non-union). AOFAS, VAS and EQ-5d scores showed similar results for the two groups (p=0.86, p=0.12 and p=0.61, respectively); only SEFAS score revealed a difference favoring the A-PRF group (p=0.04). No revision surgery or complication was recorded in any group.

CONCLUSIONS

A tendency for increased union rate was mainly found at 6 weeks in patients treated with MTPJ1 fusion associated to A-PRF compared to isolated fusion. The use of A-PRF was not associated with an increased complication rate at final follow-up.

LEVEL OF EVIDENCE

Level 3, therapeutic study, retrospective comparative study.

Management of high-grade hallux rigidus: a narrative review of the literature

Hallux rigidus is a disease characterized by an osteoarthritic degeneration of the first metatarsophalangeal joint. Aetiology of hallux rigidus is not clear in the literature. History of trauma is considered one of the most common causes of unilateral hallux rigidus. Also, repetitive microtraumas or inflammatory and metabolic causes such as gout, rheumatoid arthritis and seronegative arthropathy can cause degeneration of the joint. The aim of this literature narrative overview is to summarize and expose the great amount of management concepts and information, including the well-codified main operative procedures to treat of hallux rigidus. This may provide current information for med-school students, researchers and physicians. A comprehensive literature search using PubMed database has been performed. The management for hallux rigidus can involve a variety of therapeutic interventions, conservative or operative. High-grade hallux rigidus represents a complex disease characterized by several clinical and pathological findings, and to achieve optimal results, surgical treatment should be chosen between several surgical techniques depending on the degree of arthritis and other different clinical conditions.

Biomechanical Comparison of Low-Profile Contoured Locking Plate With Single Compression Screw to Fully Threaded Compression Screws for First MTP Fusion

BACKGROUND

Open metatarsophalangeal (MTP) arthrodesis using locked plates produces good clinical outcomes. However, arthroscopic fusion with new-generation fully threaded compression screws is emerging as an alternative. The purpose of this study was to compare low-profile contoured locked plates with fully threaded compression screws for first MTP fusion, in a biomechanical cadaveric model.

METHODS

The first rays of 8 matched pairs of fresh frozen cadaveric feet underwent dissection and dual-energy x-ray absorptiometry (DEXA) scanning to measure bone mineral density (BMD). The "plate" group was prepared with cup-and-cone reamers, and fixation of the MTP joint with 1 compression screw and low-profile dorsal locked plate. The matched-pair "screws" group was prepared through a simulated arthroscopic technique, achieving fixation with 2 new-generation fully threaded compression screws. The plantar MTP gap was recorded with an extensometer during 250 000 90-N cyclic loads followed by a single load to failure.

RESULTS

The screw group demonstrated significantly greater stiffness, 31.6 N/mm (plates) and 51.7 N/mm (screws) (P = .0045). There was no significant difference in plantar gapping or load to failure, 198.6 N (plates) and 290.1 N (screws) (P = .2226). Stiffness and load to failure were highly correlated to BMD for the screw group, r =0.79 and r = 0.94, respectively, but less so for the plate group, r = 0.36 and r = 0.62, respectively. The maximum metatarsal head height measured on the lateral view was strongly correlated with load to failure for both the plate- and screw-only groups (r > 0.9).

CONCLUSION

These data demonstrate that hallux MTP arthrodesis utilizing fully threaded compression screws had similar plantar gapping and load to failure when compared with the low-profile locking plate, but with significantly more stiffness. These results support an increased role of fully threaded screws for MTP arthrodesis using either the arthroscopic or open technique. However, with decreased BMD plate fixation may remain the better fixation choice.

CLINICAL RELEVANCE

Our data suggest that with regard to construct stability, fully threaded headless compression screws may be just as effective as low-profile locking plates, but BMD and MTP joint fluoroscopic measurements should be considered in the decision-making process for fixation.

First metatarsophalangeal fusion using joint specific dorsal plate with interfragmentary screw augmentation: Clinical and radiological outcomes

BACKGROUND

This study reports the outcome of a plating system for arthrodesis of the first metatarsophalangeal joint (1st MTPJ) that incorporates a lag compression screw within a low profile titanium plate with a predetermined contour. This is the first report of the outcomes of this implant from a non-affiliated centre.

PATIENT AND METHODS

This is a prospective cohort study of 40 consecutive primary 1st MTPJ arthrodesis procedures. The mean age of the cohort was 56 years (range, 20-74 years). The diagnosis was hallux rigidus in 31 patients and inflammatory arthropathy in 7 patients.

RESULTS

All patients achieved clinical union at 6 weeks and radiological union was confirmed on plain radiographs between 6-16 weeks. One case of hardware removal was reported.

CONCLUSION

The cohort achieved consistently satisfactory results with a reliable and reproducible MTPJ position and a 100% union rate. There was a low rate of hardware removal.

LEVEL OF EVIDENCE

Level IV evidence. Prospective cohort study.

