Hallux metatarsophalangeal joint fusion for the rheumatoid forefoot

Sprunggelenk- und Vorfußtherapie in der Rheumatologie – wie lange können wir den aufrechten Gang erhalten?

Die Therapie des rheumatischen Fußes ist komplex und erstreckt sich über ein breites Spektrum von konservativen und operativen Behandlungsmethoden. Das Ziel ist, bei guter Stabilität, möglichst viel Beweglichkeit zu erhalten. Nebenerkrankungen wie die Polyneuropathie mit und ohne Diabetes mellitus beeinflussen die Behandlungsoptionen entscheidend. Aufgrund dessen, dass beim Rheumatiker multiple Gelenke befallen sind, unterliegen die orthopädische Schuhversorgung und die operative Therapie des rheumatischen Fußes speziellen Anforderungen im Hinblick auf das Gewicht, die Stabilität des Schuhs und Bettung des Fußes bzw. die Zugangswege und die Primärstabilität der Osteosynthesen. Der aufrechte Gang kann durch einen stadiengerechten zielgerichteten Einsatz aller Therapieoption sehr lange erhalten bleiben. Hierfür müssen die therapeutischen Fenster erkannt und genutzt sowie eine Übertherapie vermieden werden.

Rate of Development of Hallucal Interphalangeal Degenerative Joint Disease After First Metatarsophalangeal Joint Arthrodesis: A Retrospective Radiographic Analysis

The development of hallux interphalangeal joint (IPJ) arthritis after an arthrodesis of the first metatarsophalangeal joint has been established in the literature. However, the significance has not been well reported. A retrospective, radiographic review of patients who had undergone a first metatarsophalangeal joint arthrodesis was performed. The Coughlin classification for degree of arthritic degeneration, hallux abductus angle, and hallux interphalangeus angle were measured in 107 radiographs of 103 patients preoperatively and postoperatively. Postoperative angles were measured immediately following surgery at approximately 6 weeks, 3 months, 6 months, 12 months, and 24 months. We found that the hallux abductus angle had decreased in the patients postoperatively; however, the hallux abductus interphalangeus angle increased on average after first metatarsophalangeal fusion. The majority of patients started with a Coughlin classification I of the hallux IPJ, which remained unchanged over the postoperative period, with no statistically significant difference in IPJ degeneration in the patients with or without fusion of the first metatarsophalangeal joint. In addition, no patients had a symptomatic hallux IPJ postoperatively within our limited study period. Further prospective studies would be beneficial with longer follow-up times to assess IPJ degeneration following first metatarsophalangeal joint fusions. Levels of Evidence: Level III: Retrospective, comparative study.

1st metatarsophalangeal joint fusion: A comparison of non-union and gender differences between locking and non-locking plating systems

BACKGROUND

Fusion of the first metatarsophalangeal joint (1st MTPJ) is a common surgical procedure used to treat a variety of diseases and deformities of the forefoot. Fixation methods vary and typically fusion rates are good.

OBJECTIVES

The objectives of the study are to demonstrate whether there is any advantage to using locking as opposed to non-locking plates for 1st MTPJ fusion. Additionally the study aims to determine whether there is any difference in non-union rates according to gender.

METHODS

One hundred and seventy two consecutive 1st MTPJ fusions were performed for 153 patients. 40 patients (23%) were male and 132 (77%) female. Twenty patients received Hallu-fix™ plates, 76 Charlotte™ plates and 76 Anchorage™ plates. Postoperative radiographs were reviewed for non-union. Failure rates were compared using Fisher's exact tests (p=0.05).

RESULTS

Twelve (6.9%) non-unions were identified. The difference in failure rates between all systems was not statistically significant. However, the difference in fusion rates between males (17.5%) and females (3.8%) was significant.

CONCLUSION

This study finds that 1st MTPJ fusion is an effective method to treat diseases of the 1st MTPJ. Locking plates may offer better fusion rates than their non-locking counterparts. This is especially evident in male patients.

[Rheumatic forefoot deformities]

The frequency and extent of rheumatic forefoot deformities have been greatly reduced since the introduction of disease-modifying antirheumatic drugs (DMARD). The accompanying reduction in arthritic destruction of joints opens up new treatment options whereby priority is given to joint preservation. This is true for the first middle foot ray as well as for the small toe rays. Whereas resection arthroplasty of the metatarsophalangeal joints II-V was previously considered the gold standard treatment, joint-preserving operative procedures (e.g. metatarsal osteotomy and periarticular soft tissue interventions) are now being increasingly more propagated. Resection arthroplasty of the first midfoot ray has major biomechanical disadvantages so that it is not surprising that reconstructive procedures are given priority. In patients with severe arthritic destruction of the first metatarsophalangeal joint, arthrodesis has substantial biomechanical advantages compared to resection arthroplasty. Nevertheless, it has not yet been confirmed that fusion leads to superior clinical results.

A comparison of nonlocking semitubular plates and precontoured locking plates for first metatarsophalangeal joint arthrodesis

BACKGROUND

First metatarsophalangeal (MTP) joint arthrodesis is a successful, commonly performed procedure for many conditions affecting this joint. The purpose of this retrospective study was to compare the clinical and radiographic outcomes between patients who had primary first MTP joint fusions with either noncontoured stainless steel semitubular plates or precontoured plates. Our hypothesis was that there would be no difference in clinical or radiographic outcomes between these groups.

METHODS

A search based on operative report coding was performed to detect all patients who had undergone primary first MTP joint arthrodesis with a dorsal plating construct at our institution from 2005 to 2010. A retrospective review of electronic medical records and postoperative radiographs was performed to determine time to clinical and radiographic union, pain scores, complications, MTP angle, and proximal phalanx to floor angle. A Kruskal-Wallis test was used for continuous variables, and a chi-square or Fisher exact test was used for categorical variables to determine statistical significance between the 2 groups.

RESULTS

We identified 128 patients who met our inclusion criteria. One hundred and two feet in 97 patients underwent arthrodesis with a noncontoured, stainless steel 1/3 tubular plate (group 1) and 26 feet in 21 patients with a precontoured, locking plate (group 2). The patients presented with a variety of inflammatory and noninflammatory preoperative diagnoses. The overall union rate, complication rate, time to radiographic healing, MTP angle, and patient-reported visual analog scale (VAS) score were similar between the 2 groups. Clinical time to healing was more rapid in the noncontoured group (3.7 months vs 4.8 degrees in precontoured) (P = .02). The radiographically measured proximal phalanx to floor angle was significantly decreased in noncontoured patients (2.6 degrees vs 4.6 degrees in precontoured, P = .04). In patients who had a diagnosis of an inflammatory arthropathy, the union rate fell to 84.3% (27/32) in the noncontoured group and 87.5% (7/8) in the precontoured group, and time to radiographic as well as clinical union increased in both groups. When patients with inflammatory arthropathies were compared with noninflammatory patients within groups, it was found that the time to both clinical and radiographic union was significantly longer in the noncontoured group for those with an inflammatory arthropathy (P = .0052, P = .022). For the precontoured group, these values were not statistically significant (P = .089, P = .43). Additionally, the cost of the noncontoured implants was significantly less than that of the precontoured implants.

CONCLUSION

In this study, clinical time to healing of primary first MTP fusion with dorsal plate and screw constructs was improved with the use of noncontoured plates. However, other clinical indicators such as pain, complication rate, MTP angle, and VAS score did not differ between groups. Noncontoured plates are less expensive, and thus the decision to use precontoured plates routinely should be made cautiously. However, in the presence of inflammatory arthropathy, the use of precontoured plates may be justified given that the use of these plates in the inflammatory group resulted in improved radiographic and clinical union.

LEVEL OF EVIDENCE

Level III, comparative series.

Hallux IP arthritis after MP arthrodesis managed with interpositional arthroplasty of MP joint and IP fusion: case report

Level of Evidence: V, Expert Opinion

Locked versus nonlocked plate fixation for hallux MTP arthrodesis

BACKGROUND

Dorsal plate fixation is used commonly for arthrodesis of the hallux first metatarsophalangeal (MTP) joint. Custom dorsal plates incorporating locking technology have been developed recently for applications in the foot to provide relative ease of application and theoretically superior mechanical properties. The purpose of this study is to compare the radiographic and clinical outcomes of patients undergoing hallux MTP joint arthrodesis using a locked plate, or a nonlocked plate.

MATERIALS AND METHODS

We compared consecutive patients who underwent hallux MTP arthrodesis for a variety of diagnoses with either a precontoured locked titanium dorsal plate (Group 1) or a precontoured, nonlocked stainless steel plate (Group 2). All patients were evaluated with radiographs, visual analog pain scale, American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, and a detailed patient satisfaction survey.

RESULTS

There were 73 feet in Group 1 and 107 feet in Group 2. There was a trend toward a higher nonunion rate in Group 1 compared to Group 2. When considering only patients without rheumatoid arthritis (RA), the union rate was significantly higher in Group 2 compared to Group 1. Hardware failure and the overall complication rate was equivalent between the two Groups.

CONCLUSION

As locked plate technology continues to gain popularity for procedures in the foot, it is important that clinical outcomes are reported. Locked titanium plates were associated with higher nonunion rates. Improved plate design, patient selection, and an understanding of plate biomechanics in this unique loading environment may optimize future outcomes for hallux MTP arthrodesis.

First metatarsophalangeal joint interpositional arthroplasty using a meniscus allograft for the treatment of advanced hallux rigidus: surgical technique and short-term results

Hallux rigidus is a progressive disorder of the first metatarsophalangeal (MTP) joint. The disorder is characterized by a loss of range of motion, degenerative changes, and pain within the joint. In later stages of the disease, the surgical procedure of choice is arthrodesis of the joint. Recently, salvage procedures of the first MTP joint using soft tissue interposition has gained popularity. In this retrospective review of 12 patients (13 total procedures) who had late-stage hallux rigidus, we evaluated the effectiveness of a newly proposed salvage procedure using a cadaver meniscus allograft for interposition. First MTP joint dorsiflexion improved from 15.77° (range, 5° -30°) preoperatively to 47.77° (range, 40° -57°; P < .0001). AOFAS (American Orthopaedic Foot and Ankle Society) scores improved from 52.54 points (range, 35-69 points) preoperatively to 90.01 points (range, 82-95 points; P < .0001), with all patients showing improvement. The mean length of follow-up for this study was 16.46 months (range, 5-26 months) with no complications being recorded. The results show that cadaver meniscus allograft interposition is a viable procedure for end-stage hallux rigidus.

LEVEL OF EVIDENCE

therapeutic, level III: retrospective review.

Review of 107 hallux MTP joint arthrodesis using dome-shaped reamers and a stainless-steel dorsal plate

BACKGROUND

The purpose of this study was to retrospectively review the results of patients treated with hallux MTP joint arthrodesis using dome-shaped reamers for joint preparation and a precontoured dorsal stainless steel plate for internal fixation.

MATERIALS AND METHODS

A series of 145 patients (155 feet) were identified. Postoperative evaluation included weightbearing radiographs, physical examination, and chart review. Outcomes were assessed with a pain visual analog scale, AOFAS hallux score, as well as a detailed questionnaire and a subjective satisfaction survey.

RESULTS

Ninety-eight patients (107 feet) met the criteria for the study. The mean followup was 61 weeks. Revision cases accounted for 18.7% (20/107). Rheumatoid arthritis (RA) was present in 32.7% (35/107). The average postoperative AOFAS hallux score was 79.7 and pain VAS was 19. The average pre- and postoperative hallux valgus angle was 26.5 and 12.3 degrees, respectively (p < 0.05). Eighty-nine of 107 patients (83.1%) reported good to excellent results at final followup. Discomfort related to prominence of the plate occurred in 14.9% (16/107). The nonunion rate was 12.1% (13/107). The nonunion rate for patients with/without RA was 22.9% (8/35) and 6.9% (5/72), respectively (p < 0.05). Patients with a nonunion noted more hardware related pain than those with a union (p < 0.05).

CONCLUSION

First MTP joint arthrodesis using this technique achieves a high union rate. RA patients have a lower union and higher complication rate.

The surgical reconstruction of the rheumatoid forefoot

Rheumatoid arthritis is an autoimmune disorder that presents in females more often than males, and may affect people belonging to any age group. This disease shows no regional or ethnic preference. Although genetic and environmental causes have been proposed, the definitive cause of immunologic susceptibility, as well as viral and bacterial infectious processes that may cause rheumatoid arthritis, have not been identified. This article discusses various reconstructive forefoot surgeries to correct rheumatoid arthritis and the perioperative care of the patients who undergo surgery, along with the radiographic and magnetic resonance imaging findings associated with the disease.