Radiographic outcomes following primary arthrodesis of the first metatarsophalangeal joint in hallux abductovalgus deformity

Crossed screws versus plating supplemented with an interfragmentary screw in first metatarsophalangeal joint fusion: A systematic review and meta-analysis

First metatarsophalangeal joint (MTPJ) fusion is an effective surgical intervention for conditions such as hallux valgus and hallux rigidus. This systematic review and meta-analysis aims to compare the safety and efficacy of crossed screws versus plating supplemented with an interfragmentary screw. A literature search of the Scopus, Embase, Web of Science, and MEDLINE databases was performed to identify all studies directly comparing the two techniques. Meta-analysis was carried out using RevMan Web. Nine studies with 976 patients (1,035 toes in total, 512 toes in the crossed screws group, and 523 toes in the plate supplemented with screws group) were included. There was no significant difference in union rates (OR=0.75, CI 0.45 - 1.27, p = 0.29), overall complication rates (OR = 1.13, CI = 0.71 - 1.77, p = 0.61), superficial complications, (OR = 0.41, CI = 0.10 - 1.68, p = 0.22), revision surgery (OR = 1.92, CI 0.81 - 4.57, p = 0.14), hardware removal (OR = 1.07, CI = 0.55 - 2.08, p = 0.85), and malunion (OR = 1.63, CI 0.27 - 10.00, p = 0.60). Plate and screws had a significantly shorter time to fusion than crossed screws (MD = 0.51, CI = 0.10 - 0.92, p = 0.02). No significant difference was noted in patient-reported outcome measures or in postoperative hallux valgus, intermetatarsal, and lateral metatarsophalangeal angles. Other potential factors that should influence the decision to use one technique over the other include the indication for MTPJ fusion, the patient's bone quality, and the differing costs of surgery.

Prediction of angular correction following first metatarsal-phalangeal joint arthrodesis

The literature has established that the first metatarsal-phalangeal joint arthrodesis procedure will provide some correction of the first intermetatarsal and hallux valgus angles. But while this has previously primarily been investigated as a simple association (i.e. comparison of pre-operative to post-operative values), the objective of this investigation was to consider angular change as a continuous variable and to specifically correlate it with pre-operative values. Radiographs from 100 consecutive first metatarsal-phalangeal joint arthrodeses meeting selection criteria were evaluated. A negative Pearson correlation coefficient was observed between the pre-operative first intermetatarsal angle and intraoperative change in the first intermetatarsal angle (Pearson -0.547; p<0.001). In other words, with progressively increased levels of pre-operative intermetatarsal angle deformity, one should expect greater intermetatarsal angle correction. The relationship is described by the equation Y = 2.82 - 0.38X indicating that for every one degree of pre-operative intermetatarsal deformity over approximately 7 degrees, 0.38 degrees of post-operative correction might be expected. A negative Pearson correlation was observed between the pre-operative hallux valgus angle and the intraoperative change in the first hallux valgus angle (Pearson -0.806; p<0.001). In other words, with progressively increased levels of pre-operative hallux valgus angle deformity, one should expect greater hallux valgus correction. The relationship is described by the equation Y = 5.5 - 0.63X indicating that for every one degree of pre-operative hallux valgus angle deformity over approximately 9 degrees, 0.63 degrees of hallux valgus angle post-operative correction might be expected. Results of this investigation demonstrate a statistical correlation between pre-operative radiographic deformity and intermetatarsal angle and hallux valgus angle post-operative correction, and might provide foot and ankle surgeons with a degree pre-operative prediction of expected angular correction following the procedure.

Modified minimally invasive chevron osteotomy versus traditional incision chevron osteotomy

PURPOSE

This study aimed to compare modified minimally invasive chevron osteotomy (MIC group) and traditional incision chevron osteotomy (TIC group) for correction of mild to moderate hallux valgus deformity.

