Nonunion after arthrodesis of the first metatarsal-phalangeal joint: a systematic review

Revision surgeries for failed hallux valgus correction: A systematic review

BACKGROUND

Failure of hallux valgus (HV) correction is not uncommon, and its management can be challenging. The available literature is not exhaustive. Therefore, we conducted a systematic review to investigate the current evidence on the role of revision surgery for failed HV correction, including clinical presentation, indications, surgical strategies and outcomes.

MATERIAL AND METHODS

The present systematic review was performed according to the PRISMA guidelines. Pubmed, EMBASE, Google Scholar and Scopus online databases were accessed in November 2020. All the clinical studies on revision for failed HV correction were analysed, and only studies reporting quantitative data under the outcomes of interest were considered for inclusion.

RESULTS

Data from 20 studies (586 procedures) were retrieved. The HV angle, the intermetatarsal angle and the distal metatarsal articular angle were reduced of 17.8° (P < 0.001), 3.3° (P = 0.05) and 7.3° (P < 0.001) respectively. The American Orthopaedic Foot & Ankle Society score improved of 24.7% (P < 0.001). The visual analogue scale improved by 40.8% (P < 0.001). Dorsiflexion and plantar flexion of the first metatarso-phalangeal joint remained similar to their preoperative values (P = 0.2 and P = 0.4, respectively). After revision surgery the following complications were further detected: recurrences 5.1% (30 of 586 patients), non-unions 4.1% (24/586), additional surgical procedures 8.7% (51 of 586 patients).

CONCLUSION

Revision surgery for failed primary HV correction can yield satisfying results. Accurate preoperative planning is necessary to try and identify the causes of failure, and address them appropriately.

Valenti resection arthroplasty for hallux rigidus: A systematic review

BACKGROUND

Valente Valenti proposed in 1976 a "V" resection of the first metatarsophalangeal joint (MPT1) on the sagittal plane for advanced stages of hallux limitus/rigidus, preserving length of the first ray, flexor hallux brevis and sesamoid function. The available literature concerning correct indications, management and clinical outcomes of the Valenti procedure (VP) and its modifications in patients affected by hallux limitus/rigidus was systematically analyzed.

METHODS

Titles and abstracts of all selected articles were independently screened by two authors to assess their suitability to the research focus.

RESULTS

Selection produced 8 articles as full-text, for a total of 347 patients, with a mean follow-up of 6±7.1 (range 0.2-17.5) years. Most common complication was transient sesamoiditis in 21 (7.4%) patients. No substantial differences in clinical outcomes were found between the original and modified techniques.

CONCLUSIONS

VP appears to allow an early recovery with few complications, if compared to fusion, interposition arthroplasties or osteotomies. The wide joint resection does not prevent, if necessary, further procedures such as fusion or implants.

LEVEL OF EVIDENCE

Level I, systematic review.

Minimally invasive arthrodesis of the first metatarsophalangeal joint: A systematic literature review

AIM

Currently, cohort studies reported the use of minimally invasive arthrodesis of the first metatarsophalangeal joint (MTP I). The aim of this systematic literature review was to analyse clinical, radiological outcome and complications with this technique.

METHODS

A systemic literature search of the databases Google Scholar, PubMed, Scopus, EMBASE and Cochrane to identify studies reporting on clinical, radiological outcome or complications of minimally invasive MTP I arthrodesis was conducted.

RESULTS

A total of 6 studies (1 Level V, 5 Level IV) reporting on 109 minimally invasive MTP arthrodesis in 105 patients were included. Validated scores were reported in 103 cases. Clinical outcome improved in 57 cases from a mean of 36.9 to 82.6 points American Orthopedic Foot and Ankle Score (AOFAS) and in 46 cases from 38.7 to 18.4 points Manchester Oxford Foot Questionnaire (MOXFQ). Radiological fusion rate was 87% (n = 94 out of 109) achieved after 6-12 weeks. Overall complication rate was 11.9% (13 cases) leading to revision surgeries in 5.5% (6 cases). Most common complications Most common complications were symptomatic non-union (n = 6, 5.5%), asymptomatic non-union (n = 2, 1.8%) and subsequent interphalangeal joint arthritis (n = 2, 1.8%).

CONCLUSION

Minimally invasive MTP I arthrodesis is a promising technique with comparable clinical, radiological outcome and complication rates to open surgery in hallux rigidus and rigido-valgus. Future studies are needed providing higher level of evidence to prove the potential benefit of minimally invasive compared to open MTP I arthrodesis.

The Functional Outcome of Hallux Metatarsophalangeal Joint Arthrodesis Using Hallux Intramedullary Fusion Device

Functional outcome of first metatarsophalangeal joint (MTPJ) arthrodesis using intramedullary implant was reviewed in retrospective series of 12 patients who had MTPJ arthritis. The outcome measures were improvements seen in VAS for pain and AOFAS scores recorded pre-operatively and post-operatively at the time of achieving complete union. VAS for pain improved from mean of 7.5 pre-operative to 1.8 post-operative (p < 0.001). AOFAS Score improved from mean of 35.58 pre-operative to 80.91 post-operative (p < 0.001). The fusion rate was 100 percent and mean time needed for fusion was 9.6 weeks. Only one patient had malunion which was acceptable to patient and was not revised. The fusion using intramedullary intra-osseous Hallux Fusion implant is a promising technique with good functional outcome and low complications.

Motion Preservation in Hallux Rigidus After Failure of Hydrogel Implantation: Treatment Considerations and a Report of 2 Cases

Hallux rigidus is a common condition treated daily by surgeons worldwide. During the past decade, the standard treatment algorithm has been questioned by both patients and surgeons seeking alternatives to arthrodesis, which was previously considered the gold standard for advanced disease. Patients are living longer, and many have a more active lifestyle; thus, recreating and improving range of motion and achieving pain relief are increasingly desirable. The treatment spectrum and implant options for motion-preserving techniques in the metatarsophalangeal joint has been widened with the recent US Food and Drug Administration approval of a polyvinyl-alcohol hydrogel implant. In the controlled US Food and Drug Administration trial, the 2-year revision rate was 9.2% and all failures were revised to a first metatarsophalangeal arthrodesis. Outcomes comparison of these revisions to primary fusions showed less predictable pain relief and may warrant alternative treatment considerations, preferably those that allow for continuation of motion preservation. Revision of failed hydrogel implants to arthrodesis can be performed through various first metatarsophalangeal fusion techniques or, as introduced in this review, with a fourth-generation threaded hemiarthroplasty. Excellent 10-year results with primary hemiarthroplasty supported its use as revision procedure in 2 failed polyvinyl-alcohol implantations, preserving arthrodesis for future salvage if necessary. The purpose of this report was to outline a motion-preserving technique after failed hydrogel implants and describe preoperative, intraoperative, and postoperative considerations for optimized outcomes.

