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

Effect of lag screw on stability of first metatarsophalangeal joint arthrodesis with medial plate

Background

First metatarsophalangeal joint (MTP-1) arthrodesis is a commonly performed procedure in the treatment of disorders of the great toe. Since the incidence of revision after MTP-1 joint arthrodesis is not insignificant, a medial approach with a medially positioned locking plate has been proposed as a new technique. The aim of the study was to investigate the effect of the application of a lag screw on the stability and strength of first metatarsophalangeal joint arthrodesis with medial plate.

Methods

The bending tests in a testing machine were performed for models of the first metatarsal bone and the proximal phalanx printed on a 3D printer from polylactide material. The bones were joined using the locking titanium plate and six locking screws. The specimens were divided into three groups of seven each: medial plate and no lag screw, medial plate with a lag screw, dorsal plate with a lag screw. The tests were carried out quasi-static until the samples failure.

Results

The addition of the lag screw to the medial plate significantly increased flexural stiffness (41.45 N/mm vs 23.84 N/mm, p = 0.002), which was lower than that of the dorsal plate with a lag screw (81.29 N/mm, p < 0.001). The similar maximum force greater than 700 N (p > 0.50) and the relative bone displacements lower than 0.5 mm for a force of 50 N were obtained for all fixation techniques.

Conclusions

The lag screw significantly increased the shear stiffness in particular and reduced relative transverse displacements to the level that should not delay the healing process for the full load of the MTP-1 joint arthrodesis with the medial plate. It is recommended to use the locking screws with a larger cross-sectional area of the head to minimize rotation of the medial plate relative to the metatarsal bone.

Treatment of hallux rigidus with percutaneous metatarsophalangeal arthrodesis: a case series with a minimum follow-up of 2 years

BACKGROUND

Percutaneous metatarsophalangeal arthrodesis is an option for the treatment of hallux rigidus in more advanced cases. The aim of this study was to investigate the clinical and radiographic results at least 2 years after percutaneous metatarsophalangeal arthrodesis in patients with hallux rigidus.

METHODS

This is a case series of consecutive patients undergoing percutaneous metatarsophalangeal arthrodesis in patients with hallux rigidus grades III and IV with a minimum of 24 months of clinical and radiographic follow-up. The primary outcome was clinical assessment using the Visual Analog Scale for Pain (VAS). Secondary outcomes included American Orthopedic Foot & Ankle Society (AOFAS) score, patient satisfaction, complications, and bone healing (radiographic analysis).

RESULTS

Between August 2017 and February 2020, 29 feet (24 patients) underwent percutaneous metatarsophalangeal arthrodesis. The mean follow-up was 38.4 (range 24-54) months. There was an improvement in the pain (VAS) from 7.8 to 0.6 (p < 0.001) and in the AOFAS score from 49.9 to 83.6 (p < 0.001). There was a rate of bone union of 82.8% and screw removal of 13.8%. All patients considered the result to be excellent or good.

CONCLUSION

The treatment of grade III and IV hallux rigidus with percutaneous metatarsophalangeal arthrodesis demonstrated high patient satisfaction and significantly improves in clinical outcomes but the nonunion rate was higher than reported outcomes for open 1st metatarsophalangeal joint arthrodesis.

LEVEL OF EVIDENCE

IV, case series.

A novel approach for joint line restoration in revision total ankle arthroplasty based on the three-dimensional registration of the contralateral tibia and fibula

PURPOSE

The use of total ankle arthroplasty (TAA) is increasing over time, as so will the need for revision TAAs in the future. Restoration of the ankle joint line (JL) in revision TAA is often difficult due to severe bone loss. This study analyzed the accuracy of a three-dimensional (3D) registration of the contralateral tibia and fibula to restore the ankle joint line (JL) and reported side-to-side differences of anatomical landmarks.

METHODS

3D triangular surface models of 96 paired lower legs underwent a surface registration algorithm for superimposition of the mirrored contralateral lower leg onto the original lower leg to approximate the original ankle JL using a proximal, middle and distal segment. Distances of the distal fibular tip, anterior and posterior medial colliculus to the JL were measured and absolute side-to-side differences reported. Anterior lateral distal tibial angle (ADTA) and lateral distal tibial angle (LDTA) were measured.

