Interposition arthroplasty of the first metatarsophalangeal joint with a fascia lata allograft

Converting 1st metatarsophalangeal joint fusion to interposition arthroplasty. Mid-term results of a case series

BACKGROUND

Fusion of the first metatarsophalangeal (MTP) joint has been considered as the gold standard for treatment of advanced hallux rigidus. The main disadvantage is the restriction of movement which may not be as favorable as anticipated by several patients. The purpose of this study was to report clinical and functional outcomes on patients who were treated with interposition arthroplasty after a 1st MTP joint fusion which had not fulfilled their expectations.

METHODS

Between 2009 and 2014, 11 patients who were not satisfied by 1st MTP joint fusion for hallux rigidus, underwent a conversion to interposition arthroplasty. After removal of hardware, the fusion was taken down by removal of a bone block from the fused joint. A fascia lata graft was interposed. Intraoperative and postoperative complications, range of motion of the first MTP joint, length of first ray, and patients' satisfaction were recorded as the primary outcomes.

RESULTS

Mean age was 34 years (range, 24-42 y). The mean ± SD AOFAS/H/MTP/IP score was 61 ± 5.5 preoperatively, 90.5 ± 4.5 at one year and 92 ± 4 at five years postoperatively (p < 0.001). The mean ± SD VAS-FA score was 91 ± 3.5 preoperatively, 94.5 ± 2.5 at one year and 95 ± 2.5 at five years postoperatively (p > 0.05). Mean ROM at the final follow-up was 58° ± 5° of dorsiflexion and 27° ± 4° of plantarflexion. No inter- or postoperative complications were encountered. The length of the hallux was decreased by a mean of 1.5 mm (range, 1-2.5 mm). All patients were satisfied with the overall outcome, walking ability and shoe-wear convenience and graded their condition as excellent (9 cases) or good (2 cases).

CONCLUSIONS

Converting a 1st MTP joint fusion to interposition arthroplasty with a fascia lata allograft could be a safe alternative with promising results in selected cases especially in relatively young and athletic population.

LEVEL OF EVIDENCE

Level IV retrospective case series.

The use of polyvinyl alcohol hydrogel implants in the lesser metatarsal heads. Is it safely doable? A cadaveric study

BACKGROUND

The use of synthetic polyvinyl alcohol hydrogel (PVAH) implants for treatment of lesser toe metatarsophalangeal joint (MTPJ) arthritis is promising and currently limited by the size of implants available. The primary objective of this cadaveric study was to investigate the maximum drilling size and largest PVAH implant dimension that could be safely introduced while still preserving an intact bone rim of the lesser metatarsal heads.

METHODS

Height and width of all lesser metatarsals were measured on CT and during anatomic dissection. Sequential reaming of the second to fourth metatarsals was performed. Maximum reaming size, largest implant inserted, and failure of the metatarsal head were recorded. Metatarsal head sizes were compared and a multiple regression analysis evaluated measurements that influenced maximum drilling and implant size.

RESULTS

CT and anatomical measurements demonstrated significant correlation (ICC range, 0.-0.85). Mean values for height and width of the metatarsal heads were respectively: second (14.9 mm and 9.9 mm), third (14.8 mm and 8.8 mm), fourth (14.0 mm and 8.7 mm) and fifth (12.3 mm and 9.3 mm). All the second, third and fourth metatarsal heads could be safely drilled up to 7.5 mm, preserving an intact bone rim. At 80% of the time, the heads could be safely drilled up to 8.0 mm. Height of the metatarsal heads was the only factor to significantly influence the size of maximum reaming and implant introduced. In respectively 20%, 40% and 50% of the second, third, and fourth metatarsal heads, neither 8 mm nor 10 mm PVAH implants could be used.

CONCLUSIONS

Our cadaveric study found that the even though the majority of the lesser metatarsal heads could be safely drilled up to 8 mm, the smallest PVAH implant size currently available in most countries (8 mm) could be inserted in most of the second, but only in about half of the third and fourth metatarsal heads. The remaining bone rim around inserted implants was considerably thin, usually measuring less than 1 mm. In order to optimize the use PVAH in lesser metatarsal heads, smaller implant options are needed.

Minimal resection interposition arthroplasty of the first metatarsophalangeal joint

BACKGROUND

Interposition arthroplasty of the first metatarsophalangeal (MTP) joint is a viable alternative to fusion in patients with advanced hallux rigidus. The purpose of this study is to evaluate the midterm results of a modification of the technique.

METHODS

Case series of 18 interposition arthroplasties were performed on 13 female patients with Grade III-IV hallux rigidus. The technique included cheilectomy, bunionectomy when needed, minimal resection of the base of the proximal phalanx and interposition of a fascia lata allograft in the first metatarsophalangeal joint. Mean follow up was nine years (range 75-136 months). Patients were evaluated according to the AOFAS score, the ability to tip toe and their subjective satisfaction.

RESULTS

There was a significant difference between preoperative (mean 43.2, range 15-83) and postoperative (mean 77.3, range 40-100) AOFAS scores (p<0.001). The patients were able to tip toe on 12 of the 18 operated feet and 9 of the 13 patients were satisfied from the operation. All dissatisfied patients had a coexistent hallux valgus deformity.

CONCLUSIONS

The technique had satisfactory midterm outcomes in older patients with advanced hallux rigidus without hallux valgus. Advantages of the method are the preservation of tip toe function in most patients and a technically easy conversion to fusion when needed.

