First metatarsophalangeal joint arthrodesis and revision arthrodesis

Surgical Management of Failed First Metatarsophalangeal Joint Arthroplasty

This article describes the etiology, clinical presentation, surgical management, and outcomes for treatment of the failed first metatarsophalangeal (MTP) joint arthroplasty. Failure following implant arthroplasty typically creates large osseous deficits and surgical management can be difficult. Salvage arthrodesis provides reliable joint stability while maintaining hallux length. Outcomes following conversion of a failed MTP joint arthroplasty to MTP joint arthrodesis have demonstrated consistent pain relief and high satisfaction: however, high rates of complication and nonunion have been reported. Bone graft may be necessary to fill large voids in the joint. Other revision options for failed arthroplasty have been described, but outcomes remain inconsistent and varied. Ultimately, conversion to MTP joint arthrodesis is the recommended intervention for treatment of the failed MTP arthroplasty implant, providing sufficient stability and pain relief.

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.

A Novel Plating System for First Metatarsophalangeal Joint Arthrodesis: A Retrospective Comparison of Hybrid and Traditional Locking Plate Constructs

BACKGROUND

Dorsal plate fixation is commonly used for first metatarsophalangeal joint (1st MTPJ) arthrodesis and plate design continues to evolve. A new staple compression plate (SCP) design attempts to utilize the continuous compression of a nitinol staple across the fusion site while simultaneously providing the stability of a dorsal locked plate. Herein, we compare the radiographic, clinical, and patient-reported outcomes of 1st MTPJ joint arthrodesis using 2 dorsal locking plate constructs including a novel SCP construct.

METHODS

Forty-four patients who underwent 1st MTPJ arthrodesis between 2016 and 2020 were retrospectively evaluated. There were 2 group cohorts. Group 1 cohort included 23 patients who received a CrossRoads Extremity SCP, and Group 2 cohort included 21 patients who received a Stryker dorsal locking precontoured titanium plate (LPP). All patients were evaluated with radiographs, Patient-Reported Outcomes Measures Information System (PROMIS) outcome scores, and Foot Function Index (FFI).

RESULTS

The complication and union rates did not vary between groups with a fusion rate of 95.7% in the SCP group and 90.5 % in the LPP group. Similarly, we found no significant differences in PROMIS or FFI scores between the SCP and LPP plates.

CONCLUSION

Use of either dorsal locking plate construct for 1st MTPJ arthrodesis was associated with high union rates and comparable functional outcomes. As locked plate technology continues to evolve for 1st MTPJ arthrodesis, it is important that clinical outcomes are reported.

LEVELS OF EVIDENCE

Level IV.

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

BACKGROUND

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).

METHODS

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.

RESULTS

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.

CONCLUSION

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 OF EVIDENCE

Level II, prospective analysis of MTP-1 hemiprosthesis.

An Innovative Application of a Computer Aided Design and Manufacture Implant for First Metatarsal Phalangeal Joint Arthrodesis: A Case Report

The definitive treatment to correct the deformity of hallux abducto valgus involves surgical fixation. This pathological condition focuses on combined abnormalities of the first metatarsal phalangeal joint (MPJ), medial progression of the first metatarsal, and lateral deviation of the hallux. In most known literature described to date, a computer aided design/manufacture implant has not yet been reported as a viable salvage tool used as an inter-positional structural implant for a first MPJ arthrodesis. The fundamentals of this salvage procedure are to restore anatomical length of the first ray, furnish continuity to the forefoot parabola, administer a robust inter-positional implant^TM (Additive Orthopaedics, Little Silver, NJ) of optimal strength, and provide biomechanical reclamation of the tripod foot. This case study describes a procedural technique that required a 2-stage surgical approach consisting of primary external fixation with a SideKick^TMCoreTrack^TM (Wright Medical, Memphis, TN) tube fixator monorail to expand soft tissues for approximately 1 month.  Followed by a secondary procedure utilizing BioCUE® (Biomet Orthopaedics, Warsaw, Indiana) Bone Marrow Aspiration Concentration system, Augment® Injectable (Wright Medical, Memphis, TN), and custom GAME PLAN^TM (Additive Orthopaedics, Little Silver, NJ) Technology with computer assisted design/manufacture first MPJ inter-positional caged implant^TM arthrodesis.  We present the case of a 46-y-old active female who suffered avascular necrosis of her left foot first metatarsal head from a previous Austin bunionectomy correctional procedure.