METHODS

This retrospective study enrolled 42 patients (60 feet) with mild to moderate hallux valgus deformities who were treated with modified MIC osteotomy or TIC osteotomy between January 2020 and June 2021. The patients were divided into the MIC and TIC groups according to whether the treatment received was minimally invasive. The MIC group included 20 patients (28 feet), comprising 1 male and 19 female patients; aged 37.15 ± 14.60 years, with mild hallux valgus deformity in 12 cases (14 feet) and moderate hallux valgus deformity in 8 cases (14 feet). In the TIC group comprising 22 patients (32 feet), including 1 male and 21 female patients, aged 40.95 ± 11.60 years, mild and moderate hallux valgus deformities were observed in 10 (18 feet) and 12 cases (14 feet), respectively. Preoperatively and at the last follow-up, the American Orthopedic Foot and Ankle Society (AOFAS) hallux, lesser toe score, and visual analog scale (VAS) pain were used to evaluate clinical efficacy. The hallux valgus angle (HVA), 1-2 metatarsal angle (1-2IMA), and distal metatarsal articular angle (DMAA) were measured and compared on the weight-bearing X-ray film of the foot preoperatively and postoperatively. At the last follow-up, recurrence of hallux valgus deformity, hallux adduction deformity, metatarsal head necrosis, metastatic plantar pain, and other complications were recorded.

RESULTS

All 42 patients were followed up, and the follow-up time of the MIC group was 24.70 ± 6.63 months; The follow-up time of the TIC group was 22.82 ± 6.12 months, and there was no significant difference in follow-up time between the two groups (P > 0.05). One patient in the MIC group experienced pain in the dorsal side of the front foot postoperatively; one patient in the TIC group had a superficial infection of the incision postoperatively. There were no significant differences in age, gender, side classification, course of the disease, degree of hallux valgus deformity, and postoperative complications between the two groups (P > 0.05). The AOFAS scores, VAS, HVA, 1-2IMA, and DMAA in the MIC group improved from 54.61 ± 7.60, 4.50 ± 0.79, 28.38° ± 5.02°, 12.88° ± 1.50°, 12.03° ± 1.88°preoperatively to 89.93 ± 4.96, 2.04 ± 1.10, 10.27° ± 1.68°, 7.49° ± 0.95° and 7.83° ± 1.33° at the last follow-up, the difference was statistically significant (P < 0.05); the AOFAS score, VAS, HVA, 1-2IMA, and DMAA of the TIC group improved from 57.31 ± 7.59, 4.34 ± 0.70, 28.45° ± 4.47°, 12.88° ± 1.50°, 12.16° ± 1.81° preoperatively to 87.97 ± 5.96, 2.00 ± 1.11, 10.99° ± 2.25°, 7.49° ± 0.95°, and 8.25° ± 1.12° at the last follow-up, the difference was statistically significant (P < 0.05), but there was no significant difference in AOFAS score, VAS, HVA, 1-2IMA, and DMAA between the two groups (P > 0.05). The incision length of the MIC group was 2.06 ± 0.20 cm, and the incision length of the TIC group was 5.04 ± 0.54 cm, which was statistically significant (P < 0.05).

CONCLUSION

Whether it is modified minimally invasive chevron osteotomy or traditional incision chevron osteotomy, mild and moderate hallux valgus deformity is effectively treated, and the clinical efficacy and imaging results after surgery are significantly improved. Compared with traditional incision chevron osteotomy, the modified minimally invasive chevron osteotomy has a smaller incision and less trauma for mild to moderate hallux valgus.

Immediate Weightbearing Following First Metatarsal Phalangeal Joint Arthrodesis With 2 Nickel Titanium Alloy Staples

The use of staples has been shown to be a reasonable fixation technique to achieve stability of a first MTPJ arthrodesis. Although it has been shown to be a weaker construct than crossed screws or plate and screw combinations, their ease of insertion, low profile, and stability make them a desirable choice for first MTPJ arthrodesis fixation. However, because of this relative weakness, the question remains whether immediate weightbearing when using staples is advisable. The aim of this study is to determine whether the use of 2 nickel-titanium alloy (NITINOL) staples, placed at 90 degrees to one another is a stable enough construct to support full, immediate weightbearing following first MTPJ arthrodesis. We performed a retrospective chart review of patients undergoing first MTPJ arthrodesis by a single surgeon utilizing 2 NITINOL staples placed at 90 degrees to one another. Patients were allowed to be fully weightbearing immediately postoperatively. Forty-seven of 50 (94%) patients achieved complete radiologic consolidation of fusion at 12 weeks, with only 3 requiring revision surgery for nonunion. All of the patients requiring revision surgery for nonunion, had preoperative diagnosis of hallux abducto valgus. We concluded that the use of 2 NITINOL staples placed at 90 degrees to one another is a viable option for first MTPJ arthrodesis, and immediate weightbearing does not increase rate of nonunion or incidence of revision surgery when compared to other fixation techniques.

