Osteochondral autogenous transplantation for an osteochondral defect of the first metatarsal head: a case report

Surgical management of osteochondral lesions of the first metatarsal head: A systematic review

BACKGROUND

Treating osteochondral lesions of the first metatarsal head can help reducing pain and preventing end-stage arthritic cartilage degeneration and hallux rigidus. Several surgical techniques have been described, but no clear indications are reported. This systematic review aims to offer an overview of the current surgical treatments for focal osteochondral lesions of the first metatarsal head.

METHODS

The selected articles were examined to extract data about population, surgical technique, and clinical outcomes.

RESULTS

Eleven articles were included. Mean age at surgery was 38,2 years. Osteochondral autograft was the most used technique. After surgery, an improvement was achieved in AOFAS, VAS, and hallux dorsiflexion but not in plantarflexion.

CONCLUSION

There is limited evidence and knowledge regarding the surgical management of the first metatarsal head osteochondral lesions. Various surgical techniques have been proposed, drawn from other districts. Good clinical results have been reported. Further high-level comparative studies are necessary to design an evidence-based treatment algorithm.

Arthroscopic accessibility of the first metatarsophalangeal joint for osteochondral defects of the metatarsal head by two-portal technique - comparing joint distraction and plantarflexion

BACKGROUND

Several techniques and approaches for first metatarsophalangeal (MTP1) joint arthroscopy have been reported, where joint accessibility plays a key role. This study aimed to evaluate differences in arthroscopic accessibility of the first metatarsal head (MTH1) comparing non-invasive distraction and maximum plantarflexion in a two-portal approach.

METHODS

Forty fresh-frozen lower leg specimens were included and divided into a distraction group (D-group) and a plantarflexion group (PF-group). A two-portal technique (1.9 mm-30°-scope) was used for arthroscopy, maximum reach at the MTH1 was marked. Following arthroscopy, specimens were dissected and examined for iatrogenic injuries. The reached area at the chondral surface was pinned and accessibility calculated.

RESULTS

Accessibility of the MTH1 was 58.03 % ± 13.64 (D-group) and 55.93 % ± 10.30 (PF-group, p = 0.51). The dorsomedial hallucal nerve was injured in one specimen (2.5 %).

CONCLUSION

Maximum plantarflexion showed no difference in arthroscopic MTP1 joint accessibility compared to non-invasive distraction in a two-portal approach. During dorsomedial portal placement, the dorsomedial hallucal nerve is at risk for iatrogenic injury.

Treatment of Osteochondral Lesion of the First Metatarsal Head: Osteochondral Graft Transplantation Combined With Moberg Osteotomy: Case Report

Most osteochondral lesions of the first metatarsal head are likely traumatic in etiology. The treatment ranges from microfractures to mosaicplasty. In this case report, we describe a central osteochondral lesion of the first metatarsal head treated with osteochondral graft obtained from the head of the same metatarsal in combination with Moberg osteotomy. After surgical treatment, the patient's American Orthopedic Foot and Ankle Society Forefoot Scale score improved from 58 to 85, and the range of motion also improved. This technique may be an alternative treatment modality for osteochondral lesions of the first metatarsal.Level of Evidence: Level V.

A Novel Technique to Treat Hallux Rigidus in Athletic Patients With Central Osteochondral Defects: Preliminary Report on 12 Cases

Osteochondral defects, often caused by traumatic injuries, are focal areas of articular damage resulting in joint pain and stiffness ultimately leading to degenerative joint disease. This has not been well studied in the first metatarsal head, but is an often encountered problem in the active population in other joints. In this study, we prospectively evaluated the results of 12 patients who received autogenous bone grafting for repair of osteochondral defects of the first metatarsal head. Clinical outcomes were evaluated by the visual analog scale for pain and the Roles and Maudsley (RM) score. Between the years of 2009 and 2016, 12 patients received treatment for this particular surgical intervention and their outcomes were measured. The patients' average age was 43.5 ± 10.6 years and were followed from 52.3 ± 26.7 months postoperatively. Average return to activity was 4.7 ± 1.1 months. The average preoperative RM score was 4.0 ± 0.0 and postoperative RM score was 1.4 ± 0.7 (p = .0001). The encouraging outcomes of this study suggest that autogenous bone grafting for osteochondral defects of the first metatarsal head is an effective treatment to help restore the function of the first metatarsophalangeal joint.

