The Valenti technique in the treatment of hallux rigidus

Percutaneous arthroscopically assisted cheilectomy combined to percutaneous proximal phalanx osteotomy in hallux rigidus: Clinical and radiological outcomes in 30 feet at a 48-month follow-up

BACKGROUND

Hallux rigidus is a degenerative condition affecting the middle age population. It affects patients by limiting their first metatarsophalangeal range of motion (ROM) and also, their shoe wear. The objective of our work was to present an original operative technique which preserves the native joint and improves pain with minimal complications.

METHODS

We conducted a retrospective multicenter cohort study of 28 patients (30 feet) suffering from moderate hallux rigidus, operated between October 2010 and October 2017 with at least 48months of follow-up. Clinical and radiological assessments included pre- and postoperative ROM, the American Orthopedic Foot and Ankle Society (AOFAS) score and forefoot radiological evaluation. No patients were lost to follow-up.

RESULTS

The mean AOFAS score increased from 59 (range, 51 to 67) preoperatively to 84 (range, 80 to 88) at final follow-up. A total of 37 patients (97%) were satisfied. From a ROM point of view, this remained relatively unchanged between preoperative and postoperative values.

CONCLUSION

The percutaneous arthroscopically assisted cheilectomy combined with a percutaneous proximal phalanx osteotomy, significantly improves pain in hallux rigidus with index minus in patients with Coughlin stage I and II after a mean of 4-year follow-up.

LEVEL OF EVIDENCE

IV.

Nonoperative Management of Hallux Limitus Using a Novel Forefoot Orthosis

Hallux limitus is among the most common arthritides of the foot and ankle, with increasing incidence in the aging population. Despite its prevalence and disease burden, treatment of the condition remains poorly understood. Many patients will fail initial conservative management, whereas controversy exists surrounding indications for and outcomes of surgery. The present study sought to examine the impact of a novel forefoot orthosis on foot function, pain, and plantar pressure distributions in patients with symptomatic hallux limitus. Nineteen adult patients completed a questionnaire consisting of the 23-item Foot Function Index and a 10-point visual analogue scale measuring pain. Standing pedobarographic maps were generated using a foot scanning system. Participants were instructed to wear the orthosis in athletic shoes for 4 weeks. Eighteen participants (94.7%) experienced improvements in foot function and pain, with 12 (63.2%) reporting complete resolution of pain at the end of the 4-week trial. Mean Foot Function Index scores improved significantly from 43.0% at baseline to 11.0% with the orthosis (p < .001). Similarly, mean visual analogue scale pain scores decreased significantly from 4.87 to 1.18 (p < .001). Pedobarographic analysis while wearing the orthosis demonstrated increased ability of participants to bear weight on the arthritic hallux metatarsophalangeal joint and restoration of physiologic stance. Compared to existing products, the device was well tolerated and did not require footwear modifications or impede normal gait. Overall, the orthosis offers an appealing solution to patients dissatisfied with existing treatment options as well as those who may be averse to or ineligible for surgery.

Adverse events involving hallux metatarsophalangeal joint implants: Analysis of the United States Food and Drug Administration data from 2010 to 2018

BACKGROUND

The prevalence of osteoarthritis of the hallux metatarsophalangeal joint (MTPJ) is 1 in 40 people over the age of 50. Surgical treatment options for MTPJ arthritis include joint preservation, joint resurfacing, and arthrodesis. Hallux MTPJ implants have evolved over the past several decades, but are associated with various complications. The aim of this study was to examine the MAUDE database to determine reported adverse events for hallux MTPJ implants.

MATERIALS AND METHODS

The US Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was reviewed from 2010 to 2018 to review voluntary reported adverse event reports for approved implants within the United States. We recorded the type of adverse event and excluded duplicate reports and those extracted from already published literature.

RESULTS

Among 64 reported hallux MTPJ implant adverse events, the most common modes of adverse events were component loosening (34%), infection (14.1%), component fracture (9.4%), inflammation (9.4%), and allergic reaction (7.8%). Regarding implant type, Cartiva SCI had the highest percentage of adverse events (23.4%), followed by Arthrosurface ToeMotion (20.3%), Ascension MGT (12.5%), Arthrosurface HemiCAP® (10.9%), Futura primus (9.4%), and Osteomed Reflexion (6.3%). There was an increase in reported adverse events after 2016. The MAUDE database does not report the total incidence of implant insertion.