A Novel Plating System for First Metatarsophalangeal Joint Arthrodesis: A Retrospective Comparison of Hybrid and Traditional Locking Plate Constructs

BACKGROUND

Dorsal plate fixation is commonly used for first metatarsophalangeal joint (1st MTPJ) arthrodesis and plate design continues to evolve. A new staple compression plate (SCP) design attempts to utilize the continuous compression of a nitinol staple across the fusion site while simultaneously providing the stability of a dorsal locked plate. Herein, we compare the radiographic, clinical, and patient-reported outcomes of 1st MTPJ joint arthrodesis using 2 dorsal locking plate constructs including a novel SCP construct.

METHODS

Forty-four patients who underwent 1st MTPJ arthrodesis between 2016 and 2020 were retrospectively evaluated. There were 2 group cohorts. Group 1 cohort included 23 patients who received a CrossRoads Extremity SCP, and Group 2 cohort included 21 patients who received a Stryker dorsal locking precontoured titanium plate (LPP). All patients were evaluated with radiographs, Patient-Reported Outcomes Measures Information System (PROMIS) outcome scores, and Foot Function Index (FFI).

RESULTS

The complication and union rates did not vary between groups with a fusion rate of 95.7% in the SCP group and 90.5 % in the LPP group. Similarly, we found no significant differences in PROMIS or FFI scores between the SCP and LPP plates.

CONCLUSION

Use of either dorsal locking plate construct for 1st MTPJ arthrodesis was associated with high union rates and comparable functional outcomes. As locked plate technology continues to evolve for 1st MTPJ arthrodesis, it is important that clinical outcomes are reported.

LEVELS OF EVIDENCE

Level IV.

What Do Patients Report Regarding Their Real-World Function Following Triplane Metatarsophalangeal Joint Arthrodesis for Hallux Valgus?

First metatarsal phalangeal (MTP) joint arthrodesis has been employed for decades for pain related to arthritis and other associated abnormalities. Despite the commonality of the procedure there continues to be questions regarding functional expectations following the procedure especially when employed for correction of hallux valgus deformity. We surveyed 60 patients who had a tri plane MTP joint arthrodesis at mean 28.4 months (median 27.8) regarding their activities of daily living and sports activity through a direct conversation. Secondary endpoints assessed were return to activity, deformity correction and arthrodesis healing rate based on chart review and weightbearing radiographs. The primary outcomes showed robust return to all activities of daily living with 96.7% able to walk without restrictions and or pain, 98.3% were able to walk at a normal pace and 95% responded that loss of motion of their big toe did not affect their daily function. Regarding return to sports all patients that participated in sports before surgery resumed participation after with a trend toward increased sports activity. Early return to walking in a fracture boot was noted in this cohort at mean 4.1 days, return to athletic shoe at mean 6.3 weeks and full unrestricted activity at mean 13.3 weeks with no non-unions identified on radiographic or clinical exam. Deformity correction of the typical components of hallux valgus deformity was similar to previously published studies. This data set supports the hypothesis that patients undergoing first MTP joint arthrodesis can expect rapid and full return to activities of daily living and sports with a low complication rate.

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.

What Do Patients Report Regarding Their Real-World Function Following Triplane Metatarsophalangeal Joint Arthrodesis for Hallux Valgus?

First metatarsalphalangeal (MTP) joint arthrodesis has been employed for decades for pain related to arthritis and other associated abnormalities. Despite the commonality of the procedure there continues to be questions regarding functional expectations following the procedure especially when employed for correction of hallux valgus deformity. We surveyed 60 patients who had a triplane MTP joint arthrodesis at mean 28.4 months (median 27.8) regarding their activities of daily living and sports activity through a direct conversation. Secondary endpoints assessed were return to activity, deformity correction and arthrodesis healing rate based on chart review and weightbearing radiographs. The primary outcomes showed robust return to all activities of daily living with 97% able to walk without restrictions and or pain, 98% were able to walk at a normal pace and 95% responded that loss of motion of their big toe did not affect their daily function. Regarding return to sports all patients that participated in sports before surgery resumed participation after with a trend toward increased sports activity. Early return to walking in a fracture boot was noted in this cohort at mean 4.1 days, return to athletic shoe at mean 6.3 weeks and full unrestricted activity at mean 13.3 weeks with no non-unions identified on radiographic or clinical exam. Deformity correction of the typical components of hallux valgus deformity was similar to previously published studies. This data set supports the hypothesis that patients undergoing first MTP joint arthrodesis can expect rapid and full return to activities of daily living and sports with a low complication rate.