Intrinsic Fixation of the Tibial Sesamoid in First Metatarsophalangeal Joint Arthrodesis: A Cadaveric Study

Nonunion rate of first metatarsophalangeal joint (MTP) joint arthrodesis is reportedly less than 6%, regardless of fixation type. Robust modern plating constructs aim to decrease incidence of nonunion while also allowing early postoperative weight-bearing. Quicker transition to weight-bearing postoperatively increases patient adherence, decreases adjacent joint stiffness, and reduces risk of deep vein thrombosis in the postoperative period. The purpose of this study was to investigate the effect tibial sesamoid fixation has on first MTP joint arthrodesis.

Silastic first metatarsophalangeal joint arthroplasty for the treatment of end-stage hallux rigidus

AIMS

Arthroplasty for end-stage hallux rigidus (HR) is controversial. Arthrodesis remains the gold standard for surgical treatment, although is not without its complications, with rates of up to 10% for nonunion, 14% for reoperation and 10% for metatarsalgia. The aim of this study was to analyze the outcome of a double-stemmed silastic implant (Wright-Medical, Memphis, Tennessee, USA) for patients with end-stage HR.

METHODS

We conducted a retrospective review of 108 consecutive implants in 76 patients, between January 2005 and December 2016, with a minimum follow-up of two years. The mean age of the patients at the time of surgery was 61.6 years (42 to 84). There were 104 females and four males. Clinical, radiological, patient reported outcome measures (PROMS) data, a visual analogue score (VAS) for pain, and satisfaction scores were collected.

RESULTS

The survivorship at a mean follow-up of 5.3 years (2.1 to 14.1) was 97.2%. The mean Manchester Oxford Foot and Ankle Questionnaire (MOXFQ) scores improved from 78.1 to 11.0, and VAS scores for pain from 7/10 to 1.3/10. The rate of satisfaction was 90.6%. Three implants (2.8%) required revision; one for infection, one-month postoperatively, and two for stem breakage at 10.4 and 13.3 years postoperatively. There was a 1.9% reoperation rate other than revision, 23.1% of patients developed a minor complication, and 21.1% of patients had non-progressive and asymptomatic cysts on radiological review.

CONCLUSION

We report a 97.2% survivorship at a mean follow-up of 5.3 years with this implant. We did not find progressive osteolysis, as has been previously reported. These results suggest that this double-stemmed silastic implant provides a predictable and reliable alternative with comparable outcomes to arthrodesis for the treatment of end-stage HR. Cite this article: Bone Joint J 2020;102-B(2):220-226.

Incidence of hallux valgus primary surgical treatment. Finnish nationwide data from 1997 to 2014

BACKGROUND

Many surgical procedures have been described for hallux valgus. Evidence provided by the current literature on the different procedures is, however, poor. The purpose of this study was to assess the incidence of HV surgery in Finland between 1997 and 2014 and to find out whether changes in operation techniques of HV have occurred during the study period.

METHODS

The study included all adult patients (≥18 years) who underwent primary HV operation. Patients were included into study if they had been operated with a diagnosis of HV (ICD-10 code M20.1). The data were collected by the Finnish National Hospital Discharge Register (NHDR).

RESULTS

The total incidence of primary HV operations was 66.7 per 100,000 person-years in 1997 and 41.4 per 100,000 person-years in 2014. The incidence of arthroplasty operations of the MTP-1 joint decreased while at the same time the incidence of the MTP-1 joint arthrodesis and TMT-1 arthrodesis increased. The gender difference (13% men, 87% women) is consistent with previous studies.

CONCLUSION

This study shows a significant decreasing trend of HV operations in Finland between 1997 and 2014. During the study period, the incidence of MTP I joint arthroplasty decreased, and since 2005 the incidence of MT-1-osteotomies has almost halved. At the same time, the incidence of MTP-1 joint arthrodesis increased by over 1000% and TMT-1 joint arthrodesis by nearly 2000%.

Dorsiflexory Phalangeal Osteotomy for Grade II Hallux Rigidus: Patient-Focused Outcomes at Eleven-Year Follow-Up

Dorsiflexory phalangeal osteotomy has been shown to be an effective treatment for mild to moderate hallux rigidus in short- to medium-term follow-up studies. It is speculated that the procedure alters the mechanical function of the joint and reduces the demand for hallux dorsiflexion by elevating the proximal phalanx into a more dorsiflexed position. However, it has been demonstrated that the first metatarsophalangeal (MTP) joint space and joint range of motion are reduced by the procedure, calling into question the long-term effectiveness of the operation. This study reviewed 27 dorsiflexory phalangeal osteotomy cases at an average of 11 years postoperatively. Twenty-one (77%) patients reported that they were completely satisfied with the results of their surgery; 4 (15%) patients reported that they were satisfied with reservations; and 2 (7%) patients reported that they were dissatisfied. The patients who were satisfied with reservations complained of interphalangeal (IP) joint pain or stiffness. One patient developed second MTP joint metatarsalgia after surgery, and in 1 patient first MTP joint pain returned at 24 months after surgery. One dissatisfied patient complained of second MTP joint metatarsalgia, and a second patient required revision excisional arthroplasty for continued joint pain. Ten patients (38%) reported stiffness of the first MTP joint, but only 2 patients reported any restriction of activity. Footwear restrictions were reported by 15 (58%) patients preoperatively and by 9 (35%) patients at final follow-up. Dorsiflexory phalangeal osteotomy maybe a reliable long-term treatment for grade II or moderate hallux rigidus and is a safe and effective alternative to first MTP joint fusion in joints where movement is still present and joint cartilage is viable.

