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

Reviewing Evidence and Patient Outcomes of Cheilectomy for Hallux Rigidus: A Systematic Review and Meta-Analysis

Background: Cheilectomy is a joint-sparing surgery for the treatment of moderate stages of Hallux Rigidus (HR). The purpose of this systematic review was to assess the clinical outcomes, range of motion (ROM), complications, and revision rates associated with cheilectomy. Methods: A literature search of the PubMed, Scopus, and Cochrane databases was performed. PRISMA guidelines were used. Risk of bias was assessed through the Newcastle-Ottawa Scale. Meta-analysis of the clinical outcomes scores was performed. Results: The initial search identified 317 articles, with 16 included. Cheilectomy improved ROM by 51.15% (41.23° to 62.32°), with greater gains in traditional (67.72%) vs. minimally invasive (48.74%) techniques. VAS decreased by 72.61%, more in traditional (79.35%) than minimally invasive (64.97%). AOFAS improved by 33.99%, from 61.83 to 82.85. Complications occurred in 11% (11.68% traditional, 9.73% minimally invasive), with residual pain (7.46%) more common in traditional and nerve injury (3.78%) in minimally invasive procedures. Revision rates were 7.4% overall (6.1% traditional, 8.8% minimally invasive). Conclusions: This procedure showed satisfactory results regardless of whether the traditional or minimally invasive technique is used. Current evidence does not allow for a definitive indication, but careful patient selection is advisable, particularly for mild to moderate cases.

Clinical Outcomes After Joint-Preserving and Joint-Sacrificing Surgery for Hallux Rigidus

Introduction Hallux rigidus (HR) is a degenerative condition affecting the first metatarsal phalangeal joint, causing stiffness and pain. Surgery is indicated for those who have failed a trial of conservative management. The purpose of this paper is to evaluate the functional outcomes at short and medium term after surgery for HR. Methods All patients who underwent surgical treatment for HR between 2017 and 2022 at the time of this study were identified and invited to return for a follow-up evaluation. Outcomes were assessed by comparison of pre-operative and post-operative visual analogue scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) scores. Results A total of 26 patients were included in our study with a mean follow-up of 31 months. There was a mean improvement in VAS score by 5.6 (p-value < 0.0001) and 5.7 (p-value = 0.0012) in patients who underwent joint-preserving (JP) and joint-sacrificing (JS) surgery, respectively. Patients who underwent JP surgery had a mean increase of 28.1 points (p-value < 0.0001) in the AOFAS Hallux score, while patients who underwent JS surgery had a mean increase of 27.29 points (p-value = 0.0066). Conclusion Functional outcomes after surgical management for HR are good at short- and medium-term follow-up. Good outcomes are seen with both JP and JS procedures. JP procedures should be considered as a first-line surgical option for HR as it allows revision procedures if required.

Treatment of hallux rigidus (HARD trial): study protocol of a prospective, randomised, controlled trial of arthrodesis versus watchful waiting in the treatment of a painful osteoarthritic first metatarsophalangeal joint

INTRODUCTION

Hallux rigidus is a common problem of pain and stiffness of the first metatarsophalangeal joint (MTPJ) caused mainly by degenerative osteoarthritis. Several operative techniques have been introduced for the treatment of this condition without high-quality evidence comparing surgical to non-surgical care. In this trial, the most common surgical procedure, arthrodesis, will be compared with watchful waiting in the management of hallux rigidus.

METHODS AND ANALYSIS

Ninety patients (40 years or older) with symptomatic first MTPJ osteoarthritis will be randomised to arthrodesis or watchful waiting in a ratio of 1:1. The primary outcome will be pain during walking, assessed using the 0-10 Numerical Rating Scale (NRS) at 1 year after randomisation. The secondary outcomes will be pain at rest (NRS), physical function (Manchester-Oxford Foot Questionnaire), patient satisfaction in terms of the patient-acceptable symptom state, health-related quality of life (EQ-5D-5L), activity level (The Foot and Ankle Ability Measure Sports subscale), use of analgesics or orthoses and the rate of complications. Our null hypothesis is that there will be no difference equal to or greater than the minimal important difference of the primary outcome measure between arthrodesis and watchful waiting. Our primary analysis follows an intention-to-treat principle.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Ethics Committee of Helsinki and Uusimaa Hospital District, Finland. Written informed consent will be obtained from all the participants. We will disseminate the findings of this study through peer-reviewed publications and conference presentations.

PROTOCOL VERSION

21 June 2021 V.2.0.

TRIAL REGISTRATION NUMBER

NCT04590313.

Incorporation of an Allogenic Cortical Bone Graft Following Arthrodesis of the First Metatarsophalangeal Joint in a Patient with Hallux Rigidus

Hallux rigidus is degenerative arthritis of the first metatarsophalangeal joint characterized by pain and stiffness in the joint with limitation of motion and functional impairment. Recently, bone grafts have been introduced in orthopedic procedures, namely osteosynthesis and arthrodesis. Allografts can induce bone formation, provide support for vascular and bone ingrowth and have a low risk of immunological rejection. A 52-year-old female patient with hallux rigidus underwent arthrodesis of the first metatarsophalangeal joint using Shark Screw® made of allogenic cortical bone. Corrective surgery was performed after 10 weeks, and a 5 × 3 mm large part of the Shark Screw® with the surrounding patient's bone was removed. A histological evaluation revealed a vascularized graft with the newly formed compact lamellar bone fitting exactly to the cortical graft. The bone surface was lined by plump osteoblasts with osteoid production, and osteocytes were present in the lacunae. The arthrodesis of the first metatarsophalangeal joint using an allogenic cortical bone graft results in fast, primary bone healing without immunological rejection. This case suggests that the cortical allograft is a good and safe treatment option with an excellent graft incorporation into the host bone. However, as the literature evaluating the histology of different bone grafts is scarce, further high-level evidence studies with adequate sample sizes are needed to confirm our findings.

Joint sparing management of hallux rigidus: Cartiva SCI vs cheilectomy a comparative review

BACKGROUND

Hallux rigidus, or first metatarsophalangeal joing arthritis, is a very common condition which causes pain and loss of motion in the joing which can be debilitating.

METHODS

Patient reported outcome measures were utilised to study the difference in day to day functionality between two common surgical management options for hallux rigidus.

RESULTS

55 Cartiva and 23 Cheilectomy patients were included in this study. The Manchester Oxford Foot and Ankle Questionnaire revealed statistically significant improvements in the cheilectomy patients when compared to Cartiva SCI.Foot and Ankle Ability Measure found no statistical difference was found between the two surgical treatments.

CONCLUSION

Cheilectomy offers good post-operative functional and sporting outcomes after surgery for the management of hallux rigidus at 5 years.

[Evaluation of therapeutic efficacy of arthroplasty with Swanson prosthesis in the surgical treatment of 2-5 metatarsophalangeal joint diseases]

OBJECTIVE

Metatarsophalangeal joint is an important joint for daily weight-bearing walking. Osteoarthritis, osteochondrosis of the metatarsal head, rheumatoid arthritis can often cause the destruction of 2-5 metatarsophalangeal joint, leading to pain, limited joint movement and toe deformities, severely affecting the forefoot function. The purpose of this study is to report the results of middle-long term follow-up after performing Swanson double-stem silicon implant arthroplasty in patients with diseases of 2-5 metatarsophalangeal joint.

METHODS

From January 2010 to October 2015, 21 patients with 2-5 metatarsophalangeal joint replacement were performed with Swanson double-stem silicone prosthesis. In the study, 16 cases were successfully followed up, 2 men and 14 women with an average age (66.7±5.5) years. There were 9 cases diagnosed with rheumatoid arthritis, 5 cases with severe osteoarthritis and 2 cases with osteochondrosis of the metatarsal head. The American Association of foot and ankle surgery Maryland foot scoring system and visual analogue score (VAS) were used to evaluate the walking function, metatarsophalangeal joint mobility and pain degree before and after surgery.

RESULTS

The follow-up time ranged from 17 months to 5 years, with an average of 3.2 years. According to Maryland foot scoring system of the American Association of foot and ankle surgery, the preoperative score was (60.69±6.12) points and postoperative score was (88.13±5.84) points. Range of motion of metatarsophalangeal joint: preoperative: back extension 5.4°±3.1°, plantar flexion 4.4°±2.7°; postoperative: back extension 15.7°±4.5°, plantar flexion 12.2°±4.3°, the motion of 2-5 metatarsophalangeal joint after operation was significantly improved compared with that before operation (P < 0.01). The preoperative VAS was (6.8±0.9) points and the last follow-up was (2.3±0.8) points, the pain symptom of metatarsophalangeal joint was improved obviously after operation. The postoperative score was significantly higher than the preoperative score according to Maryland foot scoring system (P < 0.01), the excellent rate was 81.3%.

CONCLUSIONS

With the advantages of alleviating pain, preserving the length and alignment of metatarsophalangeal joint, improving the function of walking, and correcting the deformity, Swanson double-stem silicon implant arthroplasty is a reproducible and safe option for the reconstruction of the 2-5 metatarsophalangeal joint. However, there is still some probability of adverse reactions and still room for improvement.

Silastic replacement of the first metatarsophalangeal joint: historical evolution, modern concepts and a systematic review of the literature

Silastic implants for the first metatarsophalangeal joint (MTPJ) have been in use for over 50 years. Initial reports were associated with high failure rates leading to development of new designs that are currently in use.The aim of this article is to review the historical evolution and the outcomes of silastic implants for the treatment of end-stage OA of the first MTPJ. Databases were searched for studies reporting the outcomes of silastic implants for the first MTPJ. Various relevant search terminologies were used. Studies reporting the outcomes of metallic implants or arthrodesis were excluded.The literature search revealed 522 studies, of which 28 were included. Eight studies used single-stemmed implants and 20 used double-stemmed implants for their patients. Twenty-eight studies had a total of 2354 feet with silastic replacements in 1884 patients (1968 to 2003) with an average age of 53 years and the average follow-up was 85.3 months. There were a total of 5.3% (124 feet) failed prostheses. Improvement in pain was reported in 76.6% (1804 feet) with an average patient satisfaction rate of 84%. Radiological changes around the implants were found to be significantly higher with single-stemmed implants (30.3%) compared to the double-stemmed implants (14.7%) (p < 0.05).Significantly more single-stemmed implants failed (11%) than the double-stemmed implants (3.6%) (p < 0.05). Despite the initial reports of failed implants and complications, first- and second-generation silastic implants were associated with high patient satisfaction and pain improvement. Current literature lacks long-term outcomes of implants currently in use. Cite this article: EFORT Open Rev 2019;4:77-84. DOI: 10.1302/2058-5241.4.180055.

Comparison of Hallux Rigidus Surgical Treatment Outcomes Between Active Duty and Non-Active Duty Populations A Retrospective Review

BACKGROUND

Our aim in this study was to compare the long-term outcomes of three different surgical procedures for the treatment of hallux rigidus (ie, cheilectomy, decompressive osteotomy, and arthrodesis) between active duty military and non-active duty patients.

METHODS

A retrospective review of 80 patients (95 feet) undergoing surgical treatment for hallux rigidus was performed. Telephone survey was used to obtain postoperative outcome measures and subjective satisfaction. Additional data recorded and analyzed included age, sex, status of patient (active duty or non-active duty), grade of hallux rigidus, surgical procedure performed, date of surgery, time to return to full activity, ability to return to full duty, and follow-up time postoperatively.

RESULTS

The decompressive osteotomy group had the highest return-to-duty rate, satisfaction rate, and Maryland Foot Scores of all three surgical groups, although these differences were not statistically significant. Active duty and non-active duty patients did not have statistically significant differences in outcomes measures (ie, time to return to full activity, ability to return to full duty, satisfaction, or postoperative Maryland Foot Score) in any of the three surgical groups.

CONCLUSIONS

Decompressive osteotomy, cheilectomy, and first metatarsophalangeal joint arthrodesis are all reliable and effective procedures for treatment of hallux rigidus in both active duty military and non-active duty patients. Active duty military personal have a high rate of returning to their prior military activities after surgical treatment of hallux rigidus.

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

BACKGROUND

Traditionally severe hallux rigidus is treated with arthrodesis. Recently arthroplasty has been used in order to retain motion at the metatarsophalangeal joint.

AIM

To assess the early to mid-term functional and radiological outcomes in patients undergoing first metatarsophalangeal arthroplasty using the Rotoglide implant.

MATERIALS AND METHODS

A prospective review was undertaken to assess functional and radiological outcomes of all patients undergoing an un-cemented three-component first metatarsophalangeal arthroplasty for hallux rigidus. Thirty four implants were performed in 28 patients over a 2-year period. Mean age was 60.5 years (range 45-77 years). Mean follow-up was 27.7 months (range 7-44 months).

RESULTS

Mean AOFAS score improved from 41.2 pre-operatively to 89.1 at final follow-up (47.9; 95% CI=43.6-54.3; p<0.0001). The mean metatarsophalangeal (MTP) range of motion improved from 29.5° pre-operatively to 68.2° post-operatively (38.7; 95% CI=35.1-42.2; p<0.0001). The mean AOFAS pain scores improved from 8.8 preoperatively to 35.0 postoperatively (26.2; 95% CI=22.4-29.9; p<0.0001). Three patients required revision surgery. No radiological complications were observed in any other patients.

CONCLUSIONS

This un-cemented prosthesis provides pain relief, while maintaining range of motion of the joint. The authors have observed clinically and statistically significant improvement in functional outcomes, with a low early complication rate and high patient satisfaction levels.

Long-Term Follow-Up of the Cheilectomy for Degenerative Joint Disease of the First Metatarsophalangeal Joint

Cheilectomy is the surgical resection of 20% to 30% of the dorsal metatarsal head and proximal phalanx. The present retrospective study evaluated the long-term efficacy of aggressive cheilectomy to address degenerative joint disease of the first metatarsophalangeal joint. To our knowledge, this is the second longest duration study to date to evaluate the long-term efficacy of the cheilectomy procedure, with a mean follow-up period of 7.14 years (range 39 weeks to 14.87 years). The mean patient age was 55.71 ± 9.51 years, and 37 (65%) of the patients were female. Age, sex, foot type, and preoperative radiographic parameters of hallux rigidus were also evaluated and correlated. The mean percentage of success with this operation was 87.69%. Of the 58 patients, 51 (87.93%) experienced no limitations in their daily activities. Only 2 patients (3.33%) subsequently required subsequent arthrodesis. The results of the present study suggest that cheilectomy offers long-term satisfaction for patients with hallux rigidus and is an acceptable alternative to the joint destructive procedure of first metatarsophalangeal arthrodesis.

Complication rates in diabetics with first metatarsophalangeal joint arthrodesis

BACKGROUND

First metatarsophalangeal joint (MTPJ) arthrodesis has been an effective surgical entity when indicated, but a range of severe to mild complications can occur from this procedure. Patients with diabetes mellitus have an increased risk in surgical complications, most commonly associated with soft tissue and bone healing, when compared to non-diabetic patients. The purpose of this study was to evaluate the complication rates of first MTPJ arthrodesis in diabetic patients and compare them to the existing complication rates for the procedure.

METHODS

A retrospective chart review was done on 76 diabetic patients, from June 2002 to August 2012. Thirty-two males and 44 females were included in the study. The authors evaluated many variables that could impact postoperative complications, including age, gender, bone graft incorporation, hemoglobin A1c, tobacco use, body mass index, peripheral neuropathy, hallux extensus, hallux interphalangeal arthritis, and rheumatoid arthritis, and compared them with the complication findings. Patient follow-up was no less than 24 months.

RESULTS

Overall, approximately two-thirds of the patients had no complications and 35.5% of patients had at least one mild or moderate complication. Of the non-union and mal-union complications, 80 and 70% had peripheral neuropathy, respectively. One hundred percent of the patients that had mal-positions or hardware failure also had peripheral neuropathy. No severe complications were seen during follow-up. Only two of the moderate complications needed revisions, and the rest of those with moderate complications were asymptomatic.

CONCLUSION

In conclusion, first MTPJ arthrodesis is overall an effective and beneficial procedure in patients with diabetes mellitus. Diabetic patients with peripheral neuropathy have an increased risk for mild and moderate complications.