First Metatarsophalangeal Arthrodesis for Hallux Rigidus and Hallux Valgus: A Comparison of Patient Reported and Clinical Outcomes

Few prior studies have compared the patient reported outcomes of first metatarsophalangeal arthrodesis between hallux rigidus and hallux valgus patients. Furthermore, we sought to examine the impact of postoperative radiographic hallux alignment on outcomes scores within each group. A retrospective review of 98 patients who a received primary metatarsophalangeal arthrodesis from January 2010 to March 2020. Clinical complications including nonunion were collected. Patient Reported Outcomes Measurement Information Systems (PROMIS) Physical Function, PROMIS Pain Interference, and the foot function index (FFI) revised short form scores were obtained via telephone. Patients were grouped based on review of preoperative radiographs of the foot and this grouping 37 hallux rigidus and 61 hallux valgus patients. Clinical and patient reported outcomes were compared between these pathologies. No differences in the rate of wound complications, radiographic union, and revision surgery were found between the 2 subgroups. At a median of 2.4 years (3.9 IQR) postoperatively, PROMIS and FFI scores did not vary by pathology group. For both groups, PROMIS scores were similar to the general population of the United States. The postoperative first MTP dorsiflexion angle in the hallux rigidus group was correlated with decreased FFI Pain, FFI Total, and PROMIS Pain Interference domain scores (|r| ≥ 0.40, p < .05 for all). When performing MTP arthrodesis in patients with hallux rigidus, increasing the first MTP dorsiflexion angle may correlate with improved intermediate term patient reported outcomes. However, further studies will need to be done to confirm this theoretical relationship.

High Utility of the 1st Metatarsal Phalangeal Joint Fusion

Fusion of the first metatarsophalangeal joint has been used by foot and ankle surgeons as a reproducible and useful means of treating end-stage arthritis of the great toe. However, the overall utility and successful outcomes of this procedure have led to its incorporation into the treatment of more significant bunion deformities, reconstruction forefoot, and salvage procedures. The authors review surgical fixation methods, offer insightful technical pearls for challenging cases and share examples of complex reconstructive and salvage procedures.

Functional Capabilities After First Metatarsal Phalangeal Joint Arthrodesis Using a Locking Plate and Compression Screw Construct

Arthrodesis of the first metatarsal phalangeal joint (MTPJ) is a widely utilized surgical procedure for a wide array of metatarsal pathologies. This study aims to explore the functional limitations following first MTPJ arthrodesis, overall satisfaction and patient's abilities to achieve activities of daily living (ADL). This prospective cohort study assessed functional limitations as well as footwear and lifestyle restrictions using several questionnaires. One hundred and three participants who had a first MTPJ arthrodesis under the care of a single surgeon were recruited. Pre- and postoperative patient-reported outcome measures were recorded. The American Orthopaedic Foot and Ankle Score (AOFAS) and the Manchester-Oxford Foot Questionnaire were also used to further examine functional status. Hallux valgus angle (HVA) and intermetatarsal angle (IMA) were compared using preoperative and postoperative weightbearing radiographs and successful fusion was recorded. Complications were documented and are discussed in detail. The duration of follow-up was more than 12 months. There was one nonunion in the cohort while 2 patients experienced delay to fusion. Approximately 97% of patients were very satisfied with the procedure and their ability to achieve ADLs post operatively. A further 82.5% of patients were able to return to wearing nonadaptive footwear. The mean reduction in HVA and IMA was 21.78° and 6.84°, respectively. This study demonstrates the safe and successful use of a compression screw/locking plate construct for arthrodesis of the first MTPJ. Furthermore, the study provides clear evidence of high levels of functionality after the procedure with statistically significant differences (p value <.05) in all 4 facets of the AOFAS questionnaire as well as several notable differences in activity levels and footwear restrictions pre and postoperatively.

Juvenile Hallux Valgus

Treatment of juvenile hallux valgus can be challenging. Initial treatment with conservative measures is appropriate until exhausted. Surgical treatment should be delayed until after skeletal maturity when possible. Before any intervention, a thorough understanding of the whole patient and any underlying systemic contributors to their hallux valgus, in addition to the radiographic foot parameters, is imperative. Careful and individualized surgical planning should be done to optimize results and decrease the risk for recurrence.

