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

Interposition Arthroplasty in the Treatment of End-Stage Hallux Rigidus: A Systematic Review

PURPOSE

Patients affected by moderate to severe hallux rigidus may opt for interposition arthroplasty to avoid the movement restrictions of arthrodesis and the complications related to prosthetic replacement. The propose of this article was to review the current literature about interposition arthroplasty to examine the overall outcomes and to evaluate the advantages and disadvantages of different types of technique, compared with more consolidated procedures.

METHODS

A literature PubMed search was performed. Studies reporting the results of interposition arthroplasty in moderate to severe hallux rigidus were included. The data were pooled and weighted for number of patients in every study.

RESULTS

The overall results for interposition arthroplasties are comparable to other alternatives for end-stage hallux rigidus, providing better plantar load distribution than arthrodesis and avoiding the drawbacks of prosthetic replacement. Among the various interposition arthroplasty techniques, the Modified Oblique Keller Capsular Interposition Arthroplasty technique preserves toe length and flexor hallucis brevis function, showing the highest satisfaction rate, with lowest metatarsalgia and revision rate.

CONCLUSION

Although long-term randomized controlled trials are lacking for interposition arthroplasty, it represents a valid alternative for the treatment of end-stage hallux rigidus also in the young active patient who wants to avoid a definitive intervention immediately.

LEVEL OF EVIDENCE

III (systematic review of level III-IV-V studies).

First Metatarsophalangeal Joint Pain in Athletes: Diagnosis, Management, and Return to Play Considerations

ABSTRACT

The first metatarsal-phalangeal joint plays a key role for athletes of various disciplines. When an athlete presents for evaluation of pain at this joint, there are several causes that should be considered. The purpose of this article is to review common injuries including turf toe, sand toe, extensor and flexor hallucis longus tendinopathy, sesamoiditis, and metatarsalgia and provide current evidence-based recommendations for diagnosis, management, and return to play considerations. Conditions not specific to athletes like gout and hallux rigidus also are discussed. Mechanism of injury, physical examination, and imaging such as weight-bearing radiographs and point-of-care ultrasound can help with diagnosis. Treatment of many of these injuries begins with nonsurgical management strategies including footwear or activity modification, physical therapy, and select interventions.

Maintenance of Correction of the Modified Lapidus Procedure With a First Metatarsal to Second Metatarsal Screw With "Spot Weld" Technique: A Retrospective and Radiographic Analysis

Lapidus first tarsometatarsal (TMT) arthrodesis gained popularity for its ability to correct large deformities especially in cases of medial column instability. Despite solid first TMT fusion, instability between the first and second columns can result in loss of intermetatarsal (IM) angle correction over time. A "spot weld" or fusion between the first and second metatarsal may improve maintenance of correction. This retrospective study reviewed cases of Lapidus arthrodesis with first to second metatarsal base screw fixation for maintenance of IM correction and determine whether a "spot weld" is predictive of maintenance. A total of 90 cases (77 patients) performed by a single surgeon met inclusion with average follow-up of 309 days. First TMT fusion occurred in 87/90 (96.7%) cases with 76 dorsal plate, 10 dorsal staple, and 4 all screws. No incidence of complications related to the 1-2 screw was noted. Mean preoperative IM 1-2 angle 14.90°, mean correction to 6.22° post-operative and final maintained correction at 7.10°, mean loss of correction 0.87°. There were "spot welds" in 65/90 (72.2%) with mean loss of 0.48° versus loss of 1.88° in "no spot weld" subgroup (p < .001). Cases with no spot weld and screw lucency lost 2.25° (p < .001). Loss of IM 1-2 correction can occur due to first and second ray intra-column instability even in cases of solid first TMT arthrodesis. Incorporating a completed "spot weld" with bone grafting and first to second metatarsal screw was found to maintain correction with minimal loss (0.87°).

Relationship of Joint Hypermobility with Ankle and Foot Radiographic Osteoarthritis and Symptoms in a Community-Based Cohort

OBJECTIVE

To explore associations of joint hypermobility (a condition where range of motion is greater than normal) with ankle and foot radiographic osteoarthritis (OA) and symptoms in a large community-based cohort of African American and white adults ages 55-94 years old.

METHODS

Ankle and foot radiographs and joint hypermobility data (Beighton score for joint hypermobility criteria) were available for 848 participants (from 2003 to 2010) in this cross-sectional study. General joint hypermobility was defined as a Beighton score ≥4 (range 0-9); knee hypermobility was defined as hyperextension of at least 1 knee. Standing anteroposterior and lateral foot radiographs were read with standard atlases for Kellgren-Lawrence grade, osteophytes, and joint space narrowing (JSN) at the tibiotalar joint, and for osteophytes and JSN to define OA at 5 foot joints. Ankle or foot symptoms were self-reported. Separate person-based logistic regression models were used to estimate associations of ankle and foot OA and symptom outcomes with hypermobility measures, adjusting for age, sex, race, body mass index, and history of ankle/foot injury.

RESULTS

This sample cohort included 577 women (68%) and 280 African Americans (33%). The mean age of the participants was 71 years, with a mean body mass index of 31 kg/m2 . The general joint hypermobility of the participants was 7% and knee hypermobility was 4%. Having a history of ankle injury was 11.5%, and foot injury was 3.8%. Although general joint hypermobility was not associated with ankle and foot outcomes, knee hypermobility was associated with ankle symptoms, foot symptoms, and talonavicular OA (adjusted odds ratios of 4.4, 2.4, and 3.0, respectively).

CONCLUSION

Knee joint hypermobility may be related to talonavicular OA and to ankle and foot symptoms.

Interpositional arthroplasty with palmaris longus tendon graft for osteonecrosis of the second metatarsal head: a case report

Osteonecrosis of the second metatarsal head is often attributed to Freiberg's disease. We describe the case of a 27-year-old Taiwanese male soldier with persistent painful disability of the right forefoot of 9 months' duration, but no history of trauma. A series of radiographs suggested the diagnosis of late-stage Freiberg's disease. The lesion was treated with interpositional arthroplasty using a palmaris longus tendon graft, in a modification of the traditional interpositional arthroplastic technique for treating Freiberg's disease. After 2 years of follow-up examinations, the patient was satisfied with the clinical outcome, despite having a limited range of motion of the right second metatarsophalangeal joint relative to the adjacent toes. The patient returned to his army group with functional activity that was better than he had experienced before surgery. We believe this modified interpositional arthroplastic treatment strategy will provide more symptom relief and satisfactory functionality for the treatment of late-stage Freiberg's disease.

End-stage osteoarthritis of the great toe/hallux rigidus: a review of the alternatives to arthrodesis: implant versus osteotomies and arthroplasty techniques

Hallux rigidus is defined as end-staged arthrosis of the first metatarsophalangeal joint. Although the literature supports arthrodesis as being the gold standard for the treatment of end-staged hallux rigidus, there are several other treatments available that can either prolong the life of the remaining joint or artificially mimic the original biomechanics by replacing a portion of or the entire joint with the added advantage of preserving joint mobility. There are several new and emerging joint preservative techniques that may delay or prevent the need for a joint-destructive procedure, such as arthrodesis or arthroplasty.

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.

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.