A case report of osteochondritis dissecans of the first metatarsophalangeal joint treated with autologous cancellous bone and chondral flap reconstruction

Although osteochondritis dissecans (OD) is well-described in the bibliography, cases of OD in the 1st metatarsophalangeal joint (MTP) are rare clinical situations. We present a 25-year-old male who presented to our department for big toe pain on the left side. Clinical and radiological examination showed the typical findings of OD lesion on the 1st metatarsal head (MH), establishing the diagnosis of OD. Intraoperatively the articular cartilage of the partially detached part of the MH was intact and under it, an empty cavity with a big defect was obvious. Autogenous cancellous bone transplantation from the metatarsal metaphysis, reattachment of the cartilage surface as a chondral flap and edge sealing with fibrin glue was our treatment of choice. OD of the 1st MH should be included in the differential diagnosis of big toe pain, as early diagnosis and treatment are crucial to prevent future osteoarthritis of the 1st MTP.

Osteochondral Defect of the Calcaneocuboid Joint: A Case Study

Osteochondral lesions (OCLs) are injuries affecting the articular cartilage surface of a joint. OCLs are well reported in the literature to affect the knee, talus, tibia, navicular, and first metatarsal. This rare case of a bipolar osteochondral lesion of the cuboid and calcaneus presented as lateral heel pain after a traumatic injury. After an unsuccessful course of conservative therapy, the lesion was treated with curettage and application juvenile particulate cartilage allograft. Eight months postoperatively, the patient was ambulating in supportive shoe gear without pain. The mechanism of injury leading to calcaneocuboid joint osteochondral lesions is not clearly understood. It is also questionable whether anatomic variances are contributory. Regardless of causality, OCLs should be included in the differential diagnoses for patients presenting with calcaneocuboid joint or lateral hindfoot pain.

Clinical outcomes of mesenchymal stem cell injection with arthroscopic treatment in older patients with osteochondral lesions of the talus

BACKGROUND

The ideal treatment for osteochondral lesions of the talus (OLTs) is still controversial, especially in older patients. Recently, mesenchymal stem cells (MSCs) have been suggested for use in the cell-based treatment of cartilage lesions.

PURPOSE

To compare the clinical outcomes of MSC injection and arthroscopic marrow stimulation treatment with those of arthroscopic marrow stimulation treatment alone for the treatment of OLTs in older patients.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Among 107 patients with OLTs treated arthroscopically, only the patients older than 50 years (65 patients) were included in this study. Patients were divided into 2 groups: 35 patients (37 ankles) treated with arthroscopic marrow stimulation treatment alone (group A) and 30 patients (31 ankles) who underwent MSC injection along with arthroscopic marrow stimulation treatment (group B). Clinical outcomes were evaluated according to the visual analog scale (VAS) for pain, the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, and the Roles and Maudsley score. The Tegner activity scale was used to determine outcomes in activity levels.

RESULTS

The mean VAS score in each group was significantly improved (P < .05) from 7.2 ± 1.1 to 4.0 ± 0.7 in group A and from 7.1 ± 1.0 to 3.2 ± 0.9 in group B. The mean AOFAS score in each group was also significantly improved (P < .05) from 68.0 ± 5.5 to 77.2 ± 4.8 in group A and from 68.1 ± 5.6 to 82.6 ± 6.4 in group B. There were significant differences in mean VAS and AOFAS scores between the groups at final follow-up (mean, 21.8 months; range, 12-44 months) (P < .001). The Roles and Maudsley score showed significantly greater improvement in group B than in group A after surgery (P = .040). The Tegner activity scale score was significantly improved in group B (from 3.5 ± 0.7 to 3.8 ± 0.7; P = .041) but not in group A (from 3.5 ± 0.8 to 3.6 ± 0.6; P = .645). Large lesion size (≥109 mm(2)) and the existence of subchondral cysts were significant predictors of unsatisfactory clinical outcomes in group A (P = .04 and .03, respectively). These correlations were not observed in group B.

CONCLUSION

Injection of MSCs with marrow stimulation treatment was encouraging in patients older than 50 years compared with patients treated with marrow stimulation treatment alone, especially when the lesion size was larger than 109 mm(2) or a subchondral cyst existed. Although still in the early stages of application, MSCs may have great potential in the treatment of OLTs in patients older than 50 years, and more evaluations of its effect should be performed.

Clinical comparison of the osteochondral autograft transfer system and subchondral drilling in osteochondral defects of the first metatarsal head

BACKGROUND

Osteochondral defects of the first metatarsal head can deteriorate to osteoarthritis of the first metatarsophalangeal joint if left untreated. Treatment options for osteochondral defects of the first metatarsal head vary widely.