CONCLUSION

Our study of the MAUDE database demonstrated that component loosening and infection are the most common modes of adverse events for hallux MTPJ implants. Cartiva accounted for one-fourth of the implant-related adverse events during our study period, followed by ToeMotion, and Ascension MGT implants. Continued reporting of adverse events will improve our understanding on short and long-term complications of various hallux MTPJ implants.

LEVEL OF EVIDENCE

Level IV; Case Series from Large Database Analysis; Treatment Study.

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.

Long-Term Results of Surgical Treatment of Valenti Procedures for Hallux Rigidus: A Minimum Ten-Year Follow-Up Retrospective Study

Few studies reporting long-term results of surgical treatment of hallux rigidus have been published. The aim of this study is to assess the clinical outcome of Valenti procedures in a series of patients with hallux limitus/rigidus with a minimum 10-year follow-up time. We retrospectively evaluated 38 patients (40 feet) who underwent a Valenti procedure with a mean follow-up of 132 ± 19.6 (range 114 to 184) months. All patients were clinically reassessed on the basis of the evaluation of pain (visual analogue scale), function (American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale Assessment and Foot & Ankle Disability Index), and subjective satisfaction. The scores before and after treatment, obtained from clinical recordings and clinical evaluation during the last follow-up visits, were compared. We found significant improvement of the mean values of the visual analogue score (p < .0001), Foot & Ankle Disability Index (p < .0001), and American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale Assessment (p < .0001) during the latest follow-up visits. The results suggest that the Valenti technique represents a safe, reproducible surgical procedure that allows satisfying long-term results. The few reported complications were essentially the progressive worsening of the joint stiffness, but no sesamoiditis, metatarsal overload, secondary surgeries, or failures were documented.

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.

Nonimplant Arthroplasty for the Treatment of End-Stage Hallux Rigidus

Surgical management of end-stage hallux rigidus involves joint-sparing techniques, including cheilectomy and decompression osteotomies, and joint-destructive procedures, including arthroplasty (resection, interpositional, implant, Valenti) and arthrodesis. Joint-destructive procedures have traditionally been reserved for the end stages of hallux rigidus involving grade 3 and 4. We present a modification of the previously reported Valenti arthroplasty with short-term patient outcomes. We performed a retrospective review of the medical records of 96 patients who had undergone the nonimplant arthroplasty procedure for treatment of end-stage hallux rigidus with a minimum follow-up period of 6 months. The preoperative and postoperative dorsiflexion of the first metatarsophalangeal joints and visual analog scale (VAS) scores were compared. Of the 96 medical records, 27 (28%) met the inclusion criteria. The mean patient age was 60.2 (range 48 to 73) years, and the mean follow-up period was 12 (range 6 to 23) months. The mean preoperative range of motion for first metatarsophalangeal joint dorsiflexion was 4.69° (range -3° to 10°), and the mean postoperative dorsiflexion was 48.23° (range 30° to 65°), with a mean difference of 43.54° (range 25° to 60°). The preoperative VAS score averaged 6.46° (range 4° to 10°), and the postoperative VAS score averaged 0.69° (range 0° to 3°). Nonimplant arthroplasty was found to increase first metatarsophalangeal joint dorsiflexion and significantly decrease patient pain. Thus, it is a viable option for the treatment of end-stage hallux rigidus.

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.

Pain after cheilectomy of the first metatarsophalangeal joint: diagnosis and management

Cheilectomy is commonly performed for osteoarthritis of the first metatarsophalangeal joint and generally has a successful outcome and high rate of patient satisfaction over the short to medium term. Despite the relatively good results achieved in most cases, a proportion of patients have ongoing pain after cheilectomy. This article outlines the potential causes of ongoing pain, including progression of osteoarthritis, neuralgic symptoms, and transfer metatarsalgia. Management strategies for treating the ongoing symptoms are discussed.

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.