RESULTS

Mean JL approximation was most accurate for the distal segment (0.1 ± 1.4 mm (range: -3.4 to 2.8 mm)) and middle segment (0.1 ± 1.2 mm (range: -2.8 to 2.5 mm)) compared to the proximal segment (-0.2 ± 1.6 mm (range: -3.0 to 4.9 mm)) (p = 0.007). Distance of the distal fibular tip, the anterior, and posterior medial colliculus to the JL, ADTA and LDTA yielded no significant side-to-side differences (n.s.).

CONCLUSION

3D registration of the contralateral tibia and fibula reliably approximated the original ankle JL. The contralateral distal fibular tip, anterior and posterior medial colliculi, ADTA and LDTA can be used reliably for the planning of revision TAA with small side-to-side differences reported.

LEVEL OF EVIDENCE

IV.

[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.

An Umbrella Systematic Review and Meta-Analysis of Systematic Reviews on the Topic of Foot and Ankle Arthrodesis Nonunion Rates

The purpose of this systematic review and meta-analysis was to appraise and combine the available systematic reviews reporting nonunion incidence and prevalence in foot and ankle arthrodesis procedures. The Cochrane Library and MEDLINE were searched for relevant systematic reviews from inception to January 2022. Two independent reviewers selected and reviewed eligible studies. Studies were included if they were systematic reviews or meta-analyses reporting nonunion incidence and prevalence in foot or ankle arthrodesis procedures. Fourteen systematic reviews of 8 types of joint arthrodesis procedures were included for meta-analysis. These reviews comprised 138 studies with 5793 joint arthrodesis procedures. Quality of the included reviews were assessed using the AMSTAR2 checklist. Overall and subgroup meta-analysis of prevalence were performed using random effects model. Publication bias was determined by evaluation of a DOI plot with the Luis Furuya-Kanamori index of asymmetry. The pooled prevalence for foot and ankle nonunion rate was 8.1% (95% confidence interval [CI] 6.5%-9.9%). Overall prevalence of nonunion for single joint foot and ankle joint arthrodesis was 6.1% (95% CI 4.8%-7.6%). Subgroup analysis found that the highest rate of nonunion occurred during tibiotalocalcaneal arthrodesis with 27.1% (95% CI 19.4%-35.2%). We have reported the first meta-analysis of systematic reviews on nonunion rates in foot and ankle arthrodesis procedures. The overall nonunion rate for foot and ankle arthrodesis procedures was 8.1%. For single joint fusion procedures, the nonunion prevalence was 6.1%. Our reported nonunion rates are lower than previously published numbers.

Two Orthogonal Nitinol Staples and Combined Nitinol Staple-Screw Constructs for a First Metatarsophalangeal Joint Arthrodesis: A Biomechanical Cadaver Study

BACKGROUND

End-stage hallux metatarsophalangeal (MTP) joint arthritis is commonly treated with arthrodesis using stainless steel or titanium implants. These implants provide static compression that is maximal at the time of implant insertion. Alternatively, nitinol staples are capable of dynamic compression. They have most frequently been used for midfoot arthrodesis procedures. However, their biomechanical performance during hallux MTP arthrodesis has not been described.

METHODS

8 matched pairs of cadaveric feet (4 female, 4 male) were prepared for hallux MTP arthrodesis using cup and cone reamers. Cadaveric pairs were then instrumented with either (1) a transarticular lag screw and dorsal nitinol staple or (2) orthogonal nitinol staples placed dorsally and medially. Walking in a short leg cast for 6 weeks was simulated by applying 90-N forces at 3 Hz to the plantar proximal phalanx for up to 250 000 cycles. Failure was defined as catastrophic implant failure or plantar gapping beyond 7 mm.

RESULTS

15 of 16 specimens failed cyclic loading. All 8 specimens fixed with orthogonal staples failed at an average of 37 ± 81 cycles. 7 of 8 specimens fixed with a dorsal staple and crossed screw failed at 14 900 ± 39 000 cycles. Collectively, 5 specimens failed because of bone fracture (1 in orthogonal staples, 4 in staple-screw group) and 10 failed because of excessive gap formation (7 in orthogonal staples, 3 in staple-screw group). The number of cycles to failure was significantly lower (P = .0469) in the orthogonal staple constructs compared with the dorsal staple and crossed screw constructs.

CONCLUSION

The tested constructs permit significant motion at the first MTP fusion surface during simulated protected weightbearing. Although multiple in vivo factors should be considered when extrapolating results from this cadaveric study, this motion may result in clinical failure with early postoperative weightbearing protocols.

CLINICAL RELEVANCE

We report the first biomechanical evaluation of hallux MTP arthrodesis using modern nitinol staples in 2 separate constructs.

Clinical and Radiologic Outcome of First Metatarsophalangeal Joint Arthrodesis Using a Human Allogeneic Cortical Bone Screw

Background:

Different fixation techniques are established for first metatarsophalangeal joint (MTPJ) arthrodesis, including compression screws, plates, Kirschner wires, metal- and bioabsorbable screws as well as staples. The purpose of this study was to investigate and present first clinical and radiologic results using a novel human, allogeneic cortical bone screw for arthrodesis of the first MTPJ.

Methods:

Arthrodesis of the first MTPJ was performed in 31 patients with hallux rigidus. Percentage union and time to union were the first outcomes; visual analog scale for pain, hallux valgus angle (HVA), intermetatarsal angle, and American Orthopaedic Foot & Ankle Society (AOFAS) hallux score were secondary outcomes.

Results:

Median time to union was 89 days, and union was observed in all patients. There were 4 complications (2 osteolysis margin, 1 cystic brightening, and 1 severe swelling at the first follow-up) all of that resolved at last follow-up. Pain significantly decreased from visual analog scale 8.0 to 0.2 points ( P < .0001). The HVA decreased from 30.4 to 10.2 degrees in the patient group with deformities. The total AOFAS score increased significantly from 48 to 87 ( P < .0001).

Conclusion:

Primary and revision arthrodesis of hallux rigidus with the human, allogeneic cortical bone screw reveals satisfying results similar to clinical and radiologic outcomes of other surgical techniques. Within 1 year, the human, allogeneic cortical bone screw is fully remodeled to host bone.

Level of Evidence:

Level IV, retrospective case series without control group.

First metatarsophalangeal joint arthrodesis/fusion: a systematic review of modern fixation techniques

Background

First metatarsophalangeal joint arthrodesis is commonly performed for symptomatic end-stage hallux rigidus. It has been postulated to produce good results in the literature. Various fixation techniques offer differences in union rates, complications and functional outcomes, stirring debates about which produces the best outcomes for patients. Therefore, this review aims to synthesise and compare the outcomes of modern fixation techniques used for first metatarsophalangeal joint (FMPJ) arthrodesis.

Methods

The electronic database searched were PubMed, CINAHL, Cochrane Library, and Google Scholar. The critical appraisal skills programme tool for cohort study was used. The interventions consisted of screw(s), plate(s), and staple(s). Studies comprising outdated fixation techniques such as suture, metallic wire, external fixation, Rush rods or Steinmann pins were excluded. Participants were adults over 18 years, undergoing FMPJ arthrodesis in the UK. Studies with the population consisting primarily of revision cases, patients with rheumatoid arthritis or diabetes were excluded.

Results

Seven UK studies included 277 feet and a 95.7% overall union rate at a mean union time of 83.5 days. Staples had the highest union rate of 98.2% at mean union time of 84 days, followed by plates (95.2%, 92 days), and finally screws (94.9%, 71 days). The overall complication incidence is 5.8%. All of the fixation techniques produced good functional outcomes postoperatively.

Conclusions

Whilst staple techniques showed the highest union rate, plating techniques are preferable over screws or staples for better results across several outcome measures, including reduced complication incidence, stability, early ambulation, and good functional outcome. The Manchester-Oxford Foot Questionnaire and EuroQol-5Dimensional are recommended as measurement tools to assess functional outcomes following FMPJ arthrodesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00540-9.

Metallic hemiarthroplasty or arthrodesis of the first metatarsophalangeal joint as treatment for hallux rigidus: A systematic review and meta-analysis

BACKGROUND

Arthrodesis and metallic hemiarthroplasty are two surgical interventions for the treatment of end-stage osteoarthritis of the first metatarsophalangeal (MTP1) joint. This systematic review and meta-analysis aims to compare the two operations with regards to patient-reported outcomes, pain reduction, complications and revision rates.

METHODS

A systematic literature search identified all relevant studies. The methodological quality was assessed using two validated tools. Data of interest were derived and presented. For non-comparative studies, data was assessed for trends, while for comparative studies pooling statistics were performed.

