Interpositional Arthroplasty of the First Metatarsophalangeal Joint with Bioresorbable Pldla Implant in the Treatment of Hallux Rigidus and Arthritic Hallux Valgus: A 9-Year Case Series Follow-Up

What Are the MSTS Scores and Complications Associated With the Use of Three-dimensional Printed, Custom-made Prostheses in Patients Who Had Resection of Tumors of the Hand and Foot?

BACKGROUND

There are a few good options for restoring bone defects in the hand and foot. 3D-printed implants have been used in the pelvis and elsewhere, but to our knowledge, they have not been evaluated in the hand and foot. The functional outcome, complications, and longevity of 3D-printed prostheses in small bones are not well known.

QUESTIONS/PURPOSES

(1) What are the functional outcomes of patients with hand or foot tumors who were treated with tumor resection and reconstruction with a 3D-printed custom prosthesis? (2) What complications are associated with using these prostheses? (3) What is the 5-year Kaplan-Meier cumulative incidence of implant breakage and reoperation?

METHODS

Between January 2017 and October 2020, we treated 276 patients who had tumors of the hands or feet. Of those, we considered as potentially eligible patients who might have extensive loss in their joint that could not be fixed with a bone graft, cement, or any prostheses available on the market. Based on this, 93 patients were eligible; a further 77 were excluded because they received nonoperative treatment such as chemoradiation, resection without reconstruction, reconstruction using other materials, or ray amputation; another three were lost before the minimum study follow-up of 2 years and two had incomplete datasets, leaving 11 for analysis in this retrospective study. There were seven women and four men. The median age was 29 years (range 11 to 71 years). There were five hand tumors and six tumors of the feet. Tumor types were giant cell tumor of bone (five), chondroblastoma (two), osteosarcoma (two), neuroendocrine tumor (one), and squamous cell carcinoma (one). Margin status after resection was ≥ 1 mm. All patients were followed for a minimum of 24 months. The median follow-up time was 47 months (range 25 to 67 months). Clinical data; function according to the Musculoskeletal Tumor Society, DASH, and American Orthopedic Foot and Ankle Society scores; complications; and survivorship of implants were recorded during follow-up in the clinic, or patients with complete charts and recorded data were interviewed on the telephone by our research associates, orthopaedic oncology fellows, or the surgeons who performed the surgery. The cumulative incidence of implant breakage and reoperation was assessed using a Kaplan-Meier analysis.

RESULTS

The median Musculoskeletal Tumor Society score was 28 of 30 (range 21 to 30). Seven of 11 patients experienced postoperative complications, primarily including hyperextension deformity and joint stiffness (three patients), joint subluxation (two), aseptic loosening (one), broken stem (one), and broken plate (one), but no infection or local recurrence occurred. Subluxations of the metacarpophalangeal and proximal interphalangeal joints in two patients' hands were caused by the design of the prosthesis without a joint or stem. These prostheses were revised to a second-generation prosthesis with joint and stem, leading to improved dexterity. The cumulative incidence of implant breakage and reoperation in the Kaplan-Meier analysis was 35% (95% CI 6% to 69%) and 29% (95% CI 3% to 66%) at 5 years, respectively.

CONCLUSION

These preliminary findings suggest that 3D implants may be an option for reconstruction after resections that leave large bone and joint defects in the hand and foot. Although the functional results generally appeared to be good to excellent, complications and reoperations were frequent; thus, we believe this approach could be considered when patients have few or no alternatives other than amputation. Future studies will need to compare this approach to bone grafting or bone cementation.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Metatarsophalangeal Joint Reconstruction Using Talar Osteochondral Allograft following a Failed Dorsal Cheilectomy

Dorsal cheilectomy is often used as a first-line surgical treatment for hallux rigidus; however, revision surgery is needed in nearly 9% of cases. One option for revision surgery is interpositional arthroplasty, which is designed to preserve joint motion and is favorable in young, active populations. This case discusses a young female patient with persistent, painful hallux rigidus and a large osteochondral defect despite prior dorsal cheilectomy. We performed an interpositional arthroplasty of the first metatarsophalangeal joint using an osteochondral allograft from the talus. At three-year follow-up, she had greatly improved function and was able to run without pain. To our knowledge, this is the first documented use of an osteochondral allograft from the talus in conjunction with metatarsophalangeal joint interpositional arthroplasty for treatment of hallux rigidus and a severe osteochondral defect. This technique introduces osseous subchondral scaffolding as well as mature hyaline cartilage into an osteochondral lesion, thereby reestablishing proper joint architecture and congruent articulation and ultimately improving range of motion and reducing pain. We present this technique as an experimental treatment option for restoring both the integrity and function of the metatarsophalangeal joint following trauma, osteochondritis dissecans, or prior operative failure in patients who wish to delay metatarsophalangeal joint fusion.

Arthroplasty of the trapeziometacarpal joint with or without bioabsorbable polylactide scaffold (RegJoint™) interposition

The RegJoint™, a bioabsorbable polylactide scaffold, was introduced in 2011 for scaphometacarpal interposition following trapeziectomy for osteoarthritis. As previous clinical trials provided controversial results, we aimed to prove the non-inferiority of RegJoint™ interposition. In this retrospective study, first metacarpal suspension arthroplasty alone (SA) was compared to suspension with RegJoint™ interposition (RJ). Thirty-four patients with 37 treated thumbs (SA: 14; RJ: 23) were assessed clinically and radiologically at a mean follow-up of 5.3 ± 2.6 years (SA: 7.96; RJ: 3.73). Patient-reported outcomes were measured on three questionnaires (DASH, PRWE and PEM) and a visual analogue pain scale; there were no significant differences between the 2 groups. Clinical assessment comprised range of motion, opposition, pain, first-ray length, hand span, prominence, instability, force and sensitivity to touch. The RJ group showed significantly better palmar abduction (p = 0.026); the other outcome parameters were comparable in the 2 groups. Follow-up radiographs showed osteolysis in 2 SA hands and 3 RJ hands (p = 0.551). First-ray length had decreased by a mean 4.7 ± 2.7 mm at follow-up (SA: -3.8; RJ: -5.2; p = 0.056). No signs of adverse tissue reactions were observed. We conclude that RegJoint™ spacers do not produce more complications than suspension alone but provide no added benefit.

[Mini implants in foot and ankle surgery: an alternative to total joint replacement or joint fusion]

Mini implants are increasingly used in foot and ankle surgery. They preserve the joints' functions, are easy to insert and easy to convert to an alternative treatment. Early surgical attempts using silastic implants did not bring the expected success. First achievements where reached with modern metallic mini implants in the first metatarsophalangeal (MTP) joint and the ankle joint. For a few years now, a polyvinyl alcohol implant has been used to treat the arthritic first MTP joint. Even severe arthritic joints can be treated with an implant made of polylactide. This implant can also be used in the treatment of Lisfranc joint pathologies. To address severe osteochondral defects of the talus, an innovative hemiarthroplasty implant has been suggested. This article gives a summary of currently used mini implants. Their application as possible alternatives to total joint replacement or joint fusion are critically reviewed in the light of the current literature.