Outcome following first metatarsophalangeal joint replacement using TOEFIT-PLUS™: A mid term alert

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.

Metatarsophalangeal Arthroplasty in Hallux Rigidus

First metatarsophalangeal joint (MTPJ) arthroplasty provides hallux rigidus patients with pain relief and preserved motion, offering an alternative to arthrodesis. Recent advancements in implant technology and surgical techniques have broadened treatment options. Although good outcomes have been documented in the literature, concerns persist regarding increased complications, uncertain long-term efficacy, and challenges in managing failed arthroplasties. Addressing bone loss resulting from the procedure further complicates salvage procedures. Larger cohorts and extended studies are necessary to establish efficacy of first MTPJ arthroplasty. Decisions must weigh the trade-offs between pain relief and potential complications, requiring thorough patient-surgeon discussions.

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

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF CLINICAL EVIDENCE

II.

Silastic Joint Arthroplasty as a Joint-Preserving Alternative for End-Stage Hallux Rigidus: Outcomes From 112 First Metatarsophalangeal Joint Arthroplasties

Aim Osteoarthritis of the first metatarsophalangeal joint (MTPJ) is a common forefoot problem affecting patients in later years. It leads to pain, gait problems, and difficulty with activities of daily living. Treatment is controversial and varies according to patient symptoms and surgeon preference. Arthrodesis remains the gold standard but it has its own complications. It is associated with adjacent joint arthritis and transfer metatarsalgia. The aim of this study was to analyze the outcome of double-stemmed silastic joint arthroplasty (Wright-Medical, Memphis, TN) for end-stage hallux rigidus. Methods This retrospective analysis included 117 consecutive first MTPJ silastic arthroplasties done between January 2016 and February 2023 for end-stage hallux rigidus. There were 77 females and 40 males with a mean age of 65 years (46-82 years). Radiological and clinical assessments were performed, and patient-reported outcome measure data (PROMS) and visual analogue scale (VAS) scores were collected pre- and post-operatively. Results Findings showed 99.1% survivorship following a silastic joint arthroplasty with a mean follow-up of four years (six months to seven years). The MOXFQ (Manchester Oxford Foot Questionnaire) score improved from a mean of 81 (59.8-100) to 13 (0-57). The mean VAS scores improved from 7.2 (5-10) to 1.5 (0-7) postoperatively. Five patients were lost to follow-up. Two patients developed deep infection and one required revision. The other patient with infection was lost to follow-up. In total 10 patients (8.9%) developed complications, out of which eight patients responded to simple treatments. Conclusion Results have shown good to excellent outcomes following a silastic arthroplasty of the first MTPJ for the treatment of end-stage hallux rigidus. The survivorship at a mean follow-up of four years was 99.1% and the patient satisfaction rate was 90.1%. As historically reported, we did not see any soft tissue reaction or progressive osteolysis in any of our patients. It provides comparable and predictable outcomes to joint fusion for end-stage arthritis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Complications of Hallux Rigidus Surgery

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

Long-term results of total joint arthroplasty and phalangeal hemiarthroplasty of the first metatarsophalangeal joint using the ToeFit Plus™ system

BACKGROUND

This paper compares long term success rate of MTP joint replacement for hallux rigidus. We provide long term results of MTP joint replacement with the use of the ToeFit Plus™ System.

MATERIALS AND METHODS

Our group consisted of 19 total joint replacements and 12 hemiarthroplasties in 18 and 11 patients respectively, performed between 2005-2009. The average follow-up period was 12.2 years (range 9.8-13.7, SD 1.1) for total arthroplasty group and 11.1 years (range 9.5-13.9, SD 1.7) for hemiarthroplasty group. In all followed patients AOFAS score was calculated along with the range of motion assessment.

RESULTS

Average AOFAS score improved from 37 preoperatively to 79 at the time of last follow-up in total arthroplasty group and from 45 to 86 in the hemiarthroplasty group, with consideration to the statistically considerable difference of both groups. The total range of motion improved on average from 14° to the current 32° in patients with total arthroplasty and from 15° to 32° with hemiarthroplasty. The total number of cases that required surgical revision was 7 (37%) in total arthroplasty group and 2 (17%) in hemiarthroplasty group.

CONCLUSION

Due to the high percentage of failure that was shown in our long term results, we no longer utilise the ToeFit Plus™ System.