PURPOSE

To compare the clinical outcomes of the osteochondral autograft transfer system with those of subchondral drilling for the treatment of osteochondral defects of the first metatarsal head.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The authors retrospectively evaluated 24 cases of osteochondral defects of the first metatarsal head treated operatively; 14 patients underwent subchondral drilling (group A), while 10 were treated with the osteochondral autograft transfer system (group B). The association of variables of osteochondral defects with clinical outcomes was assessed in each group. Clinical outcomes were evaluated according to a visual analog scale (VAS) for pain, the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale, and the Roles and Maudsley score. The Tegner activity scale and an activity rating scale were used to determine the activity levels.

RESULTS

The mean VAS score in both groups was significantly improved (from 6.9 ± 0.9 to 3.9 ± 1.3 in group A and from 7.4 ± 0.8 to 3.4 ± 1.2 in group B; P < .05). No difference was noted between the 2 groups at final follow-up (P = .651). The mean AOFAS score in both groups was significantly improved (from 62.9 ± 5.8 to 73.2 ± 8.2 in group A and from 65.0 ± 4.1 to 81.5 ± 5.8 in group B; P < .05). There was a significant difference in mean AOFAS score between the 2 groups at final follow-up (P = .032). Large defect size (≥50 mm(2)) and the existence of a subchondral cyst were significant predictors of unsatisfactory clinical outcomes in group A (P = .047 and P = .019, respectively). Multivariate analyses showed a defect size larger than 50 mm(2) was associated with significantly worse outcomes on the last follow-up VAS and AOFAS scores in group A (P = .005 for VAS and P = .006 for AOFAS). There was no association of defect size and subchondral cyst with clinical outcomes in group B (P > .05). No association was found between location of the defect area and clinical outcome in either group.

CONCLUSION

For osteochondral defects larger than 50 mm(2) or when a subchondral cyst exists, the osteochondral autograft transfer system could potentially be used as a treatment of choice for osteochondral defects of the first metatarsal head to restore functionality of the metatarsophalangeal joint.

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

Hallux rigidus (HR) is the limitation of motion at the first metatarsophalangeal (MTP) joint, most commonly secondary to degenerative arthritis. Surgical options for treating HR include 2 general categories: joint salvage and joint destruction. A hybrid of techniques from the 2 categories has emerged: cartilage resurfacing, interpositional arthroplasty, and arthrodiastasis. These procedures address the pathologic condition of the first MTP joint more directly than joint salvage and avoid many of the negative complications, consequences, and connotations of joint destruction procedures. Alternative surgical options for the treatment of recalcitrant pain associated with HR are evolving and are discussed in this review.

Medial column rodding facilitated by transitional osteochondral graft

This is a case report using a new technique designed to allow passage of a screw through a joint while simultaneously preserving the joint cartilage. A 58-year-old woman with diabetes with midfoot Charcot neuro-arthropathy underwent reconstruction, which included a medial column rodding. A headless 8.0-mm screw was inserted into the first metatarsal head coursing along the entire medial column after temporary removal of a portion of the osteochondral surface. This allowed the screw to be positioned perpendicular to the medial column joints. Serial radiographs were collected to evaluate alignment, stability, and osteochondral graft incorporation. The patient showed preservation of joint motion and function with complete osteochondral graft incorporation without evidence of joint degeneration or pain after 45 months of follow-up. This is the first study to present the use of a local osteochondral graft to allow passage of a large diameter screw in the foot. Although graft incorporation was complete, the situation regarding joint preservation remains unclear, but midterm follow-up shows promise.

Does total joint replacement or arthrodesis of the first metatarsophalangeal joint yield better functional results? A systematic review of the literature

As first metatarsophalangeal joint arthrodesis is generally considered to be a successful procedure for the treatment of hallux rigidus, many surgeons question the usefulness of total joint replacement. In an effort to elucidate the clinical evidence, we undertook a systematic review of the literature comparing the functional outcomes of arthrodesis and joint replacement in first metatarsophalangeal surgery. Using multiple search engines and medical subject headings, 10 articles were eligible for inclusion: 5 featured arthrodesis and 5 featured total joint replacement. The American Orthopaedic Foot and Ankle Society-Hallux metatarsophalangeal-interphalangeal score was used in all articles. The mean age at operation was 53 years for joint replacement patients and 55 for those undergoing joint arthrodesis. Most patients in all studies were female. There was a significant increase from pre- to postoperative scores in both procedures. The median postoperative score for joint replacement was 83/100 (range 74-95) and 82/100 (range 78-89) for arthrodesis. The median revision rate in joint replacements was 7% (range 0%-10%) and 0% (range 0%-12%) for arthrodesis. This systematic review reveals that arthrodesis achieves better functional outcomes than total joint replacement. The operative techniques and prostheses for joint replacements are however still in an early stage of development and advances still need to be achieved to produce a more successful and anatomical prosthesis that could be functionally superior to an arthrodesis.