Conversion of First Metatarsophalangeal Joint Arthrodesis to Interpositional Arthroplasty With Acellular Dermal Matrix for First Ray Ulceration: A Case Report

The purpose of this study is to report the outcome of the conversion of a first metatarsophalangeal (MTP) joint arthrodesis to an interpositional arthroplasty with an acellular dermal matrix for a chronic nonhealing first ray wound. To our knowledge, this is the first case report converting a first ray arthrodesis to an interpositional arthroplasty to heal a chronic ulceration. A 78-year-old female developed a chronic neuropathic ulceration under the first metatarsal head and hallux after a first MTP joint arthrodesis. The patient failed local wound care and underwent gastrocnemius recession, hallux interphalangeal joint fusion, and an interpositional arthroplasty with the use of an acellular dermal matrix. Bone tunnels were placed proximal to the metatarsal neck, where absorbable sutures affixed to the dermal matrix were passed from plantar to dorsal, and the graft was secured to the reamed metatarsal head and associated capsule. Postoperative radiographs revealed improved alignment of the first MTP joint. Complete reepithelialization of the plantar ulceration occurred within 2 weeks postoperatively. At the 16-month follow-up, the patient was ambulating without restriction and continued to be free of first ray ulceration and infection. This case study details the use of an acellular dermal matrix in an interpositional arthroplasty to offload a chronic nonhealing ulceration secondary to elevated first ray pressure associated with first MTP joint arthrodesis. The goal of this treatment is to reduce pain, heal the ulceration, and prevent its recurrence.

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.

Revision of Failed First Metatarsophalangeal Joint Implant

Revision surgeries, as well as conversions from implants to arthrodesis, can present unique challenges to the foot and ankle surgeon. Proper perioperative planning assists in optimizing the outcome of the procedure. In general, some amount of bone loss and/or shortening of the first metatarsal takes place, leading to the need for augmenting the site with bone graft or a synthetic substitute. Fixation also plays a key role in obtaining a successful conversion. A solid construct combined with bone graft assists the foot and ankle surgeon in achieving an optimal outcome.

Immediate Weightbearing After First Metatarsophalangeal Joint Arthrodesis With Screw and Locking Plate Fixation: A Short-Term Review

Historically, the postoperative protocol for patients undergoing first metatarsophalangeal joint arthrodesis has included 6 weeks of non-weightbearing, followed by protected weightbearing in a below-the-knee cast boot or postoperative shoe. This prolonged period of non-weightbearing predisposes the patient to disuse atrophy, osteopenia, deep vein thrombosis risk, and, overall, a prolonged time to recovery. The present study reports a retrospective review of a patient cohort that underwent first metatarsophalangeal joint fusion with immediate full weightbearing postoperatively. Thirty consecutive first metatarsophalangeal joint arthrodeses were performed during the study period. Five patients were excluded secondary to insufficient postoperative follow-up data or a lack of adequate radiographic evaluation at regular postoperative intervals. Conical reamers were used for joint preparation. Internal fixation, consisting of a single cannulated interfragmentary compression screw and a dorsal locking plate, was used in all patients. The results showed that patients achieved clinical healing at an average of 5.92 weeks and showed radiographic fusion at an average of 6.83 weeks. The patients in the present study had an overall union rate of 96%. Complications included 1 nonunion, 1 superficial wound infection, 1 wound dehiscence, 1 case of symptomatic hardware, and 2 patients with symptomatic hallux interphalangeal joint arthralgia. The mean visual analog pain score preoperatively was 6.64 (range 4 to 8) and postoperatively was 0.6 (range 0 to 4). In conclusion, we found that immediate full weightbearing after first metatarsophalangeal joint fusion in the context of interfragmentary compression and locked plating techniques is a safe, predictable postoperative protocol that allows for a successful fusion interval and an early return to regular activity.

Arthrodesis of the first metatarsophalangeal joint-A biomechanical comparison of four fixation techniques

BACKGROUND

Arthrodesis of the first metatarsophalangeal joint is a commonly performed orthopaedic procedure. The optimum method of fixation and joint surface preparation has yet to be determined.

METHODS

This study compared four fixation techniques: Biomechanical grade sawbones were used. The dorsal plate used was a titanium, anatomically contoured locked plate. Testing was performed using an Instron machine applying force from the plantar aspect of the fused joint. Each fused sample was tested to failure. Stiffness, as calculated from the force-displacement curve, and ultimate load tolerated were recorded for each sample. The method of failure of each sample was also documented.

RESULTS

Constructs arthrodesed using dorsal plate with separate screw groups, regardless of method of joint preparation, were the stiffest (p<0.001). The weakest construct was dorsal plate alone without interfragmenary screw. There was no difference in stiffness between planar and cup-cone joint preparation (p=0.99). Maximum load tolerated was similar when comparing Crossed Screws with dorsal plate with screw with either cup-cone or planar reaming (p=0.93, p=0.89 respectively). Dorsal plating alone tolerated a significantly lower maximum load than Plate with Screw Groups or Crossed Screws (p<0.001).

CONCLUSION

This study confirms that an IFS combined with a dorsally positioned locked-plate is the ideal construct, with the joint preparation technique of little consequence.

