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

Bilateral first metatarsophalangeal joint arthrodesis: An investigation of functional, surgical and radiological outcomes

BACKGROUND

First metatarsophalangeal joint (MTPJ) arthrodesis is a commonly utilised procedure. In this study, the authors aim to explore functional outcomes of patients undergoing nonsynchronous bilateral first MTPJ arthrodesis under the care of a single surgeon using a compression screw/locking plate construct.

METHODS

This is a prospectively collected, retrospectively analysed case series of fifty five patients who underwent bilateral nonsynchronous first MTPJ arthrodesis. Clinical and radiological outcomes were assessed preoperatively and at a minimum of two years postoperatively. Clinical outcomes were assessed using the Foot and Ankle Outcome Score (FAOS), the Self-Reported Foot and Ankle Score (SEFAS) and the Sports Questionnaire version 1 (SQ). Postoperative radiographs were used to assess evidence of union and compare both hallux valgus and intermetatarsal angles. Removal of hardware, revision surgery and correction of deformities were also recorded.

RESULTS

Fifty five patients were included in the study. There was statistically significant improvements in all five facets of the FAOS (p value < 0.05). The mean postoperative SEFAS was 45.1. In total, patients participated in thirteen different sporting activities. This represented 92 patient specific activities preoperatively and 104 postoperatively. The most common activities were walking, cycling and swimming. Overall, 94.5% (N = 52) of the cohort were satisfied with their return to sport while 98.2% (N = 54) would recommend bilateral first MTPJ arthrodesis. Mean reductions in hallux valgus angles and intermetatarsal angles were noted at 18.87 and 4.69 degrees respectively. There was one non-union in the cohort which required revision surgery. One patient required removal of hardware.

CONCLUSIONS

Bilateral first MTPJ arthrodesis is a safe and effective surgical option for patients with bilateral first MTPJ pathology. It has a high union rate, low complication rate and significantly improves clinical outcomes and allows patients reliably return to physical activities.

Ten-Year Minimum Follow-up Study of First Metatarsophalangeal Joint Fusion in Young vs Old Patients

BACKGROUND

Painful degenerative joint disease (DJD) of the first metatarsophalangeal joint (MTP I), or hallux rigidus, mainly occurs in later stages of life. For end-stage hallux rigidus, MTP I arthrodesis is considered the gold standard. As young and active patients are affected considerably less frequently, it currently remains unclear, whether they benefit to the same extent. We hypothesized that MTP I arthrodesis in younger patients would lead to an inferior outcome with decreased rates of overall with lower rates of patient postoperative pain and function compared to an older cohort.

METHODS

All patients aged <50 years who underwent MTP I arthrodesis at our institution between 1995 and 2012 were included in this study. This group was then matched and compared with a group of patients aged >60 years. Minimum follow-up was 10 years. Outcome measures were Tegner activity score (TAS), a "Virtual Tegner activity score" (VTAS), the visual analog scale (VAS), and the Foot Function index (FFI).

RESULTS

Sixty-one MTP I fusions (n = 28 young, n = 33 old) in 46 patients were included in our study at an average of 14 years after surgery. Younger patients experienced significantly more pain relief as reflected by changes in VAS and FFI Pain subscale scores. No difference in functional outcomes was found with change in the FFI function subscale or in the ability to have desired functional outcomes using the ratio of TAS to VTAS. Revision rate did not differ between the two groups apart from hardware removal, which was significantly more likely in the younger group.

CONCLUSION

In patients below the age of 50 years with end-stage DJD of the first metatarsal joint, MTP I arthrodesis not only yielded highly satisfactory postoperative results at least equal outcome compared to an older cohort of patients aged >60 years at an average 14 years' follow-up. Based on these findings, we consider first metatarsal joint fusion even for young patients is a valid option to treat end-stage hallux rigidus.

LEVEL OF EVIDENCE

Level III, a case-control study.

A Novel Plating System for First Metatarsophalangeal Joint Arthrodesis: A Retrospective Comparison of Hybrid and Traditional Locking Plate Constructs

BACKGROUND

Dorsal plate fixation is commonly used for first metatarsophalangeal joint (1st MTPJ) arthrodesis and plate design continues to evolve. A new staple compression plate (SCP) design attempts to utilize the continuous compression of a nitinol staple across the fusion site while simultaneously providing the stability of a dorsal locked plate. Herein, we compare the radiographic, clinical, and patient-reported outcomes of 1st MTPJ joint arthrodesis using 2 dorsal locking plate constructs including a novel SCP construct.