Valenti resection arthroplasty for hallux rigidus: A systematic review

BACKGROUND

Valente Valenti proposed in 1976 a "V" resection of the first metatarsophalangeal joint (MPT1) on the sagittal plane for advanced stages of hallux limitus/rigidus, preserving length of the first ray, flexor hallux brevis and sesamoid function. The available literature concerning correct indications, management and clinical outcomes of the Valenti procedure (VP) and its modifications in patients affected by hallux limitus/rigidus was systematically analyzed.

METHODS

Titles and abstracts of all selected articles were independently screened by two authors to assess their suitability to the research focus.

RESULTS

Selection produced 8 articles as full-text, for a total of 347 patients, with a mean follow-up of 6±7.1 (range 0.2-17.5) years. Most common complication was transient sesamoiditis in 21 (7.4%) patients. No substantial differences in clinical outcomes were found between the original and modified techniques.

CONCLUSIONS

VP appears to allow an early recovery with few complications, if compared to fusion, interposition arthroplasties or osteotomies. The wide joint resection does not prevent, if necessary, further procedures such as fusion or implants.

LEVEL OF EVIDENCE

Level I, systematic review.

Motion Preservation in Hallux Rigidus After Failure of Hydrogel Implantation: Treatment Considerations and a Report of 2 Cases

Hallux rigidus is a common condition treated daily by surgeons worldwide. During the past decade, the standard treatment algorithm has been questioned by both patients and surgeons seeking alternatives to arthrodesis, which was previously considered the gold standard for advanced disease. Patients are living longer, and many have a more active lifestyle; thus, recreating and improving range of motion and achieving pain relief are increasingly desirable. The treatment spectrum and implant options for motion-preserving techniques in the metatarsophalangeal joint has been widened with the recent US Food and Drug Administration approval of a polyvinyl-alcohol hydrogel implant. In the controlled US Food and Drug Administration trial, the 2-year revision rate was 9.2% and all failures were revised to a first metatarsophalangeal arthrodesis. Outcomes comparison of these revisions to primary fusions showed less predictable pain relief and may warrant alternative treatment considerations, preferably those that allow for continuation of motion preservation. Revision of failed hydrogel implants to arthrodesis can be performed through various first metatarsophalangeal fusion techniques or, as introduced in this review, with a fourth-generation threaded hemiarthroplasty. Excellent 10-year results with primary hemiarthroplasty supported its use as revision procedure in 2 failed polyvinyl-alcohol implantations, preserving arthrodesis for future salvage if necessary. The purpose of this report was to outline a motion-preserving technique after failed hydrogel implants and describe preoperative, intraoperative, and postoperative considerations for optimized outcomes.

Silastic first metatarsophalangeal joint arthroplasty for the treatment of end-stage hallux rigidus

AIMS

Arthroplasty for end-stage hallux rigidus (HR) is controversial. Arthrodesis remains the gold standard for surgical treatment, although is not without its complications, with rates of up to 10% for nonunion, 14% for reoperation and 10% for metatarsalgia. The aim of this study was to analyze the outcome of a double-stemmed silastic implant (Wright-Medical, Memphis, Tennessee, USA) for patients with end-stage HR.

METHODS

We conducted a retrospective review of 108 consecutive implants in 76 patients, between January 2005 and December 2016, with a minimum follow-up of two years. The mean age of the patients at the time of surgery was 61.6 years (42 to 84). There were 104 females and four males. Clinical, radiological, patient reported outcome measures (PROMS) data, a visual analogue score (VAS) for pain, and satisfaction scores were collected.

RESULTS

The survivorship at a mean follow-up of 5.3 years (2.1 to 14.1) was 97.2%. The mean Manchester Oxford Foot and Ankle Questionnaire (MOXFQ) scores improved from 78.1 to 11.0, and VAS scores for pain from 7/10 to 1.3/10. The rate of satisfaction was 90.6%. Three implants (2.8%) required revision; one for infection, one-month postoperatively, and two for stem breakage at 10.4 and 13.3 years postoperatively. There was a 1.9% reoperation rate other than revision, 23.1% of patients developed a minor complication, and 21.1% of patients had non-progressive and asymptomatic cysts on radiological review.

CONCLUSION

We report a 97.2% survivorship at a mean follow-up of 5.3 years with this implant. We did not find progressive osteolysis, as has been previously reported. These results suggest that this double-stemmed silastic implant provides a predictable and reliable alternative with comparable outcomes to arthrodesis for the treatment of end-stage HR. Cite this article: Bone Joint J 2020;102-B(2):220-226.

