Utilization of Calnan-Nicolle implant

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.

Brachymetatarsia

Brachymetatarsia is a rare clinical entity that presents a complicated case to the treating surgeon. One-stage lengthening procedures with a variety of biologic and synthetic implants are preferred for metatarsals that only need to be lengthened up to 15 mm, whereas gradual lengthening allows for greater length gain and concomitant lengthening of the soft tissues. Adjacent metatarsal shortening may be used in conjunction with lengthening procedures to restore the parabolic arc of the metatarsal heads. Management should be tailored to the patient's individual deformity and expectations. Individualization of surgical techniques and patient selection criteria can result in a cosmetic, functional result that is satisfactory to the clinician and the patient.

Alignment of the first metatarsal-phalangeal joint: important criteria for a new joint replacement

Joint replacement is one of many options for the treatment of the first metatarsophalangeal (MTP) joint. Studies of the geometry of that joint have shown that it consists of two distinct articulations, the metatarsophalangeal and the MT-sesamoidal. Both are important, but the MT-sesamoidal tolerates only small deviations from an ideal alignment. The aim of this study was to investigate the alignment of the first MTP joint of a potential patient population, in order to design an optimal surface replacement. One measurement, the extension angle between the MT and the proximal phalanx was found to be the most important alignment criterion for the successful design of an implant and the necessary instruments. This angle controls the delicate interplay between the metatarsal head and the sesamoids and tolerates only small deviations from the normal range before the chance of sesamoidal subluxation increases significantly. The pre-operative knowledge of this and other alignment criteria is important for the ideal placement of an anatomical implant.

Complications of silastic implant arthroplasty in the hallux

A long-term follow-up was evaluated on silastic implant arthroplasty performed on five patients (seven feet) for pathology of the metatarsophalangeal joint of the hallux. Four patients (five feet) displayed an inflammatory reaction in the immediate postoperative period with considerable swelling about the operative site. Subsequently, these patients developed either delayed wound healing of mild skin necrosis with secondary superficial infection. Three patients (five feet) ultimately developed implant failure via fracture of the prosthesis and/or erosion through the articulating surface of the prosthesis. All patients had late roentgenographic findings of resorption of bone around the implants. These complications necessitated removal of implants in three patients (five feet). Implant removal was recommended but refused in two patients (two feet).