Risk Factors for Nonunion After First Metatarsophalangeal Joint Arthrodesis With a Dorsal Locking Plate and Compression Screw Construct: Correction of Hallux Valgus Is Key

First metatarsophalangeal joint (MTPJ) arthrodesis is currently the gold standard technique for advanced hallux rigidus. This retrospective study aimed to identify the risk factors for nonunion after first MTPJ arthrodesis with a dorsal locking plate and compression screw construct. Between April 2014 and April 2019, 165 consecutive patients (28 men and 137 women; mean age, 60 (range, 28-84) years) who underwent 178 primary first MTPJ arthrodeses were retrospectively reviewed. All arthrodeses were performed using either a dorsal locking plate with an integrated compression screw (Anchorage CP plate, Stryker, n = 97) or a dorsal locking plate (Anchorage V2 plate, Stryker, n = 81) with a separate compression screw (4 mm cannulated ACE screw). Union was defined as bone bridging across the fusion site on at least 2 of the 3 standard foot radiographs (anteroposterior, lateral, oblique) and no MTPJ movement or pain during clinical examination. Potential risk factors for nonunion were analyzed with the use of univariate and multivariate analyses. The overall nonunion rate was 6.2% (11 of 178 cases). The risk factors identified in the univariate analysis included preoperative hallux valgus deformity, postoperative residual hallux valgus deformity, and diabetes (p < .05). Multivariate analysis confirmed that postoperative residual hallux valgus deformity (odds ratio 6.5; p= .015) and diabetes (odds ratio 7.4; p = .019) are independent risk factors for nonunion after first MTPJ arthrodesis. Diabetes is the most important independent risk factor for nonunion after first MTPJ arthrodesis with a dorsal locking plate and compression screw construct. A residual postoperative hallux valgus deformity is associated with a significantly increased risk for nonunion. It is therefore crucial to correct the hallux valgus deformity to a hallux valgus angle of less than 20°.

The Realign-Resect Arthrodesis Technique

During traditional fusion procedures surgeons initially perform a joint resection and then the structures are realigned for correction of deformity. The procedure described herein by the author reverses this traditional surgical approach by first realigning the joint to correct deformity, then after achieving a corrected alignment, joint resection is performed in parallel without wedging. Realigning deformity as an initial step creates the conditions for an in-situ fusion wherein the deformity is corrected simultaneously with parallel bone resection. The purpose of this paper is to review the advantages and technical aspects of a realignment arthrodesis technique in which joint resection begins with the foot in the corrected position. This approach to joint fusion has been shown to simplify bone resection, eliminate post-resection adjustments, create full apposition of fusion surfaces, reliably correct deformity, and result in solid arthrodesis. The technique provides for immediate correction of deformity and is amenable for conditions that require either minimal or significant segmental shortening. There are many areas where the "Realign-resect" approach to joint fusion would be well suited. Full implementation of this technique may be particularly useful to the surgeon who does not have seasoned assistants in the operating room.

Clinical and radiological outcomes after arthrodesis of the first metatarsophalangeal joint

PURPOSE

The main aim of this study was to investigate the correlation between radiographic findings and clinical outcomes following the first metatarsophalangeal (MTP) joint arthrodesis.

METHODS

In a comparative retrospective study, on 46 patients (48 ft), the correlation between post-operative radiographic findings including hallux valgus angle (HVA) and first MTP dorsiflexion angle (MTPDA) and clinical outcomes including VAS pain, modified AOFAS hallux score, and FFI questionnaire were evaluated. Moreover, clinical outcomes were compared between cases with pre-operative diagnosis of first MTP inflammatory arthritis, hallux valgus, hallux varus, and grade 3 and 4 of hallux rigidus. The effect of first MTP arthrodesis on Meary's angle and intermetatarsal angle (IMA) were found out.

RESULTS

The mean age of the patients was 56.3 ± 9.1 (range, 29-69) years, including 42 (91.3%) females and 4 (8.7%) males. We had fusion rate of 97.9%, one asymptomatic nonunion case (2.1%). Totally, mean scores of modified AOFAS hallux score, FFI percentage, and VAS pain were 88.9 ± 12.6, 9.4 ± 16.5, and 1.23 ± 2.24, respectively. Hallux varus was associated with the most favourable outcomes; whereas, patients with first MTP arthritis got the worst outcome. Regression analysis test between clinical outcomes and HVA > 15° and first MTPDA >15° showed correlation coefficient of almost zero. No statistically significant differences were found between the clinical outcomes of grade 3 and 4 of hallux rigidus (p value of modified AOFAS hallux score, FFI percentage, and VAS pain: 0.879, 0.906, and 0.298, respectively). Mean of HVA and IMA reduction in 15 hallux valgus underwent first MTP fusion were 34.4° and 8.4°, respectively. Meary's angle increased about 4° with statistically significant difference (p value 0.001).

