Intermediate-term results of isolated minimally invasive arthroscopic cheilectomy in the treatment of hallux rigidus

Minimally Invasive Cheilectomy for Hallux Rigidus

Hallux metatarsophalangeal joint cheilectomy is a joint-sparing technique that involves resection of the dorsal metatarsal head osteophytes; this may be achieved through minimally invasive and arthroscopic techniques. General indications for minimally invasive surgery (MIS) cheilectomy are mild-to-moderate hallux rigidus (Grades I-II) with symptomatic dorsal osteophytes causing dorsal impingement and/or shoe wear irritation in those who have failed extensive nonoperative management. The literature confirms equivalent outcomes to open cheilectomy; however, it is somewhat inconsistent regarding superiority. The theoretic benefits of MIS cheilectomy include better cosmesis, reduced wound complications, less soft tissue disruption, and faster recovery.

Minimally invasive Dorsal cheilectomy and Hallux metatarsophalangeal joint arthroscopy for the treatment of Hallux Rigidus

BACKGROUND

Minimally invasive dorsal cheilectomy (MIDC) has become a popular alternative to an open approach for treating Hallux Rigidus (HR). To reduce some of the complications related to the MIDC approach, a first metatarsophalangeal (MTP) joint arthroscopy can be performed in addition to address the intra-articular pathology associated with Hallux Rigidus. This study aims to examine the effectiveness of MIDC with first MTP arthroscopy in patients with HR with a minimum 1-year follow-up.

METHODS

This was a multicenter retrospective review for adult patients with Coughlin and Shurnass Grade 0-3 who were treated with MIDC and first MTP arthroscopy between 3/1/2020 and 8/1/2022, with at least one year of follow-up data. Demographic information, first MTP range of motion (ROM), visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOXFQ), and EQ-5D-5 L scores were collected. Continuous data was expressed as a mean and standard deviation, categorical data was expressed as a percentage. Wilcoxon Rank Sum test was used to compare continuous variables. All P < 0.05 was considered significant.

RESULTS

A total of 31 patients were included in the study. Average follow-up time was 16.5 months (range: 12 to 26.2). There was 1 (3.2%) undersurface EHL tendon tear, 2 (6.5%) conversions to an MTP fusion, and 1 (3.2%) revision cheilectomy and capsular release for MTP joint contracture. There was a significant improvement in patient's ROM in dorsiflexion (50 vs 89.6 degrees, P = 0.002), postoperative VAS pain scores (6.4 vs 2.1, P < 0.001), MOXFQ pain scores (58.1 vs 30.7, P = 0.001), MOXFQ Walking/Standing scores (56.6 vs 20.6, P = 0.001), MOXFQ Social Interaction scores (47.3 vs 19.36, P = 0.002), and MOXFQ Index scores (54.7 vs 22.4, P < 0.001).

CONCLUSION

We found that MIDC with first MTP arthroscopy was effective at improving patient-reported outcomes at one year with low complication and revision rates. These results suggest that MIDC with first MTP arthroscopy is an effective treatment for early-stage HR.

LEVEL OF EVIDENCE

IV.

Outcomes following minimally invasive dorsal cheilectomy for hallux rigidus: A systematic review

BACKGROUND

Cheilectomy of the 1st metatarsophalangeal joint (MTPJ) is one of the most common procedures for the management of hallux rigidus. However, there is no consensus regarding outcomes following minimally invasive dorsal cheilectomy (MIDC) for the management of hallux rigidus.

AIM

To evaluate outcomes following MIDC for the management of hallux rigidus.

METHODS

During November 2023, the PubMed, EMBASE and Cochrane Library databases were systematically reviewed to identify clinical studies examining outcomes following MIDC for the management of hallux rigidus.

RESULTS

Six studies were included. In total, 348 patients (370 feet) underwent MIDC for hallux rigidus at a weighted mean follow-up of 37.9 ± 16.5 months. The distribution of patients by Coughlin and Shurna's classification was recorded in 4 studies as follows: I (58 patients, 27.1%), II (112 patients, 52.3%), III (44 patients, 20.6%). Three studies performed an additional 1st MTPJ arthroscopy and debridement following MIDC. Retained intra-articular bone debris was observed in 100% of patients in 1 study. The weighted mean American orthopedic foot and ankle society score improved from a preoperative score of 68.9 ± 3.2 to a postoperative score of 87.1. The complication rate was 8.4%, the most common of which was persistent joint pain and stiffness. Thirty-two failures (8.7%) were observed. Thirty-three secondary procedures (8.9%) were performed at a weighted mean time of 8.6 ± 3.2 months following the index procedure.

CONCLUSION

This systematic review demonstrated improvements in subjective clinical outcomes together with a moderate complication rate following MIDC for the management of hallux rigidus at short-term follow-up. A moderate re-operation rate at short-term follow-up was recorded. The marked heterogeneity between included studies and paucity of high quality comparative studies limits the generation of any robust conclusions.

First metatarsophalangeal joint arthroscopy: Unearthing clinical evidence - A systematic review

PURPOSE

Arthroscopy of the first metatarsophalangeal joint (1 MTP) has gained increasing attention in the last two decades. Despite numerous studies describing the surgical technique, only a few provide clinical or radiological outcome data. This systematic review aimed to analyze studies presenting objectively measurable clinical outcomes of patients who underwent 1 MTP arthroscopy as the primary procedure, categorizing results by indication pathology.

METHODS

Following PRISMA guidelines, PubMed and Cochrane databases were searched for studies reporting outcomes of primary 1 MTP arthroscopy, regardless of underlying pathology. The selected articles were thoroughly assessed to extract data regarding the demographics of included patients, pathology, preoperative and postoperative clinical and radiological outcomes, complications, and reinterventions.