Hallux Valgus

Hallux valgus is a common condition that results from a complex positional deformity of the first ray. The bunion or medial prominence that results from the lateral deviation and pronation of the hallux is only one component of the 3-dimensional deformity. Hallux valgus can lead to considerable pain and altered joint mechanics. The precise biomechanical etiology remains under debate. Predisposing factors include female sex, age, constricting footwear, and family history. Metatarsus adductus, equinus contracture, hammertoe deformity, and pes planus often coexist with hallux valgus. Nonoperative treatment involves patient education, shoe modifications, toe pads and positioning devices, and activity modifications. Surgery is considered in patients who fail nonoperative treatment with the goal of pain relief, correction of the deformity, improved first ray stability, and improved quality of life. More than 100 different procedures have been described to treat hallux valgus; they include combinations of soft tissue balancing, metatarsal osteotomies, and fusion of either the metatarsophalangeal (MTP) or tarsometatarsal (TMT) joint. The choice of procedures depends on the severity and location of the deformity as well as surgeon preference. Recent advances in operative techniques include minimally invasive surgery and correction of rotational deformity.

Long-Term Results of Surgical Treatment of Valenti Procedures for Hallux Rigidus: A Minimum Ten-Year Follow-Up Retrospective Study

Few studies reporting long-term results of surgical treatment of hallux rigidus have been published. The aim of this study is to assess the clinical outcome of Valenti procedures in a series of patients with hallux limitus/rigidus with a minimum 10-year follow-up time. We retrospectively evaluated 38 patients (40 feet) who underwent a Valenti procedure with a mean follow-up of 132 ± 19.6 (range 114 to 184) months. All patients were clinically reassessed on the basis of the evaluation of pain (visual analogue scale), function (American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale Assessment and Foot & Ankle Disability Index), and subjective satisfaction. The scores before and after treatment, obtained from clinical recordings and clinical evaluation during the last follow-up visits, were compared. We found significant improvement of the mean values of the visual analogue score (p < .0001), Foot & Ankle Disability Index (p < .0001), and American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale Assessment (p < .0001) during the latest follow-up visits. The results suggest that the Valenti technique represents a safe, reproducible surgical procedure that allows satisfying long-term results. The few reported complications were essentially the progressive worsening of the joint stiffness, but no sesamoiditis, metatarsal overload, secondary surgeries, or failures were documented.

Lesser Metatarsophalangeal Joint Pathology Addressed With Arthrodesis: A Case Series

Lesser metatarsophalangeal joint pathology is a common condition facing the foot and ankle surgeon, often beginning as a mild subluxation of the toe and progressing to a full dislocation of the metatarsophalangeal joint. In severe or recalcitrant deformities, traditional conservative and surgical methods can fail to resolve the issue. We report on 4 patients with 5 severely dislocated lesser metatarsophalangeal joints with varied etiologies and comorbidities who underwent arthrodesis of these joints using screw and plate fixation. All patients achieved radiographic and clinical signs of union at an average of 16.4 weeks.

Incidence and outcomes of revision surgery after first metatarsophalangeal joint arthrodesis: Multicenter study of 158 cases

INTRODUCTION

First metatarsophalangeal (MTP1) joint arthrodesis, described as a safe and effective procedure, has complications that may require surgical revision. These complications are rarely studied. The aim of this study was to determine the incidence and outcomes of revision surgery after MT1 arthrodesis.

HYPOTHESIS

The incidence of surgical revision after MTP1 arthrodesis is not insignificant; however, the outcomes are satisfactory.

MATERIALS AND METHODS

In this multicenter retrospective study between January 2014 and December 2015, 190 forefoot revisions in patients who had previously undergone MTP1 arthrodesis were included by 8 surgeons. There were no exclusion criteria and all patients had at least 1 year of follow-up. Over the same period, 958 primary MTP1 arthrodesis procedures were performed.

RESULTS

The mean time to revision was 4.6±10.9 years. At a mean follow-up of 20.5±7.4 months, 158 cases were available for analysis in 135 women and 20 men who had a mean age of 67.1±10.5 years. These revision procedures were carried out because of discomfort related to the hardware at the arthrodesis site (n=86, 54%), nonunion (n=22, 14%), malunion (n=13, 8%) metatarsalgia or claw toe (n=18, 11%) and first interphalangeal (IP1) joint disorders (n=13, 8%). The mean postoperative scores were 75±13.9 for the AOFAS and 65±19.6 for the SF36 total. In the nonunion cases, removal of the hardware led to better outcomes than repeating the arthrodesis procedure. Osteotomy in the malunion cases healed successfully. In the cases of IP1 osteoarthritis, secondary arthrodesis or arthroplasty led to good outcomes.

DISCUSSION

Relative to published results of primary MTP1 arthrodesis, the outcomes in our series of revision MTP1 arthrodesis surgery cases are practically equivalent, thus considered acceptable.

LEVEL OF EVIDENCE

IV, Retrospective study.