Immediate Weightbearing After First Metatarsophalangeal Joint Arthrodesis With Screw and Locking Plate Fixation: A Short-Term Review

Historically, the postoperative protocol for patients undergoing first metatarsophalangeal joint arthrodesis has included 6 weeks of non-weightbearing, followed by protected weightbearing in a below-the-knee cast boot or postoperative shoe. This prolonged period of non-weightbearing predisposes the patient to disuse atrophy, osteopenia, deep vein thrombosis risk, and, overall, a prolonged time to recovery. The present study reports a retrospective review of a patient cohort that underwent first metatarsophalangeal joint fusion with immediate full weightbearing postoperatively. Thirty consecutive first metatarsophalangeal joint arthrodeses were performed during the study period. Five patients were excluded secondary to insufficient postoperative follow-up data or a lack of adequate radiographic evaluation at regular postoperative intervals. Conical reamers were used for joint preparation. Internal fixation, consisting of a single cannulated interfragmentary compression screw and a dorsal locking plate, was used in all patients. The results showed that patients achieved clinical healing at an average of 5.92 weeks and showed radiographic fusion at an average of 6.83 weeks. The patients in the present study had an overall union rate of 96%. Complications included 1 nonunion, 1 superficial wound infection, 1 wound dehiscence, 1 case of symptomatic hardware, and 2 patients with symptomatic hallux interphalangeal joint arthralgia. The mean visual analog pain score preoperatively was 6.64 (range 4 to 8) and postoperatively was 0.6 (range 0 to 4). In conclusion, we found that immediate full weightbearing after first metatarsophalangeal joint fusion in the context of interfragmentary compression and locked plating techniques is a safe, predictable postoperative protocol that allows for a successful fusion interval and an early return to regular activity.

Incidence and outcomes of revision surgery after first metatarsophalangeal joint arthrodesis: Multicenter study of 158 cases

INTRODUCTION

First metatarsophalangeal (MTP1) joint arthrodesis, described as a safe and effective procedure, has complications that may require surgical revision. These complications are rarely studied. The aim of this study was to determine the incidence and outcomes of revision surgery after MT1 arthrodesis.

HYPOTHESIS

The incidence of surgical revision after MTP1 arthrodesis is not insignificant; however, the outcomes are satisfactory.

MATERIALS AND METHODS

In this multicenter retrospective study between January 2014 and December 2015, 190 forefoot revisions in patients who had previously undergone MTP1 arthrodesis were included by 8 surgeons. There were no exclusion criteria and all patients had at least 1 year of follow-up. Over the same period, 958 primary MTP1 arthrodesis procedures were performed.

RESULTS

The mean time to revision was 4.6±10.9 years. At a mean follow-up of 20.5±7.4 months, 158 cases were available for analysis in 135 women and 20 men who had a mean age of 67.1±10.5 years. These revision procedures were carried out because of discomfort related to the hardware at the arthrodesis site (n=86, 54%), nonunion (n=22, 14%), malunion (n=13, 8%) metatarsalgia or claw toe (n=18, 11%) and first interphalangeal (IP1) joint disorders (n=13, 8%). The mean postoperative scores were 75±13.9 for the AOFAS and 65±19.6 for the SF36 total. In the nonunion cases, removal of the hardware led to better outcomes than repeating the arthrodesis procedure. Osteotomy in the malunion cases healed successfully. In the cases of IP1 osteoarthritis, secondary arthrodesis or arthroplasty led to good outcomes.

DISCUSSION

Relative to published results of primary MTP1 arthrodesis, the outcomes in our series of revision MTP1 arthrodesis surgery cases are practically equivalent, thus considered acceptable.

LEVEL OF EVIDENCE

IV, Retrospective 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.

A Consecutive Case Series of 166 First Metatarsophalangeal Joint Fusions Using a Combination of Cup and Cone Reamers and Crossed Cannulated Screws

Fusion of the first metatarsophalangeal joint (MTPJ) is the reference standard surgery for significant hallux rigidus. A number of different techniques for first MTPJ fusion have been reported. We describe our technique of first MTPJ fusion using cup and cone reamers for joint surface preparation and 2 crossed cannulated screws for fixation. To the best of our knowledge, this is the single largest series using this technique. The present study reports on a single-surgeon, consecutive series of 166 consecutive cases in 147 patients who had undergone first MTPJ fusion. The demographic data and comorbidities of the patients were collected from the digital medical records, and the radiographs were evaluated by 2 of us (S.Q., M.A.) independently to document fusion status. Radiologic nonunion was seen in 11 of 166 cases (6.6%). The mean duration of follow up was 60 ± 29.5 (minimum 26, maximum 183) days. However, only 4 of the 11 cases (36%) of nonunion were clinically symptomatic and underwent revision using a bone graft and locking plate. A statistically significant difference was found in union rates among males and females (p = .01). Other factors, such as diabetes (p = .2), inflammatory arthritis (p = .5), steroids (p = .6), smoking (p = .5), hallux valgus deformity (p = .5), and concomitant forefoot surgery, did not have a statistically significant (p = .3) effect on union in our study. The union rate of first MTPJ fusion with our technique was comparable to that of others, with the advantage of being simple and less expensive compared with the use of a plate.

Result of IOFIX (Intra Osseous FIXation) device for first metatarsophalangeal joint arthrodesis: A single surgeon's series

BACKGROUND

Arthrodesis of the first metatarsophalangeal joint (MTPJ) is a common procedure to treat significant first MTPJ arthritis. However, dorsal plates used for this have been associated with high incidence of metalwork removal. The IOFIX (Intra-Osseous FIXation) is a fixed angle device that is noted to provide a more uniform compression over a larger aspect of the fusion surfaces than a screw construct alone with the advantage of minimizing soft tissue irritation which can reduce the need for subsequent implant removal.

METHODS

Twenty one consecutive patients who underwent primary first MTPJ fusion with the IOFIX were reviewed. The mean age of the cohort was 63 years (range 47-81), with 80% female. The ratio of left to right was 9:12. The mean follow up of was 28 months (range 13.4-48.2 months). Outcomes analyzed were rate of fusion, Manchester-Oxford foot questionnaire (MOXFQ) score, patient satisfaction, improvement in the intermetatarsal angle and complications.

