Long-term results of total joint arthroplasty and phalangeal hemiarthroplasty of the first metatarsophalangeal joint using the ToeFit Plus™ system

Long-term outcomes of first metatarsophalangeal hemiarthroplasty for hallux rigidus

Hallux rigidus (HR) is arthritis of the first metatarsophalangeal joint.First metatarsophalangeal joint hemiarthroplasty surgery is one of the treatment options for end stage hallux rigidus.The aim of this study is to evaluate the long-term outcomes of hemiarthroplasty of the first MTPJ with a metallic implant in patients with end-stage HR. Patients who underwent hemiarthroplasty surgery with the diagnosis of HR were included in the study. Self-Administered Foot Evaluation Questionnaire (SAFE-Q) and Foot and Ankle Disability Index (FADI) scores were used in pre-operative and post-operative final follow-ups to evaluate the clinical status of the patients. Post-operative 1st metatarsophalangeal joint range of motion was measured and recorded separately for each patient. The intra-hospital and follow-up complications and revision surgeries of the patients were recorded. Thirty-five patients with a mean follow-up of 8.1 years were included in the study. There was a statistically significant positive change in both FADI and SAFE-Q scores compared to the pre-operative process(p = 0.0001). The average dorsiflexion angle at the final follow-up was 22.0 ± 8.2. Thus, it was determined that the 5-year and 8-year survival rates of patients in this study were 97.1% and 87.8%, respectively. In conclusion, the long-term results show that the use of hemiarthroplasty in the treatment of end-stage HR leads to high patient satisfaction, increased range of motion and a high survival rate.

Arthrodesis vs arthroplasty for moderate and severe Hallux rigidus: Systematic review

Hallux rigidus is the most frequent arthritis of the foot, due to multiple factors. Arthrodesis and interposition arthroplasty are treatments considered in advanced stages of the disease, when conservative treatment has failed. Although arthrodesis may be considered the technique recommended by multiple authors, for patients in whom joint mobility is to be preserved, arthroplasty could represent a reliable alternative. The purpose of this systematic review is to investigate and compare the clinical outcomes and complications of arthrodesis and interposition arthroplasty for moderate and severe stages of hallux rigidus.

METHODS

For this systematic review we searched COCHRANE, EMBASE, PUBMED databases. Twenty-six research papers were obtained, with a total of 1348 feet, which were included for qualitative analysis. The following groups were included: Cartiva hemiarthroplasty (286), double stem silicone arthroplasty (276), total metallic arthroplasty (394) and arthrodesis (392).

RESULTS

In the arthrodesis group, the AOFAS-HMI score was the most used, ranging from 36 to 45 in the preoperative period and from 79 to 89 in the postoperative period. The greatest improvement in the VAS PAIN score was from 86 to 4. The fusion rate was 98.6% of the total number of cases, the most frequent complication was pain due to material discomfort. In the total metallic arthroplasty group, the ROTO-GLIDE system reported an AOFAS score of 95 points, with low complication rates; but, with the TOEFIT-PLUS and BIOMED-MERCK systems, despite the good postoperative value, they report 37% and 15% revision due to aseptic loosening in the series with the longest follow-up, respectively. The Cartiva group showed a significative increase in FAAM ADL and FAAM SPORT from 59.4 to 90.4 and from 60.9 to 89.7, respectively; similarly, 20.5% implant removal and conversion to arthrodesis were reported. Finally, the double stem silicone arthroplasty group, in the series with the longest follow-up, it manages to improve the MOXFQ score from 78.1 to 11.0, with an average range of mobility of 22.3 degrees. Lysis was reported in 10% of cases.

CONCLUSIONS

Arthrodesis has proven to be the best option for the treatment of advanced hallux rigidus. Arthroplasty can be a valid option for patients who demand to maintain the range of mobility of the joint; however, it is important to inform about the complications that may arise in the short and medium term.

LEVEL OF CLINICAL EVIDENCE

II.

Assessment and Management of Atraumatic First Metatarsophalangeal Joint Pain

Nontraumatic pain in the first metatarsophalangeal joint is frequent and can be debilitating. The metatarsophalangeal joint complex comprises four articulating surfaces including the first metatarsal, the proximal phalanx, and tibial and fibular sesamoids, which are all contained within a synovial capsule. The most common causes of pain are hallux valgus and hallux rigidus. However, other diagnoses, such as functional hallux limitus, sesamoiditis, gout, and inflammatory autoimmune arthritis, need to be considered as well. A systematic approach is key to accurately diagnose the source of pain, which can sometimes be the result of more than one condition. The most important clinical information to obtain is a focused history, meticulous clinical examination based on understanding the precise anatomy and biomechanics of the first metatarsophalangeal joint, and analysis of the relevant imaging. Each pathology has a different treatment algorithm, as such, understanding the pathoanatomy and biomechanics is important in forming an effective treatment plan.

Preoperative Risk Factors for Primary Metatarsophalangeal Arthroplasty Revision to MTP Arthrodesis for Hallux Rigidus

BACKGROUND

Revision or conversion to arthrodesis following metatarsophalangeal (MTP) joint arthroplasty are salvage procedures to manage complications of MTP joint arthroplasty. The purpose of this study is to use a national administrative database to characterize nationwide trends of patients undergoing hallux MTP arthrodesis vs arthroplasty for hallux rigidus. Additionally, the authors sought to evaluate demographic trends and evaluate influence of patient-related risk factors in those undergoing MTP arthroplasty revision to arthrodesis.

METHODS

Patients who underwent MTP arthroplasty for diagnosis of hallux rigidus from 2010 to 2019 were identified in the Mariner subset of the PearlDiver database. Patients were included if they had undergone MTP arthroplasty for the diagnosis of hallux rigidus. Notably, the database lacks resolution about critical features of the arthroplasty design and materials. The revision cohort encompassed patients who underwent subsequent ipsilateral MTP arthrodesis or arthroplasty within 2 years of index arthroplasty procedure. Demographic characteristics and medical comorbidities were examined as potential patient-related risk factors for arthroplasty revision or revision to fusion. Univariate analyses were performed to analyze differences in patient demographics, comorbidities, and risk factors. A multivariate regression analysis was subsequently conducted to control for confounding variables.

RESULTS

2750 patients underwent primary MTP arthroplasty for diagnosis of hallux rigidus. Of these, 44 (1.6%) underwent revision arthroplasty and 188 patients (6.8%) were revised to arthrodesis within the first 2 years after the index procedure. Multivariate regression analysis indicates that obesity (odds ratio [OR] 1.48, 95% CI 1.05-2.09), depression (OR 1.59, 95% CI 1.15-2.20), and steroid use (OR 2.94, 95% CI 1.30-6.65) were associated with a statistically significant increase in revision to arthrodesis from primary arthroplasty.

CONCLUSION

Revision arthrodesis following primary MTP arthroplasty for hallux rigidus within 2 years was found to be a relatively common occurrence in this national insurance database study. Risk factors for revision arthroplasty to arthrodesis within 2 years of primary arthroplasty include obesity, depression, and steroid use.

LEVEL OF EVIDENCE

Level III, case-control study.