Moje first metatarsophalangeal replacement--a case series with functional outcomes using the AOFAS-HMI score

We report the functional results of a case series of Moje first metatarsophalangeal total joint replacements carried out between February 2001 and November 2006. All patients who underwent Moje arthroplasty under the care of a single surgeon were included; outcome scores and complications were recorded annually. A total of 32 joints in 29 consecutive patients were followed for a mean duration of 34 (range 6 to 74) months, and the mean patient age at the time of operation was 56 (range 38 to 79) years. Hallux rigidus was the primary diagnosis in 28 (87.5%) of the cases. The mean American Orthopaedic Foot & Ankle Society Hallux-Metatarsophalangeal-Interphalangeal score at final follow-up was 74/100 (range 9 to 100), with 13 (40.63%) joints rated good to excellent. Two (6.25%) joints were revised to arthrodesis at a mean of 52 (range 41 to 63) months following the arthroplasty procedure, and the overall prevalence of postoperative complications was 6 (18.75%). Based on these results, we concluded that first MTPJ total joint replacement with the Moje device remains promising, but still has room for improvement before the results match those obtained with larger joint (knee, hip) arthroplasty.

First metatarsal head osteoarticular transfer system for salvage of a failed hemicap-implant: a case report

Osteochondral defects are frequently seen in patients with hallux limitus. Historically, such patients have been treated with cheilectomy, arthroplasty, osteotomy, fusion, and other joint destructive procedures. We present a case of a 54-year-old man who presented with a failed hemicap implant of the first metatarsal head. Seven months after his initial implant surgery, the patient was still experiencing pain and limited function despite conservative treatment efforts. In an effort to salvage the joint, an osteoarticular transfer system procedure was undertaken. After removal of the 12-mm hemicap implant, a 15 x 12 mm osteochondral plug was taken from the ipsilateral femoral condyle and press fit into the defect in the first metatarsal head. At 6 weeks postoperatively, complete consolidation of the graft was observed radiographically. By 6 months postoperatively, the patient was able to walk more than 15 miles per week without pain while wearing regular shoes. He was subsequently discharged at 1-year postoperatively, at which time he neither described nor demonstrated any signs or symptoms related to hallux limitus/rigidus. To our knowledge, this particular technique has not been previously reported for lesions of this size in the first metatarsal head.

LEVEL OF CLINICAL EVIDENCE

4.

Freiberg's infraction of the second metatarsal treated with autologous osteochondral transplantation and external fixation

Freiberg's infraction is a rare disorder of the lesser metatarsals that typically occurs in adolescent females. Many surgical procedures have been employed to treat this condition and have met with varying degrees of success. The authors describe the use of an external fixation device for distraction of the joint in combination with transplantation of an autogenous osteochondral graft for a 15-year-old female with Freiberg's infraction.

The case against first metatarsal phalangeal joint implant arthroplasty

This article argues the practice of first metatarsal phalangeal joint (MPJ) implant arthroplasty. Intermediate and long-term studies raise concerns about implant failure and longevity. Other causes for concern are silicone-induced synovitis and lymphadenopathy. This article presents evidence against the practice of first metatarsal phalangeal implant arthroplasty. Intermediate and long-term studies raise concerns about implant failure and longevity. Furthermore, the lack of any significant long-term results and the documented metallic breakdown from two-piece metallic implants make their use in hallux rigidus questionable. Meanwhile, a comparative study shows the superiority of arthrodesis to implant arthroplasty. Also, alternatives to joint-destructive procedures are emerging. These include arthrodiastasis and the osteochondral autograft transfer procedure. This evidence proves that implant arthroplasty is not the best treatment for patients with hallux rigidus or other first-MPJ pathology.

Osteochondral autograft transfer of the first metatarsal head: a case report

A case of an osteochondral autograft transfer performed at the head of the first metatarsal for an acute incidence of traumatic osteochondritis dissecans was presented. The donor site for the osteochondral graft was from the medial and plantar aspect of the talar head, which was found to be composed entirely of articular hyaline cartilage, yet was not part of the functional talonavicular articulation. Six months postoperatively, the graft was well seated at the head of the first metatarsal, as confirmed by magnetic resonance imaging, and the graft donor site was asymptomatic. At 12 months' follow-up, the patient had a functional metatarsophalangeal joint range of motion. Details from the case study as well as a review of the literature are presented.