RESULTS

Complete fusion of the first MTPJ was achieved in twenty (95%) patients. One patient had a non union and another patient developed a delayed union. The mean preoperative MOXFQ score improved from 49.7 (95% confidence interval: 46-52) to 17.9 (95% confidence interval: 12-22), p<0.05.Improvement gained in all the domains of the MOXFQ score (walking/standing, pain and social) was statistically significant (p<0.05). Eighteen out of 21 patients (85%) were very pleased or fairly pleased with the procedure.

CONCLUSION

Early results show that the rate of fusion achieved by using the IOFIX device for the first MTPJ arthrodesis in our series was found to be comparable to other devices quoted in the literature.

First Metatarsophalangeal Joint Arthrodesis

Background:

First metatarsophalangeal (MTP) joint arthrodesis can be fixed using either a dorsal plate or crossed screws. However, there is considerable difference in the cost of these implants, and it is not known if there is sufficient difference in outcome that might justify this cost difference. Our aim was to compare the functional results and patient satisfaction rates after first MTP joint arthrodesis in a group of patients using the same surgical technique except for the fixation devices.

Methods:

A prospective cohort of 27 patients who underwent first MTP joint fusion by the same surgeon using 2 crossed screws or a single screw with a dorsal plate was recruited over a 3-year period. Demographic information, patient satisfaction rates, complications, and union rates were evaluated. American Orthopaedic Foot & Ankle Society (AOFAS) and visual analog scale (VAS) scoring systems were used pre- and postoperatively to compare the functional outcomes. Thirty consecutive procedures (screws, n = 15; plate, n = 15) were performed. Age (55.8 ± 11.1 vs 63.3 ± 12.4 years for screws and plate respectively; P = .091) and female gender percentages (80% and 73%, P = .666) were similar between groups.

Results:

The overall union rate was 93% with no differences between groups. AOFAS and VAS scores improved significantly postoperatively for each technique, and no differences were found between the two in the improvement in AOFAS (42.4 ± 8.0 vs 44.3 ± 8.2, screws and plate respectively; P = .520) and VAS scores (66.0 ± 5.4 vs 69.0 ± 6.9; P = .195). The implant cost for screws was $40 and for dorsal plate, $328.

Conclusions:

First MTP joint fusion using either screws or plate fixation results in an improvement in AOFAS and VAS scores. Functional improvement and patient satisfaction did not differ between the 2 techniques, despite a considerable difference in cost between the two methods of fixation.

Level of Evidence:

Level III, prospective comparative study.

Comparison of Hallux Rigidus Surgical Treatment Outcomes Between Active Duty and Non-Active Duty Populations A Retrospective Review

BACKGROUND

Our aim in this study was to compare the long-term outcomes of three different surgical procedures for the treatment of hallux rigidus (ie, cheilectomy, decompressive osteotomy, and arthrodesis) between active duty military and non-active duty patients.

METHODS

A retrospective review of 80 patients (95 feet) undergoing surgical treatment for hallux rigidus was performed. Telephone survey was used to obtain postoperative outcome measures and subjective satisfaction. Additional data recorded and analyzed included age, sex, status of patient (active duty or non-active duty), grade of hallux rigidus, surgical procedure performed, date of surgery, time to return to full activity, ability to return to full duty, and follow-up time postoperatively.

RESULTS

The decompressive osteotomy group had the highest return-to-duty rate, satisfaction rate, and Maryland Foot Scores of all three surgical groups, although these differences were not statistically significant. Active duty and non-active duty patients did not have statistically significant differences in outcomes measures (ie, time to return to full activity, ability to return to full duty, satisfaction, or postoperative Maryland Foot Score) in any of the three surgical groups.

CONCLUSIONS

Decompressive osteotomy, cheilectomy, and first metatarsophalangeal joint arthrodesis are all reliable and effective procedures for treatment of hallux rigidus in both active duty military and non-active duty patients. Active duty military personal have a high rate of returning to their prior military activities after surgical treatment of hallux rigidus.

Arthrodesis of the first metatarsophalangeal joint-A biomechanical comparison of four fixation techniques

BACKGROUND

Arthrodesis of the first metatarsophalangeal joint is a commonly performed orthopaedic procedure. The optimum method of fixation and joint surface preparation has yet to be determined.

METHODS

This study compared four fixation techniques: Biomechanical grade sawbones were used. The dorsal plate used was a titanium, anatomically contoured locked plate. Testing was performed using an Instron machine applying force from the plantar aspect of the fused joint. Each fused sample was tested to failure. Stiffness, as calculated from the force-displacement curve, and ultimate load tolerated were recorded for each sample. The method of failure of each sample was also documented.

RESULTS

Constructs arthrodesed using dorsal plate with separate screw groups, regardless of method of joint preparation, were the stiffest (p<0.001). The weakest construct was dorsal plate alone without interfragmenary screw. There was no difference in stiffness between planar and cup-cone joint preparation (p=0.99). Maximum load tolerated was similar when comparing Crossed Screws with dorsal plate with screw with either cup-cone or planar reaming (p=0.93, p=0.89 respectively). Dorsal plating alone tolerated a significantly lower maximum load than Plate with Screw Groups or Crossed Screws (p<0.001).

CONCLUSION

This study confirms that an IFS combined with a dorsally positioned locked-plate is the ideal construct, with the joint preparation technique of little consequence.