RESULTS

A total of 33 studies were included for analysis. The majority of studies (>75%) reported an AOFAS-HMI score greater than 80 points after both metallic hemiarthroplasty and arthrodesis. The lowest VAS pain score was observed after arthrodesis (weighted mean difference -1.58, 95% confidence interval (CI) -2.16 to -1.00 P< 0.00001). Comparable numbers of complications (odds radio 1.48, 95% CI 0.81 to 2.73, P = 0.21, favoring: hemiarthroplasty) and revisions (odds ratio 1.16, 95% CI 0.62 to 2.15 P = 0.64, favoring: hemiarthroplasty) were observed after both interventions. The included non-comparative studies seem to confirm these findings of the comparative studies.

CONCLUSION

Metallic hemiarthroplasty and arthrodesis have excellent clinical outcomes and acceptable complication- and revision rates. Arthrodesis seems to be superior in pain reduction, while metallic hemiarthroplasty is a suitable alternative for patients performing activities that requires motion in the first metatarsophalangeal joint.

Arthrodesis of the first metatarsophalangeal joint: The “when and how”

Arthrodesis of the first metatarsophalangeal (MTP) joint has been established as the “gold standard” for the treatment of several first ray disorders, due to its perceived efficacy and the consistently reported good results in the literature. Arthrodesis is a commonly performed procedure for the treatment of end stage arthritis, rheumatoid arthritis with severe deformity, selected cases of severe hallux valgus (with or without signs of degenerative joint disease), as well as a salvage procedure after failed previous operation of the first ray. The goals of a successful 1^st MTP arthrodesis are pain alleviation and deformity correction in order to restore a comfortable gait pattern and to improve shoe wear. Several techniques have been reported with several proposals regarding the preparation of the articular surfaces and the method of definitive fixation. As with any given surgical procedure, various complications may occur after arthrodesis of the 1^st MTP joint, namely delayed union, nonunion, malunion, irritating hardware, etc.

First Metatarsophalangeal Joint Arthrodesis: A Narrative Review of Fixation Constructs and Their Evolution

First metatarsophalangeal (MTP) joint arthrodesis is a surgical procedure in which the first metatarsal head is fused to the proximal phalanx of the great toe in order to permanently stiffen the first MTP joint. It was originally proposed as a treatment for severe cases of hallux valgus deformity, but the procedure's indications and utilization have expanded since its initial development. Despite a wide variety of indications, first MTP arthrodesis has been shown to have reliable, satisfactory outcomes. As a result, the development of a wide array of surgical approaches, joint preparation techniques, and fixation devices used in the procedure has occurred. In this narrative review, we highlight the evolution of fixation constructs used in first MTP arthrodesis in order to provide a frame of reference for the various types of fixation constructs available.

Effects of Short-Term Limitation of Movement of the First Metatarsophalangeal Joint on the Biomechanics of the Ipsilateral Hip, Knee, and Ankle Joints During Walking

BACKGROUND We analyzed the effect of limitation of movement of the first metatarsophalangeal joint (FMJ) on the biomechanics of the lower limbs during walking. MATERIAL AND METHODS Eight healthy college students completed walking under barefoot (BF) and FMJ constraint (FMJC) conditions. We synchronously collected kinematics and dynamics data, and calculated the torque, power, and work of hip, knee, and ankle joints. RESULTS Compared with normal conditions, when the FMJ is restricted from walking, the maximum ankle dorsiflexion angle is significantly increased (P<0.001), the maximum plantar flexion angle is significantly reduced (P<0.001), the maximum plantar flexion torque (P<0.001) and the maximum dorsiflexion torque (P<0.05) increased significantly, the maximum power increased significantly (P<0.001), the minimum power decreased significantly (P<0.001), and the negative work increased significantly (P<0.001). The torque of hip and knee joints increased significantly (P<0.05). CONCLUSIONS After the movement of the FMJ is restricted, the human body mainly compensates and transfers compensation by increasing the angle of dorsiflexion, increasing work and the activity level of surrounding muscles through the ankle joint, thereby increasing the torque load of the knee and hip joints to maintain the dynamic balance of kinematics. FMJC condition increases the energy consumption of the human ankle, knee, and hip joints during walking. The load is compensated by the gradual attenuation of the ankle, knee, and hip. Long-term limitation may cause damage to the posterior calf muscles and increase the incidence of knee arthritis.