Is interposition arthroplasty a viable option for treatment of moderate to severe hallux rigidus? - A systematic review and meta-analysis

INTRODUCTION

When conservative therapy for hallux rigidus fails, surgical options such as arthrodesis and interposition arthroplasty can be considered. Although arthrodesis of MTP joint is the gold standard treatment. However patients desiring MTP joint movement may opt for either interposition arthroplasty or implant arthroplasty to avoid the movement restrictions of arthrodesis. The purpose of this systematic review was to investigate clinical outcomes and complications following interposition arthroplasty for moderate to severe hallux rigidus, for patietns who would prefer to maintain range of motion in the MTP joint.

METHODS

A systematic search on MEDLINE, EMBASE and Cochrane library database was performed during February 2018. Demographics, surgical techniques, clinical outcomes, radiological outcomes and complications were recorded from each included study. Pooled statistics performed for variables with homogenous data across the studies. A linear regression model used to compare the clinical outcomes between autogenous vs allogenous material interposition arthroplasty.

RESULTS

Fifteen articles were included in the systematic review. Mean AOFAS scores improved from preoperative 41.35 to postoperative 83.17. Mean pain, function, and alignment score improved from preoperative values of 14.9, 24.9, and 10 to postoperative values of 33.3, 35.8, and 14.5. Mean dorsiflexion increased from 21.27° (5-30) to 42.03° (25-71). Mean ROM improved from 21.06° to 46.43°. Joint space increased from 0.8mm to 2.5mm. The most common postoperative complications included metatarsalgia (13.9%), loss of ground contact (9.7%), osteonecrosis (5.4%), great toe weakness (4.8%), hypoesthesia (4.2%), decreased push off power (4.2%), and callous formation (4.2%).

CONCLUSION

Interposition arthroplasty is an effective treatment option with acceptable clinical outcomes in patients with moderate-severe hallux rigidus who prefer to maintain range of motion and accept the risk of future complications.

LEVEL OF EVIDENCE

IV.

A consecutive, prospective analysis of the Rotoglide 1st metatarsophalangeal joint replacement

Following 1st metatarsophalangeal joint replacement, there is a normalisation of foot pressure distribution as demonstrated by peak pressures of the 1st and 5th metatarsal heads and their ratio as measured by pedobarographs. This compares favourably with the unaffected foot. Functional dorsiflexion range of motion is maintained and there is a significant improvement in the reported patient outcome measure.

Treatment of End-Stage Hallux Rigidus Using Total Joint Arthroplasty: A Short-Term Clinical Study

The treatment of advanced hallux rigidus remains controversial. Only a few studies have analyzed the short- and mid-term results of metatarsophalangeal (MTP) joint arthroplasty to treat patients with advanced hallux rigidus. We present the short-term follow-up results of patients who underwent MTP joint arthroplasty. We reviewed the medical records of 15 consecutive patients (3 males and 12 females) who had had grade 3 or 4 hallux rigidus diagnosed according to the Coughlin and Shurnas classification. The age range at surgery was 44 to 74 (mean 61.6) years. The mean follow-up period was 21.7 (range 18 to 28) months. The mean change in the overall American Orthopaedic Foot and Ankle Society Hallux-First Ray scale score was from 26.9 ± 2.3 preoperatively to 78.7 ± 8.8 postoperatively (p < .005). The mean change in the overall visual analog scale score was from 8.3 ± 0.8 preoperatively to 1.7 ± 0.7 postoperatively (p < .005). The mean preoperative first MTP joint range of motion was 22.3° ± 7.7° (range 15° to 45°), which had increased to 77° (range 65° to 90°) at the final follow-up visit. No patient required revision surgery or removal. These results indicate that for patients with advanced-stage hallux rigidus refractory to conservative treatment, total joint arthroplasty can lead to good satisfaction and good functional results in the short term.

The Rotoglide™ total replacement of the first metatarso-phalangeal joint. A prospective series with 7-15 years clinico-radiological follow-up with survival analysis

BACKGROUND

The Rotoglide total replacement of the MTP-1 joint. 15 years survival analysis. The purpose of this prospective study was to evaluate the long-term performance clinico-radiographically of an uncemented three-component total replacement for the first metatarso-phalangeal joint (MTP-1) used for hallux rigidus (primary osteoarthritis grades 3 and 4). The follow-up was median 11.5 years (7-15).

METHODS

The AOFAS forefoot score was used preoperatively and at follow-up. Radiographs were taken weight-bearing in the AP-projection and in tip-toe standing in the lateral view. Arthrosis in the sesamoid junction, prosthetic loosening, subsidence (of prosthesis as well as sesamoids), and dorsiflexion were measured, recorded and subjected to multiple variance analysis. Survival analysis was performed for 15 years.

MATERIAL

Ninety implants in 80 patients (53 women and 27 men); median age 58 (41-76) were evaluated.

RESULTS

Six patients representing seven prostheses in situ had died from unrelated reason. The median preoperative AOFAS increased significantly from 40 to 95. The median gain was 45. Four replacements (4.4%) were extracted for other reasons than loosening. No aseptic loosenings were recorded. The survival rate at 15 years was 91.5% (83-100). Multiple variance analysis showed that arthrosis in the metatarso-sesamoid junction correlated with reduced AOFAS score.

CONCLUSION

The prosthesis has stood the test of time; the results justify its further use.

Long term results of the Toefit-Plus replacement for first metatarsophalangeal joint arthritis

Hallux rigidus is osteoarthritis affecting the metatarsophalangeal joint of the first toe. Patients often complain of pain and stiffness with pain being aggravated by walking, particularly during toe-off in the gait cycle. Osteoarthritis of the metatarsophalangeal joint is commonly treated with arthrodesis or resection arthroplasty. Metallic replacement of this joint is used sometimes but is not widely accepted. The use of silastic joints has problems with synovitis and implant failure. The authors used titanium implants, which can be screwed into the metatarsal and phalanx, allowing good fixation without the use of bone cement. Release of the tight plantar capsule and tissues is necessary to achieve better range of movement and correct implant positioning. Fifty five cases of arthritis of the first metatarsophalangeal joint were treated surgically with Toefit-Plus™ joint replacement. The implant consists of both metatarsal and phalangal components and a fixed-bearing polyethylene insert. All patients had a release of tight soft tissues on the plantar side. Follow up occurred at 84 to 144 months after surgery (mean of 134 months), and the results showed increasing numbers of implant failures and revisions (21%) of Toefit-Plus™ implants. 47 patients were available for review. Twenty four (51%) out of 47 patients reported satisfactory results with Toefit-Plus™ arthroplasty. Ten of these patients (21%) had removal of implants and further surgical procedures were needed due to implant failure. Eleven (23%) out of 47 patients still complained of pain despite having joint replacement with the Toefit-Plus ™ implant. There is a high rate of complications with the Toefit-Plus™ implant resulting in revision surgery. Patients should have the risks associated with arthroplasty clearly explained, including the risk of revision, and the option of arthrodesis should be discussed when planning surgery. Further trials and redesign of implants may help to improve results. The authors would not recommend the Toefit-Plus™ implant due to poor results seen in one third of patients.

Treatment of hallux valgus deformity

Hallux valgus deformity is a very common pathological condition which commonly produces painful disability. It is characterised as a combined deformity with a malpositioning of the first metatarsophalangeal joint caused by a lateral deviation of the great toe and a medial deviation of the first metatarsal bone.

Taking the patient’s history and a thorough physical examination are important steps. Anteroposterior and lateral weight-bearing radiographs of the entire foot are crucial for adequate assessment in the treatment of hallux valgus.

Non-operative treatment of the hallux valgus cannot correct the deformity. However, insoles and physiotherapy in combination with good footwear can help to control the symptoms.

There are many operative techniques for hallux valgus correction. The decision on which surgical technique is used depends on the degree of deformity, the extent of degenerative changes of the first metatarsophalangeal joint and the shape and size of the metatarsal bone and phalangeal deviation. The role of stability of the first tarsometatarsal joint is controversial.

Surgical techniques include the modified McBride procedure, distal metatarsal osteotomies, metatarsal shaft osteotomies, the Akin osteotomy, proximal metatarsal osteotomies, the modified Lapidus fusion and the hallux joint fusion. Recently, minimally invasive percutaneous techniques have gained importance and are currently being evaluated more scientifically.

Hallux valgus correction is followed by corrective dressings of the great toe post-operatively. Depending on the procedure, partial or full weight-bearing in a post-operative shoe or cast immobilisation is advised. Post-operative radiographs are taken in regular intervals until osseous healing is achieved.

Cite this article: Fraissler L, Konrads C, Hoberg M, Rudert M, Walcher M. Treatment of hallux valgus deformity. EFORT Open Rev 2016;1:295-302. DOI: 10.1302/2058-5241.1.000005.