CONCLUSION

Patients with first MTP fusion > 15° in coronal and transverse plans could have acceptable clinical outcomes. The clinical outcome of first MTP arthrodesis for grade 3 hallux rigidus is comparable with grade 4. First MTP fusion would have positive effect on IMA and Meary's angle.

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.

Clinical and imaging assessment and treatment of hallux valgus

Hallux valgus is a common condition estimated to affect as many as 23% of adults. The condition is associated with a variety of debilitating symptoms leading to significant morbidity and quality of life issues. Proper evaluation of this deformity and the timely management of its symptoms can improve hallux valgus-related symptomatology and quality of life. The most commonly used and readily reproduced measurements for assessing hallux valgus are the inter-metatarsal angle and the hallux valgus angle. These angles are helpful for choosing and planning surgical intervention for patients who fail initial conservative measures with distal osteotomies reserved for mild or moderate hallux valgus and proximal osteotomies indicated for more moderate to severe deformities. After reading this review article, readers will gain knowledge of the etiopathogenesis of hallux valgus, measurement parameters, and treatment strategies with representative case examples.

Modified SERI technique in the treatment of hallux valgus combined with arthritis

INTRODUCTION

Few reports encompass the treatment of first metatarsophalangeal joint (MTPJ) arthritis complicating hallux valgus. Indeed, in the literature, there is a lack of guidance concerning the management of patients affected by mild to moderate first MTPJ arthritis complicating hallux valgus. The aim of this study is to present the mid-term results of an original joint-preserving surgical technique.

MATERIALS AND METHODS

A group of 50 patients (60 feet) affected by mild to moderate first MTPJ arthritis complicating hallux valgus who underwent modified Giannini's SERI (simple, effective, rapid, inexpensive) surgical procedure were prospectively reviewed. They were clinically and radiographically evaluated preoperatively and after surgery and were also assessed using the American Orthopedic Foot and Ankle Society (AOFAS) score and Coughlin and Shurnas classification. The average follow-up was 38 months. A multivariate analysis was performed to evaluate the existing relationship between postoperative AOFAS results and radiological preoperative measured angles and sesamoid grade of dislocation.

RESULTS

The average AOFAS score significantly improved at last follow-up to an average of 90.5 ± 14.5, while preoperatively it was 45.6 ± 15.3 ( p < 0.001). On multivariate analysis, a statistically significant correlation resulted among all the radiographic preoperative registered parameters and clinical postoperative results. However, it was shown that any radiological parameter alone could not predict a better clinical recovery.

CONCLUSIONS

The surgical technique proposed here could extend the indications of the SERI procedure to those patients affected by mild to moderate hallux valgus combined with mild to moderate osteoarthritis.

First metatarsophalangeal fusion using joint specific dorsal plate with interfragmentary screw augmentation: Clinical and radiological outcomes

BACKGROUND

This study reports the outcome of a plating system for arthrodesis of the first metatarsophalangeal joint (1st MTPJ) that incorporates a lag compression screw within a low profile titanium plate with a predetermined contour. This is the first report of the outcomes of this implant from a non-affiliated centre.

PATIENT AND METHODS

This is a prospective cohort study of 40 consecutive primary 1st MTPJ arthrodesis procedures. The mean age of the cohort was 56 years (range, 20-74 years). The diagnosis was hallux rigidus in 31 patients and inflammatory arthropathy in 7 patients.

RESULTS

All patients achieved clinical union at 6 weeks and radiological union was confirmed on plain radiographs between 6-16 weeks. One case of hardware removal was reported.

CONCLUSION

The cohort achieved consistently satisfactory results with a reliable and reproducible MTPJ position and a 100% union rate. There was a low rate of hardware removal.

LEVEL OF EVIDENCE

Level IV evidence. Prospective cohort study.