Design of an implant for first metatarsophalangeal hemi-arthroplasty

This study was designed to examine the three-dimensional geometry of the head of the first metatarsal bone of the foot. Ninety-seven adult first metatarsal head (MTH1) bones were scanned using a laser scanner at 400 dpi. A best-fit ellipsoid was obtained from the articular surfaces of MTH1 for each size group using nonlinear unconstrained optimisation. Average root mean square errors between the articulating surfaces and the optimal fit surfaces of the bone specimens were between 0.29 and 0.42 mm. After classification based on sex and size groups, the profile provided a good fit to individual bones. Consideration of the thickness of cartilage overlying the metatarsal head (MTH) may further improve the fit. The proposed approach provides the basis for a design of an MTH hemi-arthroplasty that has good anatomical congruence with the native joint.

Evidence-based analysis of the efficacy for operative treatment of hallux rigidus

BACKGROUND

The aim of this article is to provide an evidence-based literature review and assessment of the quality of literature regarding operative interventions for hallux rigidus.

METHODS

A comprehensive evidence-based literature review of the PubMed database was conducted on June 24, 2011, identifying 586 articles, of which 135 were relevant in assessing the efficacy of common operative interventions for hallux rigidus. The 135 studies were then assigned a level of evidence (I-V) to denote quality. They were then reviewed to provide a grade of recommendation (A-C, I) in support of or against the operative intervention in treatment of hallux rigidus.

RESULTS

Based on the results of this evidence-based review, there is fair evidence (grade B) in support of arthrodesis for treatment of hallux rigidus. There is poor evidence (grade C) in support of cheilectomy, osteotomy, implant arthroplasty, resection arthroplasty, and interpositional arthroplasty for treatment of hallux rigidus. There is insufficient evidence (grade I) for cheilectomy with osteotomy for treatment of hallux rigidus.

CONCLUSION

There are no consistent findings in comparative studies that are properly powered with validated and appropriate outcome measures to allow any definitive conclusions on which procedure is best. However, the grade B recommendation assigned to arthrodesis may make it the logical leading candidate for future high-quality randomized controlled trials. Clearly, further studies-ideally, high-quality Level I randomized controlled trials with validated outcome measures-are needed to allow stronger recommendations to be made.

LEVEL OF EVIDENCE

Level III, systematic review.

Therapeutic management of the hallux rigidus

Background. Hallux rigidus is a chronic, disabling condition of foot characterized by reduced great toe extension. The manual therapy approaches are described theoretically however their practical published evidence has not been analyzed well. Objective. Aim of the present paper was to systematically review the literature available for therapeutic management of the hallux rigidus by identifying and evaluating the randomized controlled trials (RCTs) and non-RCTs. Methods. To view the hallux rigidus and its rehabilitation, a webbased published literature search of Pubmed, Ovid Medline, Science direct, Cochrane Database, PEDro database, CINAHL was conducted for last 35 years in August 2010 using 4 specific keywords "hallux rigidus, physical therapy, chiropractic, and manual therapy" typed in exactly same manner in the search column of the databases. Result. the review finds that there is acute need of the quality studies and RCTs for the manual therapy, chiropractic, or physiotherapeutic management of the hallux rigidus. Conclusion. Review conclude that conservative programs for hallux rigidus consists of comprehensive intervention program that includes great toe mobilization, toe flexor strengthening, sesamoid bones mobilization and long MTP joint. The clinician should put an emphasis on the mobilization program with proper follow up along with comparative studies for rehabilitation of hallux rigidus.

Quantitative review of operative management of hallux rigidus

INTRODUCTION

Surgical techniques for the management of hallux rigidus include cheilectomy, Keller resection arthroplasty, arthrodesis, Silastic implantation, phalangeal or metatarsal osteotomy, capsular arthroplasty, partial or total joint replacement, interposition arthroplasty. However, the optimal management is controversial.

SOURCES OF DATA

We performed a comprehensive search of CINAHL, Embase, Medline and the Cochrane Central Registry of Controlled Trials, from inception of the database to 2 November 2010. Sixty-nine articles published in peer reviewed journals were included in this comprehensive review.

AREAS OF AGREEMENT

Cheilectomy and first metatarsal or phalangeal corrective osteotomy may provide better outcome for patients with early and intermediate hallux rigidus (Stages I-II), while arthrodesis or arthroplasty are indicated to manage more severe conditions. The Coleman Methodology Score showed great heterogeneity in terms of study design, patient characteristics, management methods and outcome assessment and generally low methodological quality.