METHODS

Forty-four patients who underwent 1st MTPJ arthrodesis between 2016 and 2020 were retrospectively evaluated. There were 2 group cohorts. Group 1 cohort included 23 patients who received a CrossRoads Extremity SCP, and Group 2 cohort included 21 patients who received a Stryker dorsal locking precontoured titanium plate (LPP). All patients were evaluated with radiographs, Patient-Reported Outcomes Measures Information System (PROMIS) outcome scores, and Foot Function Index (FFI).

RESULTS

The complication and union rates did not vary between groups with a fusion rate of 95.7% in the SCP group and 90.5 % in the LPP group. Similarly, we found no significant differences in PROMIS or FFI scores between the SCP and LPP plates.

CONCLUSION

Use of either dorsal locking plate construct for 1st MTPJ arthrodesis was associated with high union rates and comparable functional outcomes. As locked plate technology continues to evolve for 1st MTPJ arthrodesis, it is important that clinical outcomes are reported.

LEVELS OF EVIDENCE

Level IV.

First Metatarsophalangeal Arthrodesis for Hallux Rigidus and Hallux Valgus: A Comparison of Patient Reported and Clinical Outcomes

Few prior studies have compared the patient reported outcomes of first metatarsophalangeal arthrodesis between hallux rigidus and hallux valgus patients. Furthermore, we sought to examine the impact of postoperative radiographic hallux alignment on outcomes scores within each group. A retrospective review of 98 patients who a received primary metatarsophalangeal arthrodesis from January 2010 to March 2020. Clinical complications including nonunion were collected. Patient Reported Outcomes Measurement Information Systems (PROMIS) Physical Function, PROMIS Pain Interference, and the foot function index (FFI) revised short form scores were obtained via telephone. Patients were grouped based on review of preoperative radiographs of the foot and this grouping 37 hallux rigidus and 61 hallux valgus patients. Clinical and patient reported outcomes were compared between these pathologies. No differences in the rate of wound complications, radiographic union, and revision surgery were found between the 2 subgroups. At a median of 2.4 years (3.9 IQR) postoperatively, PROMIS and FFI scores did not vary by pathology group. For both groups, PROMIS scores were similar to the general population of the United States. The postoperative first MTP dorsiflexion angle in the hallux rigidus group was correlated with decreased FFI Pain, FFI Total, and PROMIS Pain Interference domain scores (|r| ≥ 0.40, p < .05 for all). When performing MTP arthrodesis in patients with hallux rigidus, increasing the first MTP dorsiflexion angle may correlate with improved intermediate term patient reported outcomes. However, further studies will need to be done to confirm this theoretical relationship.

Comparison of Total Joint Replacement With Arthrodesis of the First Metatarsophalangeal Joint

BACKGROUND

The aim of this study was to compare outcome (clinical, patient-reported outcome measures, radiologic, joint motion and pedographic) of total joint replacement with Roto-Glide (RG) and arthrodesis (A) for severe osteoarthritis of the first metatarsophalangeal joint (MTP1).

METHODS

All consecutive patients with arthrodesis and RG from January 23, 2011, until September 18, 2019, at the authors' institution were considered for inclusion in the study. Preoperatively and at follow-up (FU), radiographs, and/or weightbearing computed tomographic imaging were obtained. Standard dynamic pedography was performed. Visual analog scale foot and ankle (VASFA), European Foot and Ankle Society (EFAS) score, MTP1 range of motion for dorsiflexion/plantarflexion (DF/PF) were registered and compared preoperatively and at FU.

RESULTS

Seventy RG and 72 arthrodesis patients were included. Preoperative VASFA and EFAS scores did not differ between the RG and arthrodesis groups (average scores: VASFA, 50.6 and 45.6; EFAS score, 10.7 and 10.6, respectively; each P > .05). Wound healing delays without further operative measures were registered in 4 patients (6%) for RG and 5 (7%) for arthrodesis (P = .67), and 5 revisions in 5 patients (7%) for RG and 12 in 8 (11%) for arthrodesis (P = .05). The longest available FU was higher in RG than in arthrodesis (47 vs 37 months on average, P < .001). Pedography showed higher first metatarsal head or sesamoids and lower great toe force percentage from force of entire foot in RG than in arthrodesis (P = .05) resulting in physiological pattern in RG only. VASFA and EFAS scores at FU was higher in RG than in arthrodesis (average scores: VASFA, 72.6 and 63.6; EFAS score, 16.1 and 14.1, respectively; each P < .05). DF/PF measurement was only possible in RG (average value: DF/PF, 36.1/14.0).

CONCLUSION

We found marginally lower revision rates and higher patient-reported outcome measures, joint motion (DