Minimally invasive arthrodesis of the first metatarsophalangeal joint for hallux rigidus

Cheilectomy, Osteotomy, Microfracture, and Matrix-Induced Chondrogenesis (COMM): A Novel Combined Procedure for Treating Hallux Rigidus

BackgroundHallux rigidus (HR) is a degenerative joint disorder of the first metatarsophalangeal joint (MTPJ), causing joint pain and stiffness. Surgical treatments, including cheilectomy, microfracture (MF) and dorsal oblique osteotomy (DOO), have been well described in current literature. However, the addition of matrix-induced chondrogenesis (MIC) via scaffold implantation with bone marrow aspirate concentrate (BMAC) is novel and hypothesized to significantly improve cartilage healing.ObjectivesThis study aimed to (1) describe the COMM procedure-a novel combination of cheilectomy, DOO, MF, and MIC, as well as to (2) evaluate its early clinical outcomes in a series of 12 HR cases.Study Design & MethodsThis is a retrospective study of 11 patients (12 feet) with HR treated with the COMM procedure in our hospital from May 2022 to June 2023 by 3 fellowship-trained foot and ankle surgeons. All the patients have completed their 1-year clinical review, where we evaluated their Numeric Pain Rating (NPR), European Foot and Ankle Society (EFAS), and Short Form-36 (SF-36) scores (Physical Function [SF-PF] and Mental Health [SF-MH]), as well as satisfaction. Preoperative and postoperative scores were compared to determine the effect of treatment.ResultsThere was statistically significant improvement in all scores (P < 0.05). EFAS Foot and/or Ankle and Sports scores improved from 9.3 to 20.0 and 3.8 to 9.4, respectively. SF-PF and SF-MH scores improved from 47.9% to 67.9% and 54.0% to 66.0%, respectively. Mean NPR at rest and during activity improved from 4.8 to 0.2 and 7.6 to 2.5, respectively. The mean postoperative satisfaction was 8.0, with 10 representing maximal satisfaction.ConclusionsDespite being a small series, our study has shown good clinical outcomes and promising satisfaction rates among all patients who have undergone our COMM procedure.

Minimally Invasive First Metatarsophalangeal Joint Arthrodesis With a Low-Profile Hybrid Locking Plate and a Beveled Compression Screw: A Surgical Technique

Arthrodesis of the first metatarsophalangeal joint (MTPJ) is a valuable intervention for a variety of hallux pathologies and is still considered the gold standard treatment for advanced hallux rigidus, one of the most commonly encountered pathologies of the forefoot. With the advent and expansion of minimally invasive surgery (MIS) techniques, MIS First MTPJ arthrodesis offers a new approach to treat hallux conditions with the potential to limit complications and further enhance patient satisfaction. We describe a technique that affords the benefits of MIS surgery without compromising the biomechanical superiority of a dorsal hybrid low-profile plate with a beveled, partially threaded compression screw.Level of Evidence: Therapeutic, Level V: Technique article.

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

Minimally Invasive Forefoot Surgeries Using the Shannon Burr: A Comprehensive Review

Since the early 2000s, minimally invasive forefoot surgery (MIS), particularly hallux valgus correction, has significantly advanced with the introduction of the Shannon burr. However, despite numerous relevant studies being published, no comprehensive review articles have summarized MIS for various forefoot conditions. Therefore, in this comprehensive review, we examined the relevant studies about the application of MIS (excluding arthroscopy and endoscopy) for various forefoot conditions. Additionally, we discuss the essential considerations for achieving favorable surgical outcomes and preventing complications associated with each technique. We analyzed the characteristics of each surgical procedure and identified areas for future focus. Effective surgical treatment not only requires MIS, but also the appropriate selection of patients based on suitable indications and executing procedures within the surgeon's capabilities. We hope that this review will help readers to enhance their expertise in this field.

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.

Minimally Invasive vs Open Approach for First Metatarsophalangeal Joint Arthrodesis: Short Report of Early Results

BACKGROUND

We aim to compare early surgical results between groups who underwent minimally invasive surgery (MIS) vs open first metatarsophalangeal (MTP) arthrodesis to treat end-stage hallux rigidus.

METHODS

We conducted a retrospective cohort review of 65 patients who underwent a first MTP fusion procedure at an academic medical center between 2015 and 2023. Success of fusion was determined radiographically. Postoperative complications were identified through medical record review.

RESULTS

Sixty-seven first MTP fusion surgeries (41 open and 26 MIS) were performed on 65 patients with a primary diagnosis of hallux rigidus. Open surgery and MIS groups had similarly high fusion rates: 95% (39/41) and 96% (25/26), respectively (P = .84). We identified no difference in overall complication rates: 20% for open surgery and 23% for MIS (P = .73).

CONCLUSION

This retrospective analysis of 67 first MTP arthrodesis procedures showed no significant differences in fusion success or complications in the short term when comparing MIS to open surgery. Further studies are needed to elucidate potential differences between MIS vs open surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

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.

Treatment of hallux rigidus with percutaneous metatarsophalangeal arthrodesis: a case series with a minimum follow-up of 2 years

BACKGROUND

Percutaneous metatarsophalangeal arthrodesis is an option for the treatment of hallux rigidus in more advanced cases. The aim of this study was to investigate the clinical and radiographic results at least 2 years after percutaneous metatarsophalangeal arthrodesis in patients with hallux rigidus.

METHODS

This is a case series of consecutive patients undergoing percutaneous metatarsophalangeal arthrodesis in patients with hallux rigidus grades III and IV with a minimum of 24 months of clinical and radiographic follow-up. The primary outcome was clinical assessment using the Visual Analog Scale for Pain (VAS). Secondary outcomes included American Orthopedic Foot & Ankle Society (AOFAS) score, patient satisfaction, complications, and bone healing (radiographic analysis).

RESULTS

Between August 2017 and February 2020, 29 feet (24 patients) underwent percutaneous metatarsophalangeal arthrodesis. The mean follow-up was 38.4 (range 24-54) months. There was an improvement in the pain (VAS) from 7.8 to 0.6 (p < 0.001) and in the AOFAS score from 49.9 to 83.6 (p < 0.001). There was a rate of bone union of 82.8% and screw removal of 13.8%. All patients considered the result to be excellent or good.

CONCLUSION

The treatment of grade III and IV hallux rigidus with percutaneous metatarsophalangeal arthrodesis demonstrated high patient satisfaction and significantly improves in clinical outcomes but the nonunion rate was higher than reported outcomes for open 1st metatarsophalangeal joint arthrodesis.

LEVEL OF EVIDENCE

IV, case series.

Minimally Invasive Foot and Ankle Surgery: A Primer for Orthopaedic Surgeons

There is rapidly growing interest in minimally invasive surgery (MIS) of the foot and ankle. Technological advances, specifically with the advent of low-speed high-torque burrs, have enabled the expansion of MIS techniques. Accordingly, there is growing literature reporting excellent outcomes of MIS surgery to address many different pathologies of the foot and ankle. MIS techniques are particularly useful for conducting percutaneous osteotomies and bony débridement. These can be used to address bunion deformity, hammertoes, metatarsalgia, bunionette deformity, bone spurs, and hindfoot deformity. A detailed understanding of the technology, equipment, and techniques is crucial to safely conduct MIS of the foot and ankle. When done safely, MIS provides favorable outcomes with an expedited recovery and limited complications.

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.

Quality of MIS vs Open Joint Preparations of the Foot and Ankle

BACKGROUND

Minimally invasive surgery (MIS) is growing in the field of foot and ankle, and the MIS burr is an emerging tool. Although commonly used to perform osteotomies, the burr can also be used for arthrodesis joint preparation that traditionally would be performed through open incisions. To date, there is no study comparing the quality of joint preparation between using a fluoroscopy-guided MIS technique compared to traditional open techniques. The goal of this cadaveric study is to compare the percentage of joint surfaces prepared between MIS and open techniques for the most common joints that are fused in foot and ankle surgery.

METHODS

Open joint preparation was performed under direct visualization with open incisions. MIS joint preparation was performed percutaneously using fluoroscopic guidance alone, without arthroscopy. After joint preparation, cadaveric samples were disarticulated, and joint surfaces were analyzed for percentage of cartilaginous surface removed. The percentage of joint surface prepared was compared between the open and MIS techniques.

RESULTS

Ten cadaveric samples were used for the MIS technique and 5 samples for the open technique. Percentage of joint surface prepared was similar for all joint surfaces.

CONCLUSION

The MIS technique in the hands of experienced surgeons was found to provide overall similar percentages of surface area prepared compared to traditional open techniques.

CLINICAL RELEVANCE

MIS joint preparation may be useful for specific patient populations. This study suggests that MIS joint preparation is a reasonable, and possibly advantageous, alternative to open preparation in arthrodesis surgery when performed by experienced MIS surgeons.

[Minimally invasive arthroscopic-assisted arthrodesis of the first metatarsophalangeal joint]

OBJECTIVE

Clinical and radiographic analysis of a minimally invasive arthrodesis technique of the first metatarsophalangeal joint.

INDICATIONS

Symptomatic hallux rigidus, symptomatic hallux rigido-valgus, hallux varus.

CONTRAINDICATIONS

Absolute contraindication (CI): osteomyelitis; relative CI: untreated diabetes mellitus, smoking.

SURGICAL TECHNIQUE

Under arthroscopic assistance, a minimally invasive arthrodesis technique of the first metatarsophalangeal joint is performed with removal of the subchondral sclerosis and remaining cartilage of the osteoarthritic joint.

POSTOPERATIVE MANAGEMENT

Immediate weight-bearing starts on day 1 using a ready-made hallux valgus shoe for 6 weeks. Physiotherapy without movement of the first metatarsophalangeal joint is allowed after surgery.

RESULTS

A series of 5 patients with symptomatic hallux rigidus and relevant medical diseases were evaluated after minimally invasive arthroscopic arthrodesis of the first metatarsophalangeal joint. In all cases osseous union was found after 8.4 months. Follow-up was 22.6 months and the American Orthopedic Foot and Ankle Society (AOFAS) score increased significantly from 42.4 to 82.8 points. No complications requiring therapy were observed in our cohort nor was revision surgery necessary. The results of our series are in line with the published results of minimally invasive fusion techniques of the first metatarsophalangeal joint.

Biomechanical Study Concerning the Types of Resection in Arthrodesis of First Metatarsophalangeal Joint

This work concerns a biomechanical study aiming to ascertain the optimal type of joint resection when performing a joint arthrodesis. A 3-dimensional digital model of the first metatarsophalangeal joint including the entire first metatarsal bone and proximal phalanx using CT scans of the forefoot was created. Using this computer model, 4 types of resections; ball-and-socket, flat-on-flat, wedge 90°, and wedge 100° were simulated. Parameters measured using this model were the force necessary to separate the 2 fused surfaces, the surface area of the resected surfaces and the shortening of the first ray. By measuring the reactive force necessary to separate the phalanx from the first metatarsal, the 90° wedge resection was found to be the most stable, with comparable results in the case of the 100° wedge resection. Wedge resections are also more favorable when comparing the shortening of the first ray. Wedge resections, though being more technically difficult to perform prove to be the most stable for metatarsophalangeal joint-1 arthrodesis using this model.

Minimally-invasive hallux arthrodesis with endomedullary and a crossed screw fixation

BACKGROUND

Minimally invasive surgery has several advantages: minor pain, smaller incisions and less tissue damage than traditional open surgery. Hallux arthrodesis with an endomedullary screw fixation provides compression and axial stability. The aim of this study was to describe the procedure and evaluate our first results of the minimally invasive first metatarsophalangeal arthrodesis with an endomedullary screw combined with a crossed screw fixation.

METHODS

We retrospectively studied 15feet, with a minimum 1year follow-up. Patients were evaluated with full-load radiographs and AOFAS score preoperatively and at last follow-up.

RESULTS

Consolidation rate was 93.3%, radiological consolidation time was 18 weeks (14-60). Radiographic alignment was achieved with satisfactory results. The preoperative AOFAS score improved from a mean 49 to 90 (p=0.001). There was one postoperative superficial site infection, which healed and a patient developed a pseudarthrosis but it was asymptomatic.

CONCLUSIONS

The minimally invasive metatarsophalangeal arthrodesis with an intramedullary screw is a secure procedure with comparable results to open techniques.

LEVEL OF CLINICAL EVIDENCE

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.

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.

Percutaneous Techniques in Orthopedic Foot and Ankle Surgery

This article presents the indications, contraindications, preoperative surgical planning, surgical technique, and postoperative management of some of the most common percutaneous procedures in orthopedic foot and ankle surgery. The background of each procedure also is presented, supported by the latest in published literature to educate surgeons. Such topics include percutaneous bunionectomy, lesser toe deformity and bunionette correction, calcaneal osteotomy, cheilectomy, and first metatarsophalangeal joint arthrodesis.

A 24-month follow-up after treatment of hallux rigidus with resection arthroplasty in combination with a resorbable polymer-based implant and platelet-rich plasma

BACKGROUND

Aim of this study was to analyze the clinical outcome after treatment of hallux rigidus with implantation of a resorbable polymer-based implant immersed with autologous platelet-rich plasma (PRP).

METHODS

Forty-five patients with hallux rigidus were treated with three-stage resection arthroplasty and subsequent covering of the metatarsal head with a polyglycolic acid-hyaluronan implant immersed with autologous PRP. Patients were clinically assessed using the AOFAS rating scale preoperatively and at 12 and 24 month follow-up. Alignment and range of motion in the metatarsophalangeal joint was measured using a goniometer.

RESULTS

The AOFAS rating scale and ROM showed significant (p<.01) improvement in all subcategories one and two years after surgery compared to the preoperative situation.

CONCLUSIONS

Covering of the metatarsal head after resection arthroplasty with the PGA-hyaluronan implant immersed with autologous PRP is safe and leads to a notable improvement of the symptoms in patients with hallux rigidus.

PRINCIPLES OF SURGICAL TREATMENT IN PATIENTS WITH OSTEOARTHRITIS OF THE FIRST METATARSOPHALANGEAL JOINT

At present, there is no general approach to choosing surgical tactics for hallux rigidus. Many surgical procedures are used to treat osteoarthritis (OA) of the first metatarsophalangeal joint (FMPJ), which are relevant at different stages of the disease. Nevertheless, this fact also suggests that all proposed methods have one or other disadvantages. At the same time, FMPJ arthrodesis that relieves pain and is functionally inferior to joint-sparing surgery remains the gold standard. However, due to the fact that not only persons over the age of 50 years, but also younger patients often suffer from FMPJ OA, the most non-damaging option of joint-sparing surgery is cheilectomy with chondroplasty of the FMPJ, which allows restoration of painless joint motions, thus sparing the anatomy of the foot. Chondroplasty using the authologous matrix-induced chondrogenesis (AMIC®) technique for knee, hip, and ankle cartilage defects is described. There are no reports on FMPJ chondroplasty with the AMIC method in either Russian or foreign literature.

Minimally invasive and percutaneous surgery of the forefoot current techniques in 2018

Minimally invasive and percutaneous techniques used to repair deformities of the forefoot have considerably developed recently. Like standard osteotomies, these techniques must take advantage of the mechanical advances made in the restoration of the foot's architecture. Instead of an endpoint, these techniques represent an additional tool implemented towards a rapid functional, post-operative recovery. This review describes the power of this surgery, details its techniques and lists its indications. We also report our own experience and review the recent literature.

Manipulation under anaesthesia and steroid injection for pain and stiffness after surgery to the first metatarsophalangeal joint

AIM

To determine the effectiveness of manipulation under anaesthesia and local steroid injection to treat stiffness of the first metatarsophalangeal joint following surgery for hallux rigidus or hallux valgus.

METHODS

Patients were identified who had undergone surgery for hallux rigidus or hallux valgus and subsequently were treated with manipulation and steroid injection for stiffness of their joint. Patient records were reviewed to determine the range of movement of the joint pre-operatively, immediately following the procedure and at subsequent follow up. Manchester-Oxford foot questionnaires (MOXFQ) were sent to patients to evaluate symptoms post-operatively.

RESULTS

In total 35 patients were analysed, which included a total of 38 foot operations. Twenty seven had prior surgery for hallux rigidus and 11 for hallux valgus correction. The total range of movement of the joint improved following manipulation by an overall mean of 44.7° (p<0.0001). At subsequent follow up, the total range of movement of the joint was still improved by 22.2° (p<0.0001) overall. The mean post-operative MOXFQ score was 24.8 but no correlation was found between MOXFQ scores and range of movement.

CONCLUSIONS

Manipulation under anaesthesia and local steroid injection is an effective way of treating stiffness following first ray surgery. Treatment results in an improved range of movement of the joint and patients report good function post-operatively.