AREAS OF CONTROVERSY

Definitive conclusions on the use of these techniques for routine management of patients with hallux rigidus are not possible. Given the limitations of the published literature, especially the extensive clinical heterogeneity, it is not possible to compare outcomes of patients undergoing different surgical procedures and determine clear guidelines.

GROWING POINTS

To assess whether benefits from surgery, validated and standardized measures should be used to compare the outcomes of patients undergoing standard surgical procedures.

RESEARCH

There is a need to perform appropriately powered randomized clinical trials of using standard diagnostic assessment, common and validated scoring system comparing reported outcomes and duration of follow-up >2 years.

The need for surgical revision after isolated valenti arthroplasty for hallux rigidus: a systematic review

Isolated Valenti arthroplasty has been proposed for treatment of moderate to severe hallux rigidus because of the perceived safety and efficacy. Furthermore, it has been proposed that undergoing isolated Valenti arthroplasty does not prevent the ability to perform revision surgery consisting of Keller resection arthroplasty, prosthetic implant arthroplasty, or arthrodesis. The author undertook a systematic review of electronic databases and other relevant sources to identify material relating to the need for surgical revision after isolated Valenti arthroplasty for hallux rigidus. Information from peer-reviewed journals as well as non-peer-reviewed publications, abstracts, and posters was also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing isolated Valenti arthroplasty, if they evaluated patients in person at mean follow-up > or = 12 months' duration, and if they included details of complications after Valenti arthroplasty requiring surgical intervention. Three studies involving isolated Valenti arthroplasty were identified that met the inclusion criteria. Therefore, a total of 44 isolated Valenti arthroplasties were identified that met the inclusion criteria, with 2 (4.6%) undergoing surgical revision in the form of Keller resection arthroplasty (n = 1) and 1 plantarflexory base osteotomy (n = 1). No studies provided detailed information regarding complications specific to the exact grade of hallux rigidus in patients who underwent isolated Valenti arthroplasty. The results of this systematic review make clear the low incidence of revision surgery required after isolated Valenti arthroplasty for hallux rigidus. However, there is still a need for methodologically sound prospective cohort studies that focus on the use of isolated Valenti arthroplasty for specific grades of hallux rigidus and compare this procedure with other accepted forms of surgical treatment for moderate to severe hallux rigidus.

Outcome following autogenous soft tissue interpositional arthroplasty for end-stage hallux rigidus: a systematic review

Autogenous soft tissue interpositional arthroplasty has been proposed as an alternative to arthrodesis and other forms of arthroplasty for treatment of end-stage hallux rigidus because of the perceived safety and efficacy. The author undertook a systematic review of electronic databases and other relevant sources to identify material relating to the outcomes following autogenous soft tissue interpositional arthroplasty for end-stage hallux rigidus. Information from peer-reviewed journals, as well as from non-peer-reviewed publications, abstracts and posters, textbooks, and unpublished works, were also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing isolated autogenous soft tissue interpositional arthroplasty for the treatment of end-stage hallux rigidus, evaluated patients at mean follow-up of 12-months' duration or longer, included pre- and postoperative range of motion of the first metatarsal-phalangeal joint, determined pre- and postoperative outcomes using a scoring system, and documented any complications. Two studies involving a total of 28 autogenous soft tissue interpositional arthroplasties for end-stage hallux rigidus were identified that met the inclusion criteria. There were 12 men (52%) and 11 women (48%) with a mean age of 58.2 years followed for a mean of 21.6 months. Both studies used the AOFAS First Metatarsal-Phalangeal-Hallux Scoring System, which had a mean of 26.0 preoperatively rising to 89.4 postoperatively. First metatarsal-phalangeal joint dorsiflexion had a mean of 16.7 degrees preoperatively rising to 51.1 degrees postoperatively. Complications occurred in 4 (14.3%) feet and no feet required surgical revision. The results of this systematic review demonstrate improvement in patient outcomes and first metatarsal-phalangeal joint dorsiflexion, as well as few complications following autogenous soft tissue interpositional arthroplasty for end-stage hallux rigidus. However, there is still a need for methodologically sound prospective cohort studies that compare autogenous soft tissue interpositional arthroplasty with other forms of arthroplasty and arthrodesis for end-stage hallux rigidus.