Treatment of first metatarsophalangeal joint arthritis using hemiarthroplasty with a synthetic cartilage implant or arthrodesis: A comparison of operative and recovery time

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

Background

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

Methods

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

Results

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

Conclusion

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

Level of Evidence

Level V, case report.

Continuous Hyaluronic Acid Supply by a UHMWPE/PEEK Interlocking Scaffold for Metatarsophalangeal Joint Prosthesis Lubricating Applications

Wear is one of the main causes of prothesis failure in hemiarthroplasty of small joints such as the metatarsophalangeal joint, to which lubrication improvement is a promising solution. Inspired by the natural joint structure and lubrication mechanisms, we developed a novel composite strategy for metatarsophalangeal joint hemiarthroplasty. An ultrahigh-molecular-weight polyethylene (UHMWPE) lubrication layer is interlocked within a 3D-printed poly(ether ether ketone) (PEEK) scaffold, and hyaluronic acid (HA) is introduced for hydrophilic modification of the UHMWPE matrix. HA encapsulated in the matrix can consistently emerge to the friction interface and firmly form a boundary lubrication layer, consequently enhancing the lubrication of the UHMWPE component. The friction coefficient of the scaffolds could be as low as 0.041 under a joint-equivalent load and a low friction velocity. Besides, the tested samples demonstrate good in vitro and in vivo biocompatibility. The bone tissues around the implantation site can heal normally and achieve implant fixation within 6 weeks. Summarily, in this work, inspired by the natural "cartilage-and-subchondral bone" structure, a continuous HA supply was attained in a UHMWPE/PEEK interlocking scaffold. Such a composite shall provide an excellent combination of tribological properties and biocompatibility, thus hopefully being a candidate material for the next-generation hemi-implants for metatarsophalangeal arthroplasty.

Cartiva: A Review of the Best Evidence

The Cartiva implant is a synthetic polyvinyl alcohol hydrogel cartilage substitute that is used as a treatment of first metatarsophalangeal joint arthritis. The implant was designed to relieve the pain associated with hallux rigidus while preserving or restoring range of motion. A summary of outcomes, reasons for these outcomes, and technique pearls will be reviewed here. Seminal articles and current evidence are all included in this article. The aim is for the surgeon to understand all the literature, allowing the surgeon to counsel their patients appropriately, optimize patient selection and to deal with complications.

Polyvinyl alcohol hydrogel implant for the treatment of hallux rigidus is associated with a high complication rate and moderate failure rate at short-term follow-up: a systematic review

PURPOSE

Moderate-to-severe hallux rigidus is a debilitating pathology that is optimally treated with surgical intervention. Arthrodesis produces reliable clinical outcomes but is limited by restriction in 1st metatarsophalangeal joint range of motion. The advent of polyvinyl alcohol hydrogel (PVA) implants have produced early promise based on initial trials, but more recent studies have called into question the efficacy of this procedure. The purpose of this systematic review was to evaluate the clinical and radiological outcomes following the use of PVA for hallux rigidus.

METHODS

The MEDLINE, EMBASE and Cochrane library databases were systematically reviewed using the preferred reporting items for systematic reviews and meta-analyses guidelines. 18 studies were included.

RESULTS

In total, 1349 patients (1367 feet) underwent PVA at a weighted mean follow-up of 24.1 ± 11.1 months. There were 168 patients (169 feet) included in the cheilectomy cohort and 322 patients (322 feet) included in the arthrodesis cohort. All 3 cohorts produced comparable improvements in subjective clinical outcomes. Postoperative imaging findings in the PVA cohort included joint space narrowing, peri-implant fluid, peri-implant edema and erosion of the proximal phalanx. The complication rate in the PVA cohort, cheilectomy cohort and arthrodesis cohort was 27.9%, 11.8% and 24.1%, respectively. The failure rates in the PVA cohort, cheilectomy cohort and arthrodesis cohort was 14.8%, 0.3% and 9.0%, respectively.

CONCLUSION

This systematic review demonstrated that PVA produced a high complication rate (27.9%) together with concerning postoperative imaging findings at short-term follow-up. In addition, a moderate failure rate (14.8%) and secondary surgical procedure rate (9.5%) was noted for the PVA cohort. The findings of this review calls into question the efficacy and safety of PVA for the treatment of hallux rigidus.

LEVEL OF EVIDENCE

IV.

Patient Satisfaction Following Hallux Rigidus Treatment With a Synthetic Cartilage Implant

BACKGROUND

There remains no clear consensus on patient satisfaction and functional outcomes following synthetic cartilage implant (SCI) implantation for hallux rigidus. The purpose of this study was to review our experience at a single academic institution using an SCI for treatment of hallux rigidus.

METHODS

A retrospective review was performed of patients who underwent the SCI procedure for treatment of hallux rigidus between January 2017 and May 2019. Functional outcomes were evaluated using Patient-Reported Outcome Measures Informational System (PROMIS)-10 scores as well as a survey investigating patient satisfaction, self-reported clinical improvement, and changes in sporting ability. Patients were divided into satisfied versus unsatisfied subgroups, and between-group differences in preoperative variables and complications were reviewed. A total of 90 patients (96 implants) were included in this study. The mean follow-up time was 26.4 months.

RESULTS

In all, 81.2% of patients reported that their foot was "much improved" (55.2%) or "improved" (26.0%) since undergoing the SCI procedure, whereas a slightly lower percentage, 74.0%, stated that they were "extremely satisfied" (41.7%) or "satisfied" (32.3%) at final follow-up. Patients were able to tolerate higher impact sporting activities after the procedure, and 75.0% of patients stated they would have the same surgery again. PROMIS-10 T-scores averaged 54.2 points for physical health and 57.4 points for mental health. Only 2.1% of patients required conversion to arthrodesis. Significant differences between the satisfied versus unsatisfied subgroups were found in preoperative corticosteroid injection use (21.1% vs 41.1%, respectively; P = .029) and preoperative VAS pain score (8.2 vs 7.1, respectively; P = .036).

CONCLUSION

The SCI procedure can be a viable option for treating hallux rigidus with high satisfaction overall, increased sport activity levels, and a very low revision rate. However, maximizing patient satisfaction may require more careful consideration of preoperative prognosticators and extensive patient counseling to ensure realistic expectations for recovery time and individual outcome.

LEVEL OF EVIDENCE

Level IV: Retrospective case series.

Surgical Outcomes of Synthetic Cartilage Implant Hemiarthroplasty for Metatarsophalangeal Arthropathy

Introduction Metatarsophalangeal joint (MTPJ) arthropathy in the great toe causes considerable pain and debilitation, severely impacting quality of life. Traditional management options included conservative measures, steroid injections, and arthrodesis. New options include Cartiva, a synthetic cartilage hemiarthroplasty for the MTPJ. This prosthesis has evidence of improved pain and function without the sacrifice of joint movement seen with arthrodesis. However, the implant itself has mixed reviews. This study aims to identify the pre-, peri, and short-term post-surgical outcomes of Cartiva surgery and review the literature for existing reported outcomes. Methods We retrospectively reviewed a cohort of 22 consecutive Cartiva procedures between 2016 and 2022 in a single UK institution. Hospital records were analyzed for peri-operative complications, implant survival, additional operative interventions, patient-reported outcomes, and functional improvement. Results Twenty-one patients underwent Cartiva for the first MTPJ pathology and one for the third MTPJ pathology. Prior to surgery, 40.9% of patients had undergone alternative therapies, including MTPJ steroid injections (seven patients), cheilectomy (four patients), and bunionectomy (one patient). Total complication rates, inclusive of medical, surgical, and implant complications were 45.5% (10/22). Total reoperation rates were 18.2% (4/22) including two revisions to arthrodesis and two manipulations under anesthesia (MUA) with local anesthetic injection. At the final follow-up, 55% were still experiencing pain, 15% neurovascular symptoms, 10% swelling, and 50% stiffness or reduced range of movement. However, 85% of patients returned to usual activities of daily living within two years. Conclusion Cartiva surgery for metatarsophalangeal arthropathy has demonstrated outcomes of persistent pain, limited range of movement, and restricted function at short-term follow-up. Rates of reoperation and revision to arthrodesis were comparable with similar studies.

A Prospective Evaluation of First Metatarsophalangeal Fusion Using an Innovative Dorsal Compression Plating System

Numerous techniques have been described for first metatarsophalangeal joint (MTPJ) fusion. The aim of this study was to prospectively evaluate an innovative plating system which uses a cross plate compression screw. Thirty consecutive first MTPJ fusions in 28 patients were evaluated. All procedures were performed by a single fellowship trained consultant foot and ankle surgeon. Patient function was evaluated preoperatively at 6 and at 12 months using the Manchester-Oxford Foot Questionnaire (MOXFQ). Union rates and complications were recorded. Postoperative MOXFQ scores demonstrated significant improvement in all domains, with mean improvement at 12 months of 35, 27, 17 and 106 points for pain, walking/standing, social interactions and combined scores respectively (p value ≤.0001). In all 30 cases, clinical and radiological evidence of union was achieved by 6 months. Superficial infection occurred in 1 (3%) case. One (3%) case required plate removal due to soft tissue irritation. There were no plate failures. This evaluation study demonstrates that this cross-plate compression plating system is safe, provides high patient satisfaction and reliable union, with low complication rates. Prospective comparative research is now required to determine the optimal technique for first MTPJ fusion.

The Use of a Synthetic Cartilage Implant for Hallux Rigidus: A Systematic Review

Background. Hallux rigidus is a common pathology afflicting the foot, for which various joint salvage techniques have been described with a multitude of different implants. Recently, a synthetic cartilage implant composed of polyvinyl alcohol (PVA) received FDA premarket approval for the treatment of arthritis of the great toe. The purpose of this study was to (1) systematically review the clinical evidence supporting the use of a PVA implant in hallux rigidus and (2) determine the strength of the recommendation that can be made supporting the use of a PVA implant by evaluating the quality of evidence available. Methods. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Using the terms "cartiva OR polyvinyl alcohol OR synthetic cartilage OR hemiarthroplasty AND hallux rigidus OR great toe arthritis OR first toe arthritis" we searched the PubMed/Medline database. The quality of the included studies was evaluated using the American Academy of Orthopaedic Surgeons Clinical Practice Guideline and Systematic Review Methodology. Results. Seven studies met the inclusion criteria, 6 of these were derived from a single randomized controlled trial. A moderate recommendation can be given for the use of a PVA implant for hallux rigidus based on short-term outcomes. A limited recommendation can be given for the use of a PVA implant for hallux rigidus based on mid-term outcomes. Conclusion. There are limited studies available detailing the outcomes of a PVA implant for hallux rigidus; however, the results that are available demonstrate a high level of evidence.Levels of Evidence: Level I: Systematic review.

Treatment of hallux rigidus by a novel bi-phasic aragonite-based implant: results of a two year multi-centre clinical trial

PURPOSE

The two year results of a multi-centre clinical trial were examined to evaluate surgical treatment of hallux rigidus using a novel, bi-phasic, biodegradable, and cell-free aragonite-based scaffold (Agili-C™, CartiHeal Ltd, Israel).

METHODS

Twenty patients with moderate-to-severe hallux rigidus were recruited. After thorough metatarsophalangeal joint (MTPJ-1) debridement, the scaffolds were implanted into the defect centre. Eight patients received concomitant osteotomy. Treatment outcome was followed clinically (Pain VAS, FAAM-ADL, FAAM-Sport, AOFAS-HMIS, maximum active range of extension ROM-EXT, and flexion ROM-FLEX), and by medical imaging, at six month intervals for two years. Adverse events were recorded throughout the study follow-up period.

RESULTS

Significant clinical improvement over time was observed in all evaluated parameters (screening to final evaluation averages: Pain VAS 59 to 26, FAAM-ADL 57 to 77, FAAM-Sport 39 to 66, AOFAS-HMIS 51 to 81, ROM-EXT 18° to 36°), except for ROM-FLEX. Radiographs showed stable MTPJ-1 width over the two years in 17/18 cases (94%). MRI demonstrated progressive implant biodegradation, coupled with articular cartilage and subchondral bone regeneration, with a repair tissue defect fill of 75-100% in 14/17 (82%) subjects at their final visit. Revision surgery with implant removal was performed in two patients.

CONCLUSION

Bi-phasic, osteochondral, biodegradable, aragonite-based scaffold demonstrated positive clinical outcome and a good safety profile in the treatment of medium-to-advanced hallux rigidus. According to the medical imaging, this implant has the potential to restore the entire osteochondral unit of metatarsal head.

Early Outcomes and Complications of Synthetic Cartilage Implant for Treatment of Hallux Rigidus in the United States

BACKGROUND

The aim of this study was to determine the early outcomes and complications following the implantation of a hydrogel synthetic cartilage implant (SCI, Cartiva) for the treatment of hallux rigidus by a single surgeon.

METHODS

A retrospective chart review was performed of consecutive patients who underwent treatment for hallux rigidus with an SCI between August 2016 and April 2018 by a single surgeon. Demographic information, radiographic assessment, and concomitant operative procedures performed were evaluated for all patients. Postoperatively, PROMIS physical function (PF) and pain interference (PI) scores, patient satisfaction, reoperation, conversion to arthrodesis, and need for further clinical treatment were collected. Sixty-four SCIs were implanted in 60 patients. Follow-up averaged 18.5 months (range 12-30 months).

RESULTS

14% (9/64) of patients were very satisfied, 28% (18/64) satisfied, 20% (13/64) neutral, 11% (7/64) unsatisfied, and 27% (17/64) very unsatisfied with their outcome. In addition, 45% of patients underwent additional procedures at the time of SCI, and 23% had a history of surgery on the hallux before implantation. PROMIS PF scores averaged 42 and PROMIS PI scores averaged 60. Overall, 63% completed PROMIS PI, 66% completed PROMIS PF, and 100% completed a satisfaction survey. In addition, 30% (19/64) underwent magnetic resonance imaging (MRI) postoperatively due to pain. There was a 20% reoperation rate, which included an 8% rate of conversion to arthrodesis.

CONCLUSION

Synthetic cartilage implantation yielded neutral patient satisfaction, mild pain, and physical dysfunction at early follow-up. We believe patient selection and counseling regarding early postoperative limitations are important before proceeding with SCI.

LEVEL OF EVIDENCE

Level IV, case series.