Percutaneous First Metatarsophalangeal Joint Fusion

The first metatarsophalangeal (MTP1) joint fusion is a very useful procedure in forefoot surgery and is still the gold standard for the treatment of severe and painful hallux rigidus. Normal walking and running are possible after MTP1 fusion, the first ray mobility being essentially in the interphalangeal (IP) joint with a compensatory hypermobility in dorsal flexion. Percutaneous MTP1 fusion is a simple procedure providing comparable results to fusions performed with open techniques. Postoperative cares are simplified with an immediate full weight bearing on rigid flat shoes and quick return to normal walking. Bone preparation is an important step and requires an experience in percutaneous forefoot surgery. Arthrodesis positioning and fixation with this percutaneous procedure are simple with possibility of clinical and radiological control. The indications for percutaneous MTP1 fusion are very large and only severe bone loss or osteoporosis represent the limits for this technique.

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.

Functional Results and Patient Satisfaction of First Metatarsophalangeal Joint Arthrodesis Using Dual Crossed Screw Fixation

A total of 262 feet in 228 consecutive patients underwent first metatarsophalangeal joint (MPJ) fusion; thus, the present study is the largest single-surgeon patient series reported. The inclusion criteria included severe painful deformity of the first MPJ due to osteoarthritis, rheumatoid arthritis, or gouty arthritis and stage 3 or 4 hallux rigidus. The exclusion criteria were revision surgery of the first MPJ, fixation other than with dual crossed screws, and a postoperative follow-up period of <3 months. Fusion of the first MPJ was fixated with dual-crossed 3.0-mm screws. The office follow-up period was ≥3 months postoperatively and the survey follow-up period was ≥6 months postoperatively. The mean duration to radiographic evidence of arthrodesis was 7.00 ± 2.33 weeks, and 252 of the feet (96.18%) achieved successful arthrodesis. The mean postoperative office follow-up duration was 30.43 ± 6.59 weeks. The mean modified American College of Foot and Ankle Surgeons scale score was 51.2 ± 3.28 of maximum possible of 68 points. The mean subjective score was 37.1 ± 2.5 (maximum possible of 50 points), and the mean objective score was 14.5 ± 1.7 (maximum possible of 18 points). Furthermore, 200 patients (87.72%) reported that they had little to no pain, 187 (82.02%) reported they either mostly liked the appearance of their toe or liked it very much, and 173 (75.88%) reported that they could wear any type of shoe most or all the time after the operation. Of the respondents, 207 (90.79%) stated they would have the surgery repeated, and 197 (86.40%) would recommend the surgery to a family member or friend.

Minimally Invasive Arthrodesis of 1st Metatarsophalangeal Joint for Hallux Rigidus

First metatarsophalangeal joint arthrodesis plays a significant role in the management of symptomatic hallux rigidus/osteoarthritis of the 1st metatarsophalangeal joint. Several open and few percutaneous techniques have been described in the literature. This article describes and discusses a percutaneous technique that has been successfully used to achieve a pain-free stable and functional 1st metatarsophalangeal joint. All aspects of surgical indication and operative technique and details of patient-reported outcomes are presented with a referenced discussion.

Minimally invasive surgery for pedal digital deformity: an audit of complications using national benchmark indicators

Background

There is increasing global interest and performance of minimally invasive foot surgery (MIS) however, limited evidence is available in relation to complications associated with MIS for digital deformity correction. The aim of this prospective audit is to report the surgical and medical complications following MIS for digital deformity against standardised clinical indicators.

Methods

A prospective clinical audit of 179 patients who underwent MIS to reduce simple and complex digital deformities was conducted between June 2011 and June 2013. All patients were followed up to a minimum of 12 months post operatively. Data was collected according to a modified version of the Australian Council of Healthcare standards (ACHS) clinical indicator program. The audit was conducted in accordance with the National Research Ethics Service (NRES) guidelines on clinical audit.

Results

The surgical complications included 1 superficial infection (0.53%) and 2 under-corrected digits (0.67%), which required revision surgery. Two patients who underwent isolated complex digital corrections had pain due to delayed union (0.7%), which resolved by 6 months post-op. No neurovascular compromise and no medical complications were encountered. The results compare favourably to rates reported in the literature for open reduction of digital deformity.

Conclusion

This audit has illustrated that performing MIS to address simple and complex digital deformity results in low complication rates compared to published standards. MIS procedures were safely performed in a range of clinical settings, on varying degrees of digital deformity and on a wide range of ages and health profiles. Further studies investigating the effectiveness of these techniques are warranted and should evaluate long term patient reported outcome measures, as well as developing treatment algorithms to guide clinical decision making.