RESULTS

Fourteen articles, involving 405 patients (419 halluces), were included. Common indications were hallux valgus and hallux rigidus. Notably, Hallux Valgus Angle improved from 28.9° to 12.7°, and Intermetatarsal Angle improved from 13.8° to 9.2°, where reported. In hallux rigidus patients, range of motion increased from 25.15° to 71.3° post-surgery. Temporary or permanent sensory loss occurred in 3% of treated halluces, with 4.28% requiring reoperation.

CONCLUSIONS

Evidence on 1 MTP arthroscopy as the primary procedure is limited. It is most effective for hallux rigidus, while in hallux valgus cases, it can achieve satisfactory angular corrections but has a relatively high recurrence and reoperation rate. Although this technique is generally safe, further research should compare it with traditional surgical approaches to provide comprehensive insights.

LEVEL OF EVIDENCE

IV.

Percutaneous arthroscopically assisted cheilectomy combined to percutaneous proximal phalanx osteotomy in hallux rigidus: Clinical and radiological outcomes in 30 feet at a 48-month follow-up

BACKGROUND

Hallux rigidus is a degenerative condition affecting the middle age population. It affects patients by limiting their first metatarsophalangeal range of motion (ROM) and also, their shoe wear. The objective of our work was to present an original operative technique which preserves the native joint and improves pain with minimal complications.

METHODS

We conducted a retrospective multicenter cohort study of 28 patients (30 feet) suffering from moderate hallux rigidus, operated between October 2010 and October 2017 with at least 48months of follow-up. Clinical and radiological assessments included pre- and postoperative ROM, the American Orthopedic Foot and Ankle Society (AOFAS) score and forefoot radiological evaluation. No patients were lost to follow-up.

RESULTS

The mean AOFAS score increased from 59 (range, 51 to 67) preoperatively to 84 (range, 80 to 88) at final follow-up. A total of 37 patients (97%) were satisfied. From a ROM point of view, this remained relatively unchanged between preoperative and postoperative values.

CONCLUSION

The percutaneous arthroscopically assisted cheilectomy combined with a percutaneous proximal phalanx osteotomy, significantly improves pain in hallux rigidus with index minus in patients with Coughlin stage I and II after a mean of 4-year follow-up.

LEVEL OF EVIDENCE

IV.

Dorsal Cheilectomy Using Great Toe Metatarsophalangeal Joint Arthroscopy for the Treatment of Hallux Rigidus

Great toe metatarsophalangeal joint (MTPJ) arthroscopy has been described in the literature for more than 50 years for treatment of a multitude of first MTPJ pathologies, including hallux rigidus, hallux valgus, and osteochondritis dissecans, among others. Despite this, the use of great toe MTPJ arthroscopy has not become widely used for treatment of these conditions as the result of reported difficulties with adequate visualization of the joint surface and manipulation of surrounding soft-tissue structures with the instruments available. We propose a simple technique with illustrations of the operating room setup and procedural steps to perform a dorsal cheilectomy in those with early-stage hallux rigidus using great toe MTPJ arthroscopy and a minimally invasive surgical burr in a way that is reproducible by foot and ankle surgeons.

Minimally Invasive Foot and Ankle Surgery: A Primer for Orthopaedic Surgeons

There is rapidly growing interest in minimally invasive surgery (MIS) of the foot and ankle. Technological advances, specifically with the advent of low-speed high-torque burrs, have enabled the expansion of MIS techniques. Accordingly, there is growing literature reporting excellent outcomes of MIS surgery to address many different pathologies of the foot and ankle. MIS techniques are particularly useful for conducting percutaneous osteotomies and bony débridement. These can be used to address bunion deformity, hammertoes, metatarsalgia, bunionette deformity, bone spurs, and hindfoot deformity. A detailed understanding of the technology, equipment, and techniques is crucial to safely conduct MIS of the foot and ankle. When done safely, MIS provides favorable outcomes with an expedited recovery and limited complications.

[Minimally invasive forefoot surgery: concept and techniques]

Minimally invasive surgery (MIS) has advanced to an established approach in the correction of all deformities of the forefoot. For the first ray the minimally invasive chevron and Akin osteotomy (MICA) shows very good clinical results and provides a broad spectrum of indications in comparison to the classical chevron osteotomy. The minimally invasive treatment of hallux rigidus also seems to achieve comparable results to the open techniques, although the surgical indications must be thoroughly evaluated. Lesser toe deformities are often easier to treat with minimally invasive osteotomy, capsule release and tendon lengthening than with complex open procedures and usually do not require any internal fixation material. Compared to the classical Weil osteotomy, distal metatarsal osteotomy shows a reduced rate of cock-up deformities and does not require internal fixation. In relation to open procedures, minimally invasive approaches should be accepted as a valuable addition and alternative to the classical open techniques due to the reduced rate of wound healing disorders and postoperative pain.

Great Toe Metatarsophalangeal Joint Arthroscopy: Simple Technique for Painful Nonunion

Great toe metatarsophalangeal joint (MTPJ) arthroscopy was first described as a viable technique for a multitude of first MTPJ pathologies in the early 1970s; however, with improving arthroscopic technique and technology, these indications will continue to expand. Arthroscopy of the first MTPJ has increasingly become a new pursuit for foot and ankle specialists. Therefore, we have proposed a simple technique and illustration from our operating room setup to traction and to our procedural technique to make great toe arthroscopy simple and reproducible for arthroscopic foot and ankle surgeons.