Techniques in Hemiarthroplasty of the First Metatarsophalangeal Joint

Surgical intervention for hallux rigidus could be necessitated when conservative attempts fail to alleviate pain and dysfunction. Controversy exists as to which procedure is ideal and will provide lasting relief of hallux rigidus pain. Many arguments have been made for and against hemi-implant arthroplasty. We advocate the use of a low-profile hemimetallic endoprosthesis (Metasurg(®)) and present our technique of using a reamer to sculpt the articular surface of the metatarsal head when necessary. We further advocate for minimal resection of the phalangeal base when using a low-profile device to maintain the soft tissue periarticular intrinsics. We present a 2- to 3-position reamer decompression of the metatarsal and discuss the benefits of maintaining range of motion at the first metatarsophalangeal joint.

The Biomechanical Evaluation of Revision First Metatarsophalangeal Arthrodesis: A Cadaveric Study

BACKGROUND

First metatarsophalangeal (MP) arthrodesis in the setting of bone loss is a difficult problem. Bone loss may compromise stability of implant fixation. Union rates may be adversely affected by these circumstances. The primary goals of this cadaveric, biomechanical study were to (1) investigate stiffness of a dual mini-plate construct versus a standard MP arthrodesis plate in the setting of severe bone loss and (2) evaluate arthrodesis interface motion when an interpositional graft is used.

METHODS

Twelve matched cadaveric samples were used in this study. In a given pair, both dual mini-plate fixation and standard MP arthrodesis plate were used. Interpositional graft was used in 6 of the specimen pairs. After implantation, soft tissues were dissected away and specimens were placed into a cantilever bending setup. A cantilever load was applied at a rate of 6 mm/min until catastrophic failure of the test construct or 5-mm plantar gapping of either bone block interface.

RESULTS

Based on load to failure data, there were no differences between the various constructs in terms of stiffness. There was a high degree of calculated plantar gapping with the placement of a bone block, irrespective of the fixation type.

CONCLUSIONS

Although no construct differences were observed in terms of stiffness, the dual mini-plate is an alternative option for fixation when asymmetric bone loss is either seen on the phalangeal or metatarsal head side. The high degree of plantar gapping of the proximal interface with the placement of the bone block may have implications for healing potential across the arthrodesis site.

CLINICAL RELEVANCE

This is the first biomechanical study investigating the stiffness of multiple constructs for MP arthrodesis in the setting of severe bone loss. Furthermore, this is the first study to introduce a biomechanical rationale for difficulties in healing for this particular clinical scenario.

LEVELS OF EVIDENCE

Level V: Bench testing.

Effects of the lapidus arthrodesis and chevron bunionectomy on plantar forefoot pressures

Hallux valgus with or without first ray insufficiency has been strongly implicated as a contributing factor in lesser metatarsal overload. The principle goals of a bunionectomy are to relieve the pain, correct the deformity, and restore first metatarsophalangeal joint congruity. Until now, little evidence has been available to assess the effects of bunionectomy procedures on forefoot pressure. The primary aim of the present prospective study was to evaluate the preoperative and postoperative plantar pressures after 2 specific bunionectomies: the chevron bunionectomy and Lapidus arthrodesis. A total of 68 subjects, 34 in each group, were included for radiographic and pedographic evaluation. Both procedures demonstrated radiographic improvements in the mean intermetatarsal and hallux abductus angles. The mean hallux plantar pressure decreased significantly in both procedure groups (p < .001). However, Lapidus group exhibited an increase in the mean fifth metatarsal head plantar pressure (p = .008) and pressure under the fifth metatarsal as a percentage of the total forefoot pressure (p = .01). Furthermore, the pressure under the second metatarsal as a percentage of the total forefoot pressure decreased significantly (p = .01). This study suggests that the Lapidus arthrodesis and chevron bunionectomy both provide correction for hallux valgus deformity, but when comparing forefoot load sharing pressures, the Lapidus arthrodesis appeared to have greater influence on the load sharing distribution of forefoot pressure than did the bunionectomy employing the chevron osteotomy.

Management of a failed metatarso-phalangeal joint fusion utilizing a hemicup prosthesis

We report a case of a 65-year-old man with a painful nonunion of the first metatarsophalangeal joint (MTPJ). It is one of the main severe complications of this surgery. Its prevalence is described between 5% and 10% across different operative techniques. The implantation of hemicup-prosthesis has been successfully used for the hallux rigidus treatment with very promising results. In our case report, we introduce a treatment method of converting a pseudoarthrosis of the first MTPJ, made of two crossing screws into a hemicup-prosthesis as a salvage procedure. This is to our best knowledge the first report using this device for treatment of pseudoarthrosis of the first MTPJ.

Locked versus nonlocked plate fixation for first metatarsophalangeal arthrodesis: a biomechanical investigation

BACKGROUND

First metatarsophalangeal (MTP) arthrodesis using dorsal plate fixation is a common procedure for painful conditions of the great toe. Locked plates have become increasingly common for arthrodesis procedures in the foot, including the hallux MTP joint. The biomechanical advantages and disadvantages of these plates are currently unknown. The purpose of this study was to compare locked and nonlocked plates used for first MTP fusion for strength and stiffness.

MATERIALS AND METHODS

The first ray of nine matched pairs of fresh-frozen cadaveric feet underwent dissection, preparation with cup-and-cone reamers, and fixation of the MTP joint with a compression screw and either a nonlocked or locked stainless steel dorsal plate. Each specimen was loaded in a cantilever fashion to 90 N at a rate of 3 Hz for a total of 250,000 cycles. The amount of plantar MTP gap was recorded using a calibrated extensometer. Load-to-failure testing was performed for all specimens that endured the entire cyclical loading. Stiffness was calculated from the final load-to-failure test.

RESULTS

The locked plate group demonstrated significantly less plantar gapping during fatigue endurance testing from cycle 10,000 through 250,000 (p < .05). Mean stiffness was significantly greater in the locked plate group compared with the nonlocked plate group (p = .02). There was no significant difference in load to failure between the two groups (p = .27).

CONCLUSION

Compared with nonlocked plates, locked hallux MTP arthrodesis plates exhibited significantly less plantar gapping after 10,000 cycles of fatigue endurance testing and significantly greater stiffness in load-to-failure testing.

CLINICAL RELEVANCE

As the use of locked plate technology is becoming increasingly common for applications in the foot, a thorough understanding of the biomechanical characteristics of these implants may help optimize their indications and clinical use.

End-stage hallux rigidus: cheilectomy, implant, or arthrodesis?

End-stage arthritis of the first metatarsophalangeal joint (MTPJ) typically results in anexophytic process with marked limitation of motion. Pain may occur from the degenerative process itself and/or the bone spur formation that may become directly inflamed from shoe gear. The best surgical treatment for end-stage arthrosis of the big toe joint continues to be a controversial topic despite hallux rigidus being recognized clinically for more than 100 years. Although joint-sparing procedures are considered, arthrodesis is recommended, as this procedure is definitive and produces predictable results.

A retrospective analysis of lesser metatarsophalangeal joint fusion as a treatment option for hammertoe pathology associated with metatarsophalangeal joint instability

Complex hammer digit deformity is commonly associated with instability of the metatarsophalangeal joint. Restoring joint stability is critical for digit alignment and function and can be challenging and unpredictable. Lesser metatarsophalangeal joint fusion might be an alternative treatment to the current soft tissue balancing, repair, and extra-articular osseous procedures used to treat joint instability. The present study was a retrospective chart and radiographic review of the pooled outcomes of 31 consecutive lesser metatarsophalangeal joint fusion procedures performed by 3 independent surgeons from May 2004 to September 2009. The clinical and radiographic outcomes were analyzed with descriptive and inferential statistics. The overall interval to radiographic union was 8.69 ± 1.7 weeks (range 6 to 12 and 95% confidence interval 7.9 to 9.4). The overall period to clinical union was 10.25 ± 4.5 weeks (range 4 to 22 and 95% confidence interval 8.5 to 11.9). The mean duration of non-weight-bearing was 4.71 ± 1.74 weeks, followed by 5.09 ± 2.8 weeks of guarded weight-bearing with a brace. Complications included nonunion in 4 (12.90%), hardware breakage in 2 (6.45%), and soft tissue infection in 1 (3.23%). Patients demonstrated a statistically significant reduction in pain (p = .035) and improved digit alignment after the procedure that enabled full return to unrestricted weight-bearing activities without limitations or the need for orthoses. These findings support metatarsophalangeal joint fusion as an alternative treatment of lesser digit metatarsophalangeal joint instability associated with hammer digit deformities that obviate the need for concomitant soft tissue procedures such as plantar plate repair or tendon balancing procedures.

Modern techniques in hallux rigidus surgery

This article is a review of the history, etiology, and clinical and radiographic presentations of hallux rigidus. The focus is on current treatment options being offered for the treatment of hallux rigidus.

First metatarsophalangeal arthrodesis for hallux rigidus

Hallux rigidus leads to a restricted and painful motion at the first metatarsophalangeal (MTP 1) joint. Decision making of the appropriate surgical procedure mainly refers to the stage of hallux rigidus. If conservative measures fail, operative procedures can be taken into consideration. Arthrodesis of the MTP 1 joint is widely accepted as the gold standard for end-stage hallux rigidus. Despite the fusion of a key joint, there is little adverse effect on gait, and weight bearing of the first ray can be restored.