Accuracy and Reliability of Postoperative Radiographic Evaluation of First Metatarsal-Phalangeal Joint Arthrodesis

The clinical value of routine postoperative radiographic evaluation after orthopedic procedures has recently been called into question. The objective of the present investigation was to evaluate the ability of foot and ankle surgeons to accurately and reliably assess postoperative radiographs after first metatarsal-phalangeal joint arthrodesis. Thirty sets of digital radiographs from 11 patients who had undergone first metatarsal-phalangeal joint arthrodesis were retrospectively evaluated by 5 podiatric physicians board-certified in foot surgery. The surgeons were asked to answer several questions, including whether the radiograph appeared to be >4 or <4 postoperative weeks; whether the radiograph appeared to be >8 or <8 postoperative weeks; their estimation of the postoperative week; and whether they would allow the patient to begin weightbearing based on the radiographic findings. With respect to whether the radiographs were >4 or <4 postoperative weeks, surgeons made accurate assessments 63.33% of the time (95 of 150; range 56.67% to 73.33%), with a kappa of 0.220. With respect to whether the radiographs were >8 or <8 postoperative weeks, surgeons made accurate assessments 60.0% of the time (90 of 150; range 53.33% to 70.0%), with a kappa of 0.203. With respect to the estimation of the postoperative week of the radiograph, surgeons accurately assessed the radiographs within a 4-week period 34.0% of the time (54 of 150; range 26.67% to 46.67%), with a kappa of 0.425. With respect to allowing the patient to bear weight according to the radiographic findings, the surgeons were in complete agreement 26.67% of the time (8 of 30), with a kappa of 0.251. These results provide evidence against the serial routine use of postoperative radiographs for the first metatarsal-phalangeal joint arthrodesis in the absence of a specific clinical indication.

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.

First Metatarsal-Phalangeal Joint Arthrodesis: Primary, Revision, and Salvage of Complications

Arthrodesis of the first metatarsal-phalangeal joint has been proposed for treatment of severe hallux valgus, end-stage hallux rigidus, rheumatoid arthritis, and revision of failed surgery due to the perceived safety and efficacy. This article discusses the principles of first metatarsal-phalangeal joint arthrodesis in primary and revision situations, joint preparation, configurations of osteosynthesis, and common complications, including salvage of nonunion and revision of malunion with realignment osteotomy.

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.

Weight-bearing recommendations after first metatarsophalangeal joint arthrodesis fixation: a biomechanical comparison

Background

This study sought to determine whether several metatarsophalangeal (MTP) fusion techniques require complete immobilization or if some level of weight-bearing could be recommended after surgery. A comparison of synthetic composite to actual bone was included in order to examine the validity of the testing conditions.

Methods

Four MTP fusion modalities were tested in synthetic composite bone models: unlocked plating, locked plating, crossed lag screws, and an unlocked plate with a single lag screw. Stiffness was calculated and then used to find the two most rigid constructs; the load to failure was recorded. Stiffness and load to failure testing for the two more rigid constructs in paired cadaveric bones were followed.

Results

The unlocked plate plus screw and crossed screw constructs were stiffest (p < 0.008). Loads to failure of the unlocked plate plus screw and crossed screws in synthetic bone were 131 and 101 N, respectively and in cadaveric bone were 154 and 94 N, respectively, which are less than the estimated 25% body weight required at the MTP joint. The plate plus screws were statistically more stiff than crossed screws (p = 0.008), but there was no statistical difference between synthetic and cadaveric bone in load to failure (p = 0.296).

Conclusions

The plate plus screw offered the greatest stiffness; the failure test showed that no construct could withstand weight-bearing as tolerated; and, synthetic composite models of the MTP joint did not provide the consistent results in stiffness and failure.

Distraction First Metatarsophalangeal Arthrodesis With Tricortical Calcaneus Autograft: Technique Tips

First metatarsophalangeal joint arthritis can stem from a biomechanical imbalance as in hallux abducto valgus, metabolic arthritidies such as rheumatoid or gout, and even in posttraumatic cases. Advanced arthritis in the foot and ankle can often become debilitating. Surgical intervention is often necessary. Revision of failed first metatarsophalangeal joint arthroplasty is often in the setting of bony erosion and lysis, cystic changes, and loss of bone stock. In this article, we describe first metatarsophalangeal distraction arthrodesis technique using tricortical calcaneus autograft with the aim of simplifying donor site graft harvesting and decreasing donor site morbidity while attaining successful osseous union.

LEVELS OF EVIDENCE

Level V.

Quality of Early Union After First Metatarsophalangeal Joint Arthrodesis

The aim of the present retrospective cohort study was to assess the quality of union and the clinical outcomes in patients who had undergone first metatarsophalangeal joint (MTPJ) fusion using a dorsal plate and plantar lag screw. From March 2011 to December 2012, the clinical and radiographic data of 39 patients (41 feet) who had undergone first MTPJ fusion using a compressive locking plate were retrospectively reviewed. All patients had undergone postoperative computed tomography at 6 weeks postoperatively to assess union. The average metatarsophalangeal angles improved from 23° ± 16° preoperatively to 14° ± 5° postoperatively. The dorsiflexion of the hallux at the preoperative assessment averaged 17° ± 11° and 23° ± 5° postoperatively. At 6 weeks postoperatively, the computed tomography scans demonstrated 3 complete fusions (7.3 %) and 38 partial unions (92.7%). Also at 6 weeks, the mean ± standard deviation joint bridging was 54% ± 14.6%. The forefoot American Orthopaedic Foot and Ankle Society scale score had improved significantly from 50 ± 13 preoperatively to 80 ± 7 at >1 year of follow-up (p = .001). Hardware removal was performed in 8 cases because of pain in 7 and infection in 1. Revision arthrodesis was required in 2 cases because of nonunion. At 6 weeks postoperatively, partial bony joint bridging could be observed in most cases after arthrodesis of the first MTPJ with the dorsal fusion plate.

Treatment of hallux valgus deformity

Hallux valgus deformity is a very common pathological condition which commonly produces painful disability. It is characterised as a combined deformity with a malpositioning of the first metatarsophalangeal joint caused by a lateral deviation of the great toe and a medial deviation of the first metatarsal bone.

Taking the patient’s history and a thorough physical examination are important steps. Anteroposterior and lateral weight-bearing radiographs of the entire foot are crucial for adequate assessment in the treatment of hallux valgus.

Non-operative treatment of the hallux valgus cannot correct the deformity. However, insoles and physiotherapy in combination with good footwear can help to control the symptoms.

There are many operative techniques for hallux valgus correction. The decision on which surgical technique is used depends on the degree of deformity, the extent of degenerative changes of the first metatarsophalangeal joint and the shape and size of the metatarsal bone and phalangeal deviation. The role of stability of the first tarsometatarsal joint is controversial.

Surgical techniques include the modified McBride procedure, distal metatarsal osteotomies, metatarsal shaft osteotomies, the Akin osteotomy, proximal metatarsal osteotomies, the modified Lapidus fusion and the hallux joint fusion. Recently, minimally invasive percutaneous techniques have gained importance and are currently being evaluated more scientifically.

Hallux valgus correction is followed by corrective dressings of the great toe post-operatively. Depending on the procedure, partial or full weight-bearing in a post-operative shoe or cast immobilisation is advised. Post-operative radiographs are taken in regular intervals until osseous healing is achieved.

Cite this article: Fraissler L, Konrads C, Hoberg M, Rudert M, Walcher M. Treatment of hallux valgus deformity. EFORT Open Rev 2016;1:295-302. DOI: 10.1302/2058-5241.1.000005.

Clinical and Operative Factors Related to Successful Revision Arthrodesis in the Foot and Ankle

BACKGROUND

Arthrodesis is a common operative procedure used to manage arthritis and deformity in the foot and ankle. Nonunion is a possible and undesirable outcome in any arthrodesis surgery. Rates of nonunion in the foot and ankle literature range from 0% to 47% depending on the patient population and joint involved. Multiple factors can contribute to developing a nonunion including location, fixation method, tobacco use, diabetes, infection, and others.

METHODS

The case logs of 3 foot and ankle surgeons were reviewed from January 2007 to September 2014 to identify nonunion arthrodesis revision cases. The patient factors reviewed included diabetes, inflammatory arthropathy, tobacco use, history of infection, nonunion elsewhere, neuropathy, Charcot arthropathy, posttraumatic arthritis, and prior attempt at revision arthrodesis at the same site. Operative records were reviewed to identify location of the nonunion, instrumention, use of allograft or autograft bone, use of iliac crest bone marrow aspirate (ICBMA) and use of orthobiologics such as bone morphogenetic protein (BMP) during the revision arthrodesis. Successful revision was defined as radiographic union on the final radiograph during follow-up. Eighty-two cases of revision arthrodesis were identified with an average follow-up of 16 months.

RESULTS

The overall nonunion rate was 23%. Neuropathy and prior attempts at revision were identified as significant risks (P <.05) for persistent nonunion. Odds ratio calculated based on previous attempts at revision arthrodesis found a 2.8-fold increase in the risk of failure for each attempt at revision.

CONCLUSION

Revision arthrodesis for nonunion in the foot and ankle was successful (77%) under a variety of patient and operative conditions. Neuropathy was a significant patient risk factor for persistent nonunions, and we believe it is important to identify even in the nondiabetic patient. As the number of attempts at revisions increases, there is a subsequent 3-fold increase in the risk of persistent nonunion.

LEVEL OF EVIDENCE

Level IV, case series.

Immediate Weightbearing of First Metatarsophalangeal Joint Fusion Comparing Buried Crossed Kirschner Wires Versus Crossing Screws: Does Incorporating the Sesamoids Into the Fusion Contribute to Higher Incidence of Bony Union?

First metatarsophalangeal joint (MTPJ) arthrodesis remains a commonly used and reliable procedure for a variety of pathologies of the first MTPJ. Many costly fixation constructions have been described to achieve union with first MTPJ arthrodesis. We hypothesized that the incidence of union would be the same for both buried Kirchner (K)-wire and solid crossed screw fixation with immediate weightbearing. To test this hypothesis, we retrospectively reviewed first MTPJ fusions performed by the senior author (C.A.C.) during a 6-year period and compared the incidence of union. Only patients who were immediately weightbearing in a surgical shoe and had undergone first MTPJ arthrodesis using K-wires or crossed screws were included. All patients had undergone incorporation of their sesamoids into the fusion. A total of 97 feet in 89 patients met the inclusion criteria. Of the 97 first MTPJ fusions, 48 (49.5%) had buried K-wire fixation and 49 (50.5%) crossed screw fixation. The mean age was 62 (range 41 to 75) years in the K-wire group and 60 (range 22 to 73) years in the crossed screw group. The mean follow-up period was 12.4 months in the K-wire group and 12.9 months in the crossed screw group. The rate of union in the K-wire group was 98% (1 nonunion) and the rate of union in the crossed screw group was 96% (2 nonunions). The 2 groups demonstrated similar high rates of fusion with immediate weightbearing, suggesting that less costly fixation is acceptable and effective for uncomplicated first MTPJ fusion.

Metatarsophalangeal Joint Fusion: Why and How?

First metatarsophalangeal (MTP) joint fusion aims at elimination of pain resulting from end-stage arthritis and obtaining a stable, plantigrade first toe. Associated deformities are corrected and greater defects are filled with interposition autograft or allograft. Fusion is generally obtained with screws, staples, and/or low-profile plates. Complications include infection, osteonecrosis, implant protrusion or failure, nonunion, and malunion, the latter 2 each occurring in approximately 6% of cases. The medium-term results of first MTP joint fusion indicate mostly good functional results with success rates of approximately 90%.

First metatarsophalangeal joint arthrodesis - Do joint configuration and preparation technique matter?

BACKGROUND

The purpose of this study was to investigate the influence of joint configuration and preparation on first metatarsophalangeal (MTPJ) union rates.

METHODS

We performed a retrospective analysis of first MTPJ arthrodeses undertaken in our institution. Clinical notes, radiographs and postal questionnaires were used to determine outcome.

RESULTS

Two hundred first MTPJ arthrodeses (172 patients) were included in the analysis (34 male: 138 female; mean age 62 yr). The overall union rate was 93.5%. Union was achieved in 109/118 MTPJs (92.4%) prepared in the flat-on-flat configuration and in 78/82 (95%) prepared in the ball-and-socket configuration (p=0.438). Higher union rates favoured low-velocity joint preparation [using rongeur only 21/21 (100%), rongeur and burr 26/27 (96.3%) and conical reamer 31/34 (91.2%)] but this did not reach statistical significance (p=0.317). There was a 95% satisfaction rate with surgery but male patients were less satisfied (p=0.031).

CONCLUSION

Union rates were not influenced by joint configuration or preparation techniques.

Effect of Osteogenic Progenitor Cell Concentration on the Incidence of Foot and Ankle Fusion

The use of biologics, namely demineralized bone matrix, bone marrow aspirate (BMA), and other growth factors, has gained popularity in foot and ankle surgery for use in compromised hosts or high-risk situations. Our research has shown the concentration of these pluripotent cells was greatest in the iliac crest. A medical record and radiographic review was performed to compare the effect of BMA harvest site osteogenic progenitor cells on the incidence of fusion. Radiographs were reviewed for radiographic evidence of trabecular bridging in 2 or more views. If fusion occurred, the number of osteogenic progenitor cells found in the combined BMA at surgery was recorded. A total of 33 patients were included in the present study. Of the 33 patients, 32 (97.0%) had radiographic fusion at a mean of 13 ± 6 (range 8 to 30) weeks, and 1 (3.0%) experienced nonunion and required revision. The patient procedures were as follows: 18 (54.5%) hindfoot arthrodeses, 8 (24.2%) forefoot arthrodeses, 4 (12.1%) fractures, and 3 (9.1%) isolated ankle fusions. The mean colony-forming units for the patients with fusion was 20.3 ± 23.5 (range 0.0 to 107.0). In the patient with nonunion, it was 0.20 colony-forming unit. Our comparison of the incidence of fusion with the use of osteogenic progenitor cells from 3 anatomic sites showed a low incidence of complications and a high incidence of fusion. No association was found between the BMA concentration and the incidence of fusion, suggesting a minimum concentration and biologic potential of pluripotent cells is necessary to achieve the clinical effect of fusion.

Effect of pathology on union of first metatarsophalangeal joint arthrodesis

BACKGROUND

Arthrodesis is an established treatment for symptomatic degeneration of the first metatarsophalangeal (MP) joint. The published case series have often been small with different surgeons using a variety of joint preparation and fixation methods. The nonunion frequency comparing the different pathologies has not been described. We describe the senior author's results comparing the union of an MP arthrodesis in hallux valgus, hallux rigidus, inflammatory arthropathy, and salvage surgery with identical joint preparation and fixation methods.

METHODS

The logbook of the senior author was used to identify the first MP joint arthrodeses from 2003 to 2011. The radiographic data were reviewed on the Picture Archiving and Communication system to assess the severity of deformity, radiographic union, type of fixation, and need for revision surgery. If there was no definite radiographic union of the last radiograph, the medical notes were reviewed. In all, 134 MP joint arthrodeses were performed in 78 females and 38 males, with a mean age of 65 ± 12 years (range, 20-94). Fixation was achieved by crossed screws (124) and dorsal plate (10). The primary diagnoses were hallux valgus in 49 joints (36.6%), hallux rigidus in 46 joints (34%), inflammatory arthropathy in 34 joints (25.4%), and salvage surgery in 5 joints (3.7%).

RESULTS

The overall radiographic union rate was 91.8% (123/134). There were significantly more nonunions in the hallux valgus group (14.3% vs 0%, OR 16, P = .05).

CONCLUSION

Biplanar cuts and crossed screw fixation gave similar union frequencies to published case series. Hallux valgus was associated with higher nonunion frequencies in this single surgeon series. It may be that the hallux valgus group needs a stronger construct to achieve comparable union frequencies to the hallux rigidus group.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

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.

Physical therapy post-hallux abducto valgus correction

This article discusses physical therapy considerations after hallux valgus correction. Hallux valgus is a fairly common occurrence, and corrective surgery is an option when conservative measures fail. Symptoms such as pain, swelling, and difficulty walking may persist after surgical correction of bunion deformity that addresses soft tissue and bone structure. Physical therapy is helpful after corrective hallux valgus surgery to address impairments and continued dysfunction and to improve overall patient outcome expectations. This article describes the benefits of a multifaceted physical therapy program after hallux valgus correction.

Retrospective analysis of the rate and interval to union for joint arthrodesis of the foot and ankle

Arthrodesis is a common procedure indicated for surgical treatment of end-stage degenerative joint disease of the foot and ankle. Many published studies have reviewed the union rate, focusing on specific technique or fixation. However, studies reporting on the average period required to achieve fusion, irrespective of the type of fixation or surgical method used, have been lacking. We report on the union rate and interval to fusion in patients who had undergone primary arthrodesis of various joints of the foot and ankle. A retrospective review of the medical records of 135 patients was performed. The specific joints studied were ankle, and the subtalar, triple, first tarsometatarsal, first metatarsophalangeal, and hallux interphalangeal joints. Our results showed that the average interval for complete fusion was significantly less for the joints in the forefoot, with the subtalar joint, ankle, and triple arthrodesis requiring a longer period to achieve complete fusion. The nonunion rate was also greater when the fusion involved the joints of the rearfoot. Our results have refuted the idea that 6 weeks is the minimum period required to achieve fusion in the foot and ankle. The results of our study support the need for additional education of the patients and surgeons that the interval required for recovery after foot and ankle fusion depends on the location and surface area that has been fused.

Incidence of nonunion of first metatarsophalangeal joint arthrodesis for severe hallux valgus using crossed, flexible titanium intramedullary nails and a dorsal static staple with immediate weightbearing in female patients

Myriad forms of fixation have been proposed for arthrodesis of the first metatarsophalangeal joint (MTPJ). Regardless of fixation type, nonunion of the arthrodesis site has been purported as a common complication. The authors performed a retrospective analysis of all patients undergoing arthrodesis of the first MTPJ for severe hallux valgus with 2 crossed, flexible titanium intramedullary nails and a dorsal static 10-mm titanium staple followed by immediate protected weightbearing. Patients were included if they had: surgery for severe hallux valgus of the first MTPJ; undergone the exact internal fixation technique described; not undergone bilateral surgery in the same setting; weightbearing preoperative radiographs; at least 6-week postoperative weightbearing radiographs; initiated weightbearing on the operative foot immediately postoperative in a protective shoe; been followed up clinically for at least 6 months' time postoperatively; and documentation of any complications. One hundred fifty-six female patients (195 feet) with a mean age of 67 ± 9.3 years met the inclusion criteria. Complications due to technical error during insertion of the crossed, flexibe titanium intramedullary nails occurred in 22 (11.3%) feet, but none led to revision surgery. There were 5 (2.6%) asymptomatic nonunions and 1 (0.5%) delayed union, but this ultimately united. The incidence of nonunion after arthrodesis of the first MTPJ using the specific internal fixation construct presented here for severe hallux valgus is lower than the historic mean for most other fixation techniques. However, there is still a need for methodologically sound prospective cohort studies that compare the technique presented here with other modern osteosynthesis techniques.

Arthrodesis of the first metatarsal-phalangeal joint with flexible, ridged titanium intramedullary nails alone or supplemented with static staples and immediate weight bearing: a consecutive series of 148 procedures

Myriad forms of fixation have been proposed for arthrodesis of the first metatarsal-phalangeal joint (MTPJ). However, nonunion of the arthrodesis site remains a common complication. The authors performed a retrospective review of all patients undergoing arthrodesis of the first MTPJ with flexible titanium intramedullary nails alone or supplemented with static staples followed by immediate protected weight bearing. Subjects were included if they had surgery performed only by one of us; not undergone bilateral surgery in the same setting; surgery for pathology of the first MTPJ other than rheumatoid arthritis; weight-bearing preoperative radiographs; postoperative weight-bearing radiographs demonstrating presence or absence of union at the arthrodesis site; initiated weight bearing on the operative foot immediately postoperative in a protective shoe; and documentation of any complications. A total of 128 patients (148 feet) met inclusion criteria and were included. There were 110 (85.9%) females and 18 (14.1%) males with a mean age ± SD of 64 ± 14.1 years. Indications included (a) 93 (62.8%) severe hallux valgus deformity, (b) 37 (25%) hallux rigidus, and (c) 18 (12.2%) failed first MTPJ surgeries. Ten different configurations where included based on the requirements needed to achieve a solid construct intraoperatively. There were a total of 9 (6.1%) complications consisting of 4 (2.7%) asymptomatic nonunions, 4 (2.7%) hardware removals, and 1 (0.7%) loss of reduction requiring revision surgery. The incidence of nonunion with flexible titanium intramedullary nails alone or supplemented with static staples followed by immediate protected weight bearing for predominantly severe hallux valgus and hallux rigidus is lower than the historic mean for most other fixation techniques. However, there is still a need for methodologically sound prospective cohort studies that focus on the use of isolated arthrodesis of the first MTPJ for purely severe hallux valgus or hallux rigidus, and comparison of the technique presented here with other modern osteosynthesis techniques. Levels of Evidence : Therapeutic, Level IV.

Nonunion rate of first metatarsal-phalangeal joint arthrodesis for end-stage hallux rigidus with crossed titanium flexible intramedullary nails and dorsal static staple with immediate weight-bearing

Myriad forms of fixation have been proposed for arthrodesis of the first metatarsal-phalangeal joint (MTPJ). Regardless of the fixation type, nonunion of the arthrodesis site has been purported to be a common complication. We performed a retrospective review of all patients undergoing arthrodesis of the first MTPJ for end-stage hallux rigidus with 2 crossed flexible titanium intramedullary nails and a dorsal static 10-mm titanium staple followed by immediate protected weight-bearing. The inclusion criteria were as follows: the exact internal fixation technique described was employed for end-stage hallux rigidus of the first MTPJ only; preoperative and at least 6 weeks of postoperative weight-bearing radiographs were available; weight-bearing was initiated on the operative foot immediately in a protective shoe; the patient was followed for at least 6 months postoperatively; any complication was documented; and bilateral surgery was not done in the same setting. A total of 42 female patients (51 feet) with a mean age ± SD of 69.4 ± 9.2 years met the inclusion criteria. Complications resulting from technical error during insertion of the crossed titanium flexible intramedullary nails occurred in 3 feet (5.9%), but none led to nonunion or revision surgery. One delayed union (2%) occurred but it ultimately united. The incidence of nonunion after arthrodesis of the first MTPJ consisting of 2 crossed flexible titanium intramedullary nails and a dorsal static 10-mm titanium staple for end-stage hallux rigidus in an exclusively female population was lower than the historic mean for most other fixation techniques. However, methodologically sound prospective cohort studies that focus on the use of isolated arthrodesis of the first MTPJ for end-stage hallux rigidus in both male and female patients are still needed, as are comparisons of the presented technique with other modern osteosynthesis techniques.

Nonunion rate of first metatarsal-phalangeal joint arthrodesis with crossed titanium flexible intramedullary nails and a dorsal static staple with immediate weightbearing

Myriad forms of fixation have been proposed for arthrodesis of the first metatarsal-phalangeal joint (MTPJ). Regardless of fixation type, nonunion of the arthrodesis site has been purported as a common complication. We performed a retrospective review of all patients undergoing arthrodesis of the first MTPJ with crossed flexible titanium intramedullary nails and a dorsal static staple followed by immediate protected weight bearing. The subjects were included if they had undergone the exact internal fixation technique described; surgery had been performed only by 1 of us; and they had not undergone bilateral surgery in the same setting. Also, the indication for surgery was required to be pathology of the first MTPJ other than rheumatoid arthritis. Weight bearing preoperative radiographs and weight bearing radiographs at least 6 weeks postoperatively were required. Also, the patients had to have initiated weight bearing on the operative foot immediately postoperatively in a protective shoe. Finally, documentation of any complications was required. A total of 83 patients (95 feet) met the inclusion criteria and were included. Of the 83 patients, 77 (92.7%) were female and 6 (7.3%) were male. Their mean age ± standard deviation was 69.7 ± 16.7 years. Of the 95 feet, 55 (57.9%) were right and 40 (42.1%) were left feet. The indications included 61 (64.2%) with severe hallux valgus deformity, 24 (25.3%) with hallux rigidus, and 10 (9.5%) with failed first MTPJ surgery. Complications related to technical error during insertion of the crossed titanium flexible intramedullary nails occurred in 16 feet (16.8%) but none led to nonunion or revision surgery. A total of 3 asymptomatic nonunions (3.2%) occurred, all in female patients with severe hallux valgus that did not require revision surgery. The incidence of nonunion after arthrodesis of the first MTPJ consisting of crossed flexible titanium intramedullary nails and a dorsal static staple for predominantly severe hallux valgus and hallux rigidus was lower than the historic mean for most other fixation techniques. However, methodologically sound prospective cohort studies are still needed that focus on the use of isolated arthrodesis of the first MTPJ for purely severe hallux valgus or hallux rigidus and a comparison of the technique we have presented with other modern osteosynthesis techniques.