Result of IOFIX (Intra Osseous FIXation) device for first metatarsophalangeal joint arthrodesis: A single surgeon's series

BACKGROUND

Arthrodesis of the first metatarsophalangeal joint (MTPJ) is a common procedure to treat significant first MTPJ arthritis. However, dorsal plates used for this have been associated with high incidence of metalwork removal. The IOFIX (Intra-Osseous FIXation) is a fixed angle device that is noted to provide a more uniform compression over a larger aspect of the fusion surfaces than a screw construct alone with the advantage of minimizing soft tissue irritation which can reduce the need for subsequent implant removal.

METHODS

Twenty one consecutive patients who underwent primary first MTPJ fusion with the IOFIX were reviewed. The mean age of the cohort was 63 years (range 47-81), with 80% female. The ratio of left to right was 9:12. The mean follow up of was 28 months (range 13.4-48.2 months). Outcomes analyzed were rate of fusion, Manchester-Oxford foot questionnaire (MOXFQ) score, patient satisfaction, improvement in the intermetatarsal angle and complications.

RESULTS

Complete fusion of the first MTPJ was achieved in twenty (95%) patients. One patient had a non union and another patient developed a delayed union. The mean preoperative MOXFQ score improved from 49.7 (95% confidence interval: 46-52) to 17.9 (95% confidence interval: 12-22), p<0.05.Improvement gained in all the domains of the MOXFQ score (walking/standing, pain and social) was statistically significant (p<0.05). Eighteen out of 21 patients (85%) were very pleased or fairly pleased with the procedure.

CONCLUSION

Early results show that the rate of fusion achieved by using the IOFIX device for the first MTPJ arthrodesis in our series was found to be comparable to other devices quoted in the literature.

Do Postoperative Hallux Angles Correlate With Outcome in MP1 Fusion? Our Experience With 71 Cases

PURPOSE

To determine if the postoperative alignment of the hallux influences the final clinical outcome of hallux metatarsophalangeal joint (first MTPJ) arthrodesis.

METHODS

A total of 71 consecutive cases (hallux rigidus) were studied in stages 3 and 4. They were operated through arthrodesis between 2008 and 2014. The follow-up mean was 7.3 years. The AOFAS (American Orthopaedic Foot and Ankle Society) test was performed preintervention and per annum. In radiology, both the hallux valgus angle and the dorsiflexion angle of the first MTPJ were studied. Furthermore, clinical outcomes were evaluated according to the type of implant used.

RESULTS

Preoperative AOFAS score was 27.5, rising to 91.3 after the intervention ( P < .01). The improvement test average was 63.6. There were 17 local complications (23%), 7 of them were considered to be major complications (9%), 6 of which needed reoperation (8.5%). The dorsiflexion angle postoperative mean was 21.7°. The hallux valgus angle postoperative mean was 10.9°. No correlations between both angles, and improved AOFAS score or complications ( P > .4 and P > .5, respectively), were found. Patients who had a dorsiflexion angle higher than 20° had greater improvement in the AOFAS score compared with those who had angles lower than 20° (64.5 vs 59.6 points). Nevertheless, this result was not statistically significant ( P = .059). No differences in AOFAS score improvement regarding arthrodesis plate ( P > .1) were found.

CONCLUSION

First MTPJ arthrodesis is a good alternative for patients in advanced hallux rigidus stages when conservative treatment fails. We could not confirm if a better postoperative alignment may influence in clinical outcomes. However, better results are obtained with dorsiflexion angle greater than 20° than with those with less than 20°. Likewise, any differences between the 2 arthrodesis plates have been able to confirm.

LEVELS OF EVIDENCE

Level III: Retrospective cohort study.

Hallux rigidus: How do I approach it?

Hallux rigidus is a degenerative disease of the first metatarsalphalangeal (MTP) joint and affects 2.5% of people over age 50. Dorsal osteophytes and narrowed joint space leads to debilitating pain and limited range of motion. Altered gait mechanics often ensued as 119% of the body force transmit through the 1st MTP joint during gait cycle. Precise etiology remains under debate with trauma being often cited in the literature. Hallux valgus interphalangeus, female gender, inflammatory and metabolic conditions have all been identified as associative factors. Clinical symptoms, physical exam and radiographic evidence are important in assessing and grading the disease. Non-operative managements including nonsteroidal antiinflammatory drugs, intra-articular injections, shoe modification, activity modification and physical therapy, should always be attempted for all hallux rigidus patients. The goal of surgery is to relieve pain, maintain stability of the first MTP joint, and improve function and quality of life. Operative treatments can be divided into joint-sparing vs joint-sacrificing. Cheilectomy and moberg osteotomy are examples of joint-sparing techniques that have demonstrated great success in early stages of hallux rigidus. Arthrodesis is a joint-sacrificing procedure that has been the gold standard for advanced hallux rigidus. Other newer procedures such as implant arthroplasty, interpositional arthroplasty and arthroscopy, have demonstrated promising early patient outcomes. However, future studies are still needed to validate its long-term efficacy and safety. The choice of procedure should be based on the condition of the joint, patient's goal and expectations, and surgeon's experience with the technique.