Early Weight-Bearing After Arthrodesis of the First Metatarsal-Phalangeal Joint: A Systematic Review of the Incidence of Non-Union

Arthrodesis of the first metatarsal-phalangeal joint is a reliable procedure for correction of both hallux limitus/rigidus and severe hallux abducto valgus deformities. However, 1 potential contraindication to the procedure is the extended period of non-weight-bearing immobilization that is typically associated with the postoperative course. The objective of this investigation was to perform a systematic review of the incidence of non-union after early weight bearing in patients who underwent arthrodesis of the first metatarsal-phalangeal joint. We performed a review of electronic databases with the inclusion criteria of retrospective case series, retrospective clinical cohort analyses, and prospective clinical trials with n ≥ 15 feet, a mean follow-up of ≥12 months, a defined postoperative early weight-bearing protocol (defined as ≤2 weeks), a clear description of the fixation construct, a reported incidence rate of non-union, and patients who underwent primary surgery for hallux abducto valgus or hallux limitus/rigidus deformities. Seventeen studies met our inclusion criteria, with a total of 898 feet analyzed. Of these, 57 (6.35%) were described as developing a non-union. This would likely be considered an acceptable crude, heterogeneous incidence of non-union when considering this procedure. It might also indicate that arthrodesis of the first metatarsal-phalangeal joint does not always require an extended period of non-weight-bearing postoperative immobilization.

Do Postoperative Hallux Angles Correlate With Outcome in MP1 Fusion? Our Experience With 71 Cases

PURPOSE

To determine if the postoperative alignment of the hallux influences the final clinical outcome of hallux metatarsophalangeal joint (first MTPJ) arthrodesis.

METHODS

A total of 71 consecutive cases (hallux rigidus) were studied in stages 3 and 4. They were operated through arthrodesis between 2008 and 2014. The follow-up mean was 7.3 years. The AOFAS (American Orthopaedic Foot and Ankle Society) test was performed preintervention and per annum. In radiology, both the hallux valgus angle and the dorsiflexion angle of the first MTPJ were studied. Furthermore, clinical outcomes were evaluated according to the type of implant used.

RESULTS

Preoperative AOFAS score was 27.5, rising to 91.3 after the intervention ( P < .01). The improvement test average was 63.6. There were 17 local complications (23%), 7 of them were considered to be major complications (9%), 6 of which needed reoperation (8.5%). The dorsiflexion angle postoperative mean was 21.7°. The hallux valgus angle postoperative mean was 10.9°. No correlations between both angles, and improved AOFAS score or complications ( P > .4 and P > .5, respectively), were found. Patients who had a dorsiflexion angle higher than 20° had greater improvement in the AOFAS score compared with those who had angles lower than 20° (64.5 vs 59.6 points). Nevertheless, this result was not statistically significant ( P = .059). No differences in AOFAS score improvement regarding arthrodesis plate ( P > .1) were found.

CONCLUSION

First MTPJ arthrodesis is a good alternative for patients in advanced hallux rigidus stages when conservative treatment fails. We could not confirm if a better postoperative alignment may influence in clinical outcomes. However, better results are obtained with dorsiflexion angle greater than 20° than with those with less than 20°. Likewise, any differences between the 2 arthrodesis plates have been able to confirm.

LEVELS OF EVIDENCE

Level III: Retrospective cohort study.

Effect of joint pathology, surface preparation and fixation methods on union frequency after first metatarsophalangeal joint arthrodesis: A systematic review of the English literature

BACKGROUND

The aim of this systematic review was to perform a qualitative synthesis of the current literature to determine the union frequencies for first metatarsophalangeal joint arthrodesis as well as the influence of pathology, joint preparation and fixation methods on union.

METHODS

MEDLINE and EMBASE were searched to identify relevant studies reporting on first metatarsophalangeal joint union frequencies.

RESULTS

26 studies with 2059 feet met our inclusion criteria. The mean age was 60 years (range 18-84) and the mean follow-up was 32.6 months (range 1.5-156). The union frequency was 93.5% (1923/2059). The union frequencies were significantly higher when low velocity joint preparation methods were used (P<0.0001, Chi Square 22.5) and the pathology was hallux rigidus (P=0.002, Chi square 9.3). There were similarly high union frequencies with crossed screws, locking plate and non-locking plates.

CONCLUSIONS

High union frequency can be expected following first metatarsophalangeal arthrodesis, especially when low velocity joint preparation methods are used in patients with hallux rigidus.

[Rheumatic forefoot deformities]

The frequency and extent of rheumatic forefoot deformities have been greatly reduced since the introduction of disease-modifying antirheumatic drugs (DMARD). The accompanying reduction in arthritic destruction of joints opens up new treatment options whereby priority is given to joint preservation. This is true for the first middle foot ray as well as for the small toe rays. Whereas resection arthroplasty of the metatarsophalangeal joints II-V was previously considered the gold standard treatment, joint-preserving operative procedures (e.g. metatarsal osteotomy and periarticular soft tissue interventions) are now being increasingly more propagated. Resection arthroplasty of the first midfoot ray has major biomechanical disadvantages so that it is not surprising that reconstructive procedures are given priority. In patients with severe arthritic destruction of the first metatarsophalangeal joint, arthrodesis has substantial biomechanical advantages compared to resection arthroplasty. Nevertheless, it has not yet been confirmed that fusion leads to superior clinical results.

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.

First metatarsophalangeal arthrodesis for hallux valgus

Arthrodesis of the first metatarsophalangeal joint is a reliable operation in the treatment of selected cases of hallux valgus. It corrects deformity of hallux valgus and metatarsus primus varus, leading to good functional results with a low complication rate. It is a technique well suited to patients with hallux valgus associated with degenerative changes or severe deformity, and those for whom primary hallux valgus surgery has failed.

First metatarsophalangeal joint arthrodesis in the treatment of hallux valgus

First metatarsophalangeal joint arthrodesis is a reliable procedure with predictable outcomes in the treatment of moderate-to-severe hallux valgus with degenerative changes of the joint. It offers better functional outcome compared to arthroplasty with or without prosthesis in appropriate patient populations. Recent studies have shown that with appropriate fixation, early weight bearing may be initiated without an increase in nonunion.

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.

Reduction of intermetatarsal angle after first metatarsophalangeal joint arthrodesis in patients with hallux valgus

We present a radiographic review of 94 patients who underwent first metatarsophalangeal joint arthrodesis. The main focus of our review was to assess the change in the intermetatarsal angle (IMA). The change in the IMA was measured for the entire group and for 2 subgroups (IMA 11° to 15° and IMA >15°). The results of the angular measurements for the total data set were as follows: mean preoperative first IMA, 15.32° (range 11° to 24°), mean postoperative IMA, 9.88° (range 3° to 18°), and mean change in IMA of 5.44° (range -2° to 13°; p < .001). Group 1, with an IMA of 11° to 15°, included 52 patients, with a mean change in the IMA of 4.21° (range -2° to 9°; p < .001). Group 2, with an IMA greater than 15° (range 16° to 24°), included 42 patients, with a mean change in the IMA of 6.83° (range 2° to 13°; p < .001). The change in the preoperative to postoperative IMA in group 1 compared with that in group 2 was statistically significant (p < .001). The results of the present study have confirmed the observations of previous investigators that arthrodesis of the first metatarsophalangeal joint for hallux abducto valgus deformity results in a reduction of the IMA and that a proportionately larger reduction can be expected when the IMA is larger.

First metatarsophalangeal joint arthrodesis; what is the best fixation option? A critical review of the literature

First metatarsophalangeal joint arthrodesis can be accomplished using many forms of fixation. Distinguishing the best fixation construct requires evaluation of many variables. A review of the literature provides a starting point for what needs to be assessed and what questions need to be asked. In vivo and in vitro studies attempt to provide answers but frequently reveal shortcomings in the evidence to date. In the end, there is always 1 best fixation technique.

Opening wedge and anatomic-specific plates in foot and ankle applications

As surgeons continually push to improve techniques and outcomes, anatomic-specific and procedure-specific fixation options are becoming increasingly available. The unique size, shape, and function of the foot provide an ideal framework for the use of anatomic-specific plates. These distinctive plate characteristics range from anatomic contouring and screw placements to incorporated step-offs and wedges. By optimizing support, compression, and stabilization, patients may return to weight bearing and activity sooner, improving outcomes. This article discusses anatomic-specific plates and their use in forefoot and rearfoot surgical procedures.

First metatarsophalangeal arthrodesis for hallux rigidus

Hallux rigidus leads to a restricted and painful motion at the first metatarsophalangeal (MTP 1) joint. Decision making of the appropriate surgical procedure mainly refers to the stage of hallux rigidus. If conservative measures fail, operative procedures can be taken into consideration. Arthrodesis of the MTP 1 joint is widely accepted as the gold standard for end-stage hallux rigidus. Despite the fusion of a key joint, there is little adverse effect on gait, and weight bearing of the first ray can be restored.