Past and present of interposition arthroplasties for joint repair with special tribute to the contribution by Vittorio Putti

Several techniques have been proposed to restore the compromised function of a joint. These include the arthroplasty by placing various tissues or materials between the articular surfaces. An important contribution to the diffusion of arthroplasty techniques was made by Vittorio Putti, head of the Rizzoli Orthopedic Institute in Bologna from 1912 to 1940. Interposition arthroplasty is still used for some non-weight-bearing joints, such as wrist and elbow, and gives good results. This type of surgery has been further developed by the improvement in biomaterials, biomechanical studies and the regenerative medicine. This paper describes the development starting from a historical survey particularly focused on Putti's contribution and ending with the state of the art of regenerative medicine in the treatment of joint diseases. Level of evidence V.

The "Pillow" Technique for Thumb Carpometacarpal Joint Arthritis: Cohort Study With 10- to 15-Year Follow-Up

PURPOSE

Arthritis of the carpometacarpal joint of the thumb is common, and there are many studies regarding its treatment. We investigated the long-term outcome of interposition arthroplasty with a fascia lata allograft (pillow technique), without ligament reconstruction, to treat thumb carpometacarpal arthritis. The technique consisted of complete trapeziectomy, use of alloplastic tensor fascia lata, and K-wire immobilization for 5 weeks.

METHODS

The outcomes of 31 thumbs in 24 female patients were measured at a mean follow-up of 12.5 years (range, 10-15 years).

RESULTS

Grip strength, key pinch, pulp-to-pulp pinch, tripod pinch, and range of motion were all improved. The Disabilities of the Arm, Shoulder, and Hand median score, which was only measured postoperatively, was an average of 5 (range, 0-52.6). No extrusion of the graft material was noted, and no revisions were performed.

CONCLUSIONS

Our results indicate that a fascia lata allograft can be used as an interposition material in thumb carpometacarpal arthroplasty. This technique provides pain relief and satisfactory function at an average of 12.5 years after surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Autogenous capsular interpositional arthroplasty surgery for painful hallux rigidus: assessing changes in range of motion and postoperative foot health

The autogenous capsular interpositional arthroplasty procedure can be a motion-sparing alternative to arthrodesis for the treatment of recalcitrant hallux rigidus deformity. Previous studies have reported positive results; however, many had small samples or lacked comparable preoperative measures. The present study used a prospective cohort study to assess the benefit of this technique for increasing range of motion, and comparative data to assess the reduction of pain and improvements in perceived foot health status for a consecutively drawn sample of patients. Thirty-four patients (44 feet) reviewed using a long-arm goniometer at a mean of 3.75 years after surgery experienced a significant increase in dorsiflexion (preoperative mean 11.09° ± 10.13°; postoperative mean 26.64° ± 10.07°; p < .001); plantar flexion remained unchanged. Additionally, 15 of 17 patients for whom the hallux abductus angle was initially greater than the normal range was within the normal range postoperatively. The postoperative patient perceptions of foot pain were significantly better than those from a comparable sample of patients presenting for a surgical opinion (t[69] = 6.80), just as were the perceptions of foot function, foot health, and footwear comfort (p < .001 for all). The postoperative perceptions of foot pain were comparable with the postoperative results from a range of previously published studies. These results have shown, with improvements in range of motion and reduction in pain, that autogenous capsular interpositional arthroplasty is a useful, motion-sparing technique in the treatment of painful hallux rigidus and should be considered for classification as a clinical practice guideline.

Management of failed and infected first metatarsophalangeal joint implant arthroplasty by reconstruction with an acellular dermal matrix: a case report

Management of failed first metatarsophalangeal joint implant arthroplasty, especially in the face of infection, is an area of debate without a clear consensus. The purpose of the present report was to explore a new option of reconstructing the joint with an acellular dermal matrix substance in a single case study during a 12-month follow-up period. A staged approach that began with removal of the failed 2-component great toe implant, Koenig(®), excisional debridement of the wound with resection of the necrotic bone (proximal phalanx and distal portion of the first metatarsal bones), and culture-specific antibiosis therapy. The final stage included incorporating the acellular dermal matrix, Graftjacket(®) into the joint in an accordion-type fashion, and reconstruction of the joint capsule. Postoperative radiographs revealed a more rectus joint with some improvement in length. At 6 months postoperatively, magnetic resonance imaging revealed incorporation of the graft material into the joint. Finally, at the 1-year mark, the patient was pain free with satisfactory function at the first metatarsophalangeal joint during gait. This is the first reported case of salvaging failed and infected first metatarsophalangeal joint implant arthroplasty with incorporation of the acellular dermal matrix and provides a new option to consider in the future.

Hallux rigidus: what lies beyond fusion, resectional arthroplasty, and implants

Hallux rigidus (HR) is the limitation of motion at the first metatarsophalangeal (MTP) joint, most commonly secondary to degenerative arthritis. Surgical options for treating HR include 2 general categories: joint salvage and joint destruction. A hybrid of techniques from the 2 categories has emerged: cartilage resurfacing, interpositional arthroplasty, and arthrodiastasis. These procedures address the pathologic condition of the first MTP joint more directly than joint salvage and avoid many of the negative complications, consequences, and connotations of joint destruction procedures. Alternative surgical options for the treatment of recalcitrant pain associated with HR are evolving and are discussed in this review.