High complication rates following revision first metatarsophalangeal joint arthrodesis: a retrospective analysis of 79 cases

Revision Surgery for Failed Polyvinyl Alcohol Hydrogel Implant in the First MTP Joint: A Case Report and Comprehensive Review

Background

Hallux rigidus is a degenerative condition of the first metatarsophalangeal (MTP) joint that can significantly impair function and quality of life. The introduction of polyvinyl alcohol (PVA) hydrogel implants, such as Cartiva, offered an alternative to arthrodesis by preserving joint motion. However, failures of these implants, often resulting in bone loss and joint instability, present a challenge for revision surgery.

Methods

We report the case of a 43-year-old woman with persistent pain and functional limitations after a failed PVA hydrogel implant in the first MTP joint. The revision surgery involved a biologic resurfacing using the Osteochondral Autograft Transfer System (OATS) with a graft harvested from the ipsilateral femoral condyle, complemented by interpositional arthroplasty with a dermal graft and a proximal phalanx closing wedge osteotomy to correct residual hallux valgus.

Results

At the 3-year follow-up, the patient-reported complete resolution of pain and returned to full activity with improved range of motion (40 degrees dorsiflexion, 15 degrees plantarflexion). Radiographic evaluation demonstrated graft incorporation and restoration of joint space, confirming the success of the procedure.

Conclusion

This case highlights the potential of OATS combined with interpositional arthroplasty as a viable option for revision surgery in complex cases of failed synthetic cartilage implants in hallux rigidus. By addressing bone loss and preserving joint function, this approach provides a patient-specific alternative to traditional arthrodesis. Further studies are warranted to establish the long-term efficacy of this technique in similar cases.

Level of Evidence

Level V, case report.

Two-Year Clinical Outcomes of Patients Undergoing Synthetic Cartilage Arthroplasty for First Metatarsophalangeal Osteoarthritis

Background Severe osteoarthritis (OA) of the first metatarsophalangeal joint (MTPJ) is usually treated by arthrodesis, which results in a loss of mobility in the joint. Cartiva (Stryker Corporation, Kalamazoo, USA) is a synthetic cartilage implant (SCI) designed to repair osteochondral defects in the treatment of the first MTP OA. Treatment using the Cartiva SCI should relieve symptoms of OA whilst sparing motion in the first MTPJ and may provide a superior alternative to arthrodesis. Objectives The objective of this article is to assess the clinical outcomes of a novel SCI, Cartiva, for arthroplasty in the management of the first MTPJ arthritis. Study design and methods We retrospectively reviewed 64 patients who had received a total of 67 Cartiva implants between May 2016 and June 2020. The average age of these patients at the time of surgery was 54.3 years with a range from 19 to 77 years. Forty-five of the 67 implants were used in females and 22 were used in males. Radiological Grade 2 OA was present in 46 cases with Grade 3 in 21 (Hattrup and Johnson classification). Validated patient-reported outcomes measures (PROMs) were used to assess the functional efficacy of the implants. All cases were performed by a single surgeon. The PROMs data was collected via follow-up phone calls with the patients who were asked questions from the American Academy of Orthopaedic Surgeons' Foot and Ankle Measure (AAOS-FAM), the EQ-5D-3L survey and the Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ). All data collected was anonymised to preserve confidentiality and local hospital ethics committee approval was sought. All statistical analysis was done using Microsoft Excel (Microsoft® Corp., Redmond, WA) and Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 23.0, Armonk, NY). Results There was a significant improvement in all PROMs at three years, and one patient developed an implant-related infection. The average scores for the EQ-5D-3L survey significantly improved from 0.69 to 0.85 post-operative (post-op) (p<0.05). The mean MOXFQ scores improved from 42.5 to 15.4 post-op (p<0.05). The radiologic evaluation demonstrated satisfactory implant positioning in all cases at the last follow-up. Conclusions The data shows significant improvements between pre-op and post-op scores. The implication of this is that synthetic cartilage arthroplasty provides a viable alternative to arthrodesis in the treatment of OA affecting the first MTPJ. However, more studies may need to be done focusing on larger sample sizes and patients should be observed over a longer term, including a formal multi-centred clinical trial.

Effect of co-morbidities on outcomes of first metatarsophalangeal joint fusion: A systematic review

Introduction

The pre-existing co-morbidities have a major impact on the outcomes of Orthopaedic procedures as shown by the several studied in various contexts. However, the specific influence of these co-morbidities on first metatarsophalangeal joint fusion remains relatively underexplored. This study aims to address this gap by examining the association between co-morbidities such as obesity, smoking, diabetes, advancing age, and rheumatoid arthritis, and the outcomes of first metatarsophalangeal joint fusion.

Methods

A comprehensive search was conducted across multiple databases, including MEDLINE, EMBASE, and CINAHL. Relevant articles were identified and processed using Covidence, with independent assessment conducted to ensure inclusion criteria were met. The focus of the review was on analysing the effects of specific co-morbidities on fusion outcomes.

Results

Seven qualifying studies were identified for full-text extraction, revealing significant heterogeneity across the literature, which hindered direct statistical comparisons. The findings presented inconclusive effects of obesity on fusion outcomes, with ambiguous impacts observed for diabetes mellitus and smoking. Additionally, no discernible variance was observed in functional outcomes across different age groups. Furthermore, steroid usage in rheumatoid arthritis cases demonstrated delayed fusion in revision procedures, while primary outcomes remained uncertain.

Conclusion

This systematic review highlights the need for further research with standardised methodologies to better understand the correlation between pre-existing co-morbidities and outcomes in first metatarsophalangeal joint fusion. By elucidating these relationships, clinicians can better tailor treatment approaches and optimise patient care in this specific Orthopaedic context.

Level of evidence

Level III.

Arthrodesis using Iliac Crest autograft in revision surgery of the first metatarsophalangeal joint total arthroplasty for the treatment of Hallux Rigidus: a retrospective study

PURPOSE

The treatments for hallux rigidus (HR) encompass a wide spectrum, including conservative methods and surgical approaches such as arthroplasty and arthrodesis. This study aims to evaluate the outcomes of revision with arthrodesis following the failure of the first metatarsophalangeal joint total arthroplasty (MTPJ1TA).

MATERIALS AND METHODS

Patients who had surgery at two advanced orthopedic centers between January 1, 2020, and January 1, 2024, were reviewed. Those with at least 6 months of postoperative follow-up were assessed for demographics (gender, age, side), reoperation rates, complications, Visual Analogue Scale (VAS) scores, Foot and Ankle Disability Index (FADI) scores, and American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal and Interphalangeal Scale (AOFAS-HMI) scores. Radiological evaluations included hallux valgus angle (HVA), intermetatarsal angle (IMA), dorsiflexion angle (DFA), and first ray length (FRL) in anteroposterior and lateral views.

RESULTS

Of 27 patients, 4 were male (15%) and 23 female (85%), with an average age of 56.18 ± 7.49 years (range 41-72). Arthrodesis was performed in 26 patients, with one requiring reoperation due to implant failure. Average VAS scores were 7.14 preoperatively and 3.55 postoperatively (p < 0.05). Average FADI scores were 50.51 preoperatively and 71.51 postoperatively (p < 0.05). Average AOFAS-HMI scores were 51.22 preoperatively and 70.59 postoperatively (p < 0.05). Average HVA was 19.7° preoperatively and 6.29° postoperatively (p < 0.05). Average IMA was 10.66° preoperatively and 11.37° postoperatively (p = 0.406). Average DFA was 34.14° preoperatively and 22.33° postoperatively (p < 0.05). Average anteroposterior FRL was 10.17 cm preoperatively and 10.77 cm postoperatively (p < 0.05). Average lateral FRL was 10.12 cm preoperatively and 10.42 cm postoperatively (p < 0.05). None of the patients in the study exhibited postoperative donor site complications or transfer metatarsalgia, while a 100% rate of bone union was observed.

CONCLUSION

We think that revision of MTPJ1TA with arthrodesis is a safe treatment option. Additionally, the use of an iliac crest autograft can be a viable option to restore bone stock and create a biological environment conducive to fusion. This study evaluates revision surgery with arthrodesis in the largest patient group with failed MTPJ1TA, highlighting its significance in the field. However, further studies are needed to determine the ideal surgical procedure.

Non-Union Treatment in the Foot, Ankle, and Lower Leg: A Multicenter Retrospective Study Comparing Conventional Treatment with the Human Allogeneic Cortical Bone Screw (Shark Screw®)

Addressing non-unions involves stabilizing the affected area through osteosynthesis and improving bone biology using bone grafts. However, there is no consensus on the optimal treatment method. This study aims to compare outcomes of non-union surgery using conventional treatment methods (metal hardware ± graft) versus osteosynthesis with the human allogeneic cortical bone screw (Shark Screw®) alone or in combination with a metallic plate. Thirty-four patients underwent conventional treatment, while twenty-eight cases received one or more Shark Screws®. Patient demographics, bone healing, time to bone healing, and complications were assessed. Results revealed a healing rate of 96.4% for the Shark Screw® group, compared to 82.3% for the conventionally treated group. The Shark Screw® group exhibited a tendency for faster bone healing (9.4 ± 3.2 vs. 12.9 ± 8.5 weeks, p = 0.05061). Hardware irritations led to six metal removals in the conventional group versus two in the Shark Screw® group. The Shark Screw® emerges as a promising option for personalized non-union treatment in the foot, ankle, and select lower leg cases, facilitating effective osteosynthesis and grafting within a single construct and promoting high union rates, low complications, and a rapid healing process.

The First Metatarsophalangeal Joint: Updates on Revision Arthrodesis and Malunions

First metatarsophalangeal joint (MPJ) arthrodesis procedures are a mainstay of forefoot surgery and are associated with high rates of patient satisfaction for addressing a multitude of first ray pathologic conditions. This procedure is often also used as a fallback option for the revision of poor outcomes after other surgical procedures involving the first ray. Despite its successes, there remain instances of complications that can develop after primary first MPJ arthrodesis. This article reviews first MPJ arthrodesis as a procedure for revisional surgery of the first ray, and potential surgical options after failed primary first MPJ arthrodesis.

"In Situ" Joint Preparation Technique for First Metatarsophalangeal Arthrodesis: A Retrospective Comparative Review of 388 Cases

"Cup-shaped power reamers" and "flat cuts" (FC) are common joint preparation techniques in first metatarsophalangeal (MTP) joint arthrodesis. However, the third option of an "in situ" (IS) technique has rarely been studied. This study aims to compare the clinical, radiographic, and patient-reported outcomes (PROMs) of the IS technique for various MTP pathologies with other MTP joint preparation techniques. A single-center retrospective review was performed for patients who underwent primary MTP joint arthrodesis between 2015 and 2019. In total, 388 cases were included in the study. We found higher nonunion rates in the IS group (11.1% vs 4.6%, p = .016). However, the revision rates were similar between the groups (7.1% vs 6.5%, p = .809). Multivariate analysis revealed that diabetes mellitus was associated with significantly higher overall complication rates (p < .001). The FC technique was associated with transfer metatarsalgia (p = .015) and a more first ray shortening (p < .001). Visual analog scale, PROMIS-10 physical, and PROMIS-CAT physical scores significantly improved in IS and FC groups (p < .001, p = .002, p = .001, respectively). The improvement was comparable between the joint preparation techniques (p = .806). In conclusion, the IS joint preparation technique is simple and effective for first MTP joint arthrodesis. In our series, the IS technique had a higher radiographic nonunion rate that did not correlate with a higher revision rate, and otherwise similar complication profile to the FC technique while providing similar PROMs. The IS technique resulted in significantly less first ray shortening when compared to the FC technique.

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.

First metatarsophalangeal joint arthrodesis/fusion: a systematic review of modern fixation techniques

Background

First metatarsophalangeal joint arthrodesis is commonly performed for symptomatic end-stage hallux rigidus. It has been postulated to produce good results in the literature. Various fixation techniques offer differences in union rates, complications and functional outcomes, stirring debates about which produces the best outcomes for patients. Therefore, this review aims to synthesise and compare the outcomes of modern fixation techniques used for first metatarsophalangeal joint (FMPJ) arthrodesis.

Methods

The electronic database searched were PubMed, CINAHL, Cochrane Library, and Google Scholar. The critical appraisal skills programme tool for cohort study was used. The interventions consisted of screw(s), plate(s), and staple(s). Studies comprising outdated fixation techniques such as suture, metallic wire, external fixation, Rush rods or Steinmann pins were excluded. Participants were adults over 18 years, undergoing FMPJ arthrodesis in the UK. Studies with the population consisting primarily of revision cases, patients with rheumatoid arthritis or diabetes were excluded.

Results

Seven UK studies included 277 feet and a 95.7% overall union rate at a mean union time of 83.5 days. Staples had the highest union rate of 98.2% at mean union time of 84 days, followed by plates (95.2%, 92 days), and finally screws (94.9%, 71 days). The overall complication incidence is 5.8%. All of the fixation techniques produced good functional outcomes postoperatively.

Conclusions

Whilst staple techniques showed the highest union rate, plating techniques are preferable over screws or staples for better results across several outcome measures, including reduced complication incidence, stability, early ambulation, and good functional outcome. The Manchester-Oxford Foot Questionnaire and EuroQol-5Dimensional are recommended as measurement tools to assess functional outcomes following FMPJ arthrodesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00540-9.