The effect of first metatarsophalangeal arthrodesis on transverse plane deviation of the second toe: a retrospective radiographic study

Which parameters predict correction of the intermetatarsal angle after first metatarsophalangeal fusion?

Fusion of the first metatarsophalangeal joint (MTPJ) is a commonly performed surgical procedure. Although the effect of first MTPJ fusion on reduction of Intermetatarsal angle (IMA) is well described, contributing factors remain unclear. The aim of this study was to identity predictive parameters for IMA reduction. Fifty-one patients (68 feet) who underwent a first MTPJ fusion and had an IMA greater than fourteen degrees were assessed retrospectively. The average age was 68 (31.4-79.3) years. Sixteen demographic and radiographic variables were evaluated using a multivariate regression analysis for association with change in IMA after surgery. The mean preoperative IMA was 16.11 (range, 14.0-22.5) degrees with a mean reduction of 4.95 (range, 0-17) degrees after surgery. Multivariate regression analysis revealed three significant independent predictors of the change in IMA. Increased preoperative IMA (β = .663, CI = .419, .908, P <.001), increased preoperative translation at base of MT1 (β = .490, CI = 0.005, .974, P = 0.039), and less postoperative translation in the fusion (β= -0.693, CI= -1.054, -.331, P= 0.002) significantly increased the amount of IMA reduction. Pre-operative IMA and translation at the base of the first metatarsal were positive predictors for correction of IMA after first MTPJ fusion. Translation at the level of the MTP I fusion was a negative predictor for the amount of IMA correction. Based on these findings, we recommend minimizing the lateral translation of the proximal phalanx relative to the metatarsal head to optimize IMA correction after MTPJ fusion.

Intermetatarsal Angle and Hallux Abductus Angle Reduction After First Metatarsophalangeal Joint Arthrodesis in Mild, Moderate, and Severe Hallux Valgus

BACKGROUND

First metatarsophalangeal joint fusion is a commonly used procedure for treating many pathologic disorders of the first ray. Historically, hallux valgus deformity with severely increased intermetatarsal angle or metatarsus primus adductus indicated need for a proximal metatarsal procedure. However, the effectiveness and reliability of first metatarsophalangeal joint arthrodesis in reducing the intermetatarsal angle has been increasingly described in the literature. We compared findings at our institution with current literature for further validation of this well-accepted procedure in correcting hallux valgus deformity with high intermetatarsal angle.

METHODS

Weightbearing preoperative and postoperative radiographs of 43 patients, 31 women and 12 men, meeting the inclusion and exclusion criteria were identified. Two independent investigators measured the hallux abductus and intermetatarsal angles. Preoperative and postoperative measurements for each angle were compared and average reduction calculated. The data were further analyzed by grouping deformities as mild, moderate, and severe. Mean follow-up was 10 months.

RESULTS

The overall mean preoperative intermetatarsal and hallux abductus angles decreased significantly (from 13.09° to 9.33° and from 23.72° to 12.19°, respectively; both P < .01). When grouping deformities as mild, moderate, and severe, all of the categories maintained reduction of intermetatarsal and hallux abductus angles (P < .01). Furthermore, the mean reduction of the intermetatarsal and hallux abductus angles seemed to correlate with preoperative deformity severity.

CONCLUSIONS

In patients undergoing correction of hallux valgus deformity, first metatarsophalangeal joint arthrodesis produced consistent reductions in the intermetatarsal and hallux abductus angles. Furthermore, these findings are consistent with those reported by other institutions.

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.

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.

Reduction of the intermetatarsal angle after first metatarsal phalangeal joint arthrodesis: a systematic review

Arthrodesis of the first metatarsophalangeal joint (MTPJ) has commonly been used for the treatment of a variety of first MTPJ disorders, including hallux valgus. We undertook a systematic review of the electronic databases and other relevant sources to identify material relating to the reduction of the first intermetatarsal angle (IMA) after first MTPJ arthrodesis. Fifteen studies with a total of 701 first MTPJ arthrodesis procedures were identified that met the inclusion criteria. Our results showed the mean preoperative IMA was 13.74° and the mean postoperative IMA was 9.38°, for a mean change in the IMA of 4.36°. The data were analyzed further in 2 subsets. The first subset included 8 studies (434 procedures) that reported a mean preoperative IMA of less than 15°. The mean change in the IMA in this group was 3.70°. The second subset included 7 studies (267 procedures) that reported a mean preoperative IMA of greater than 15°. The mean change in the IMA in this group was 5.42°. The results of the present systematic review have confirmed that a significant reduction of the first IMA can be achieved by first MTPJ arthrodesis alone and that additional procedures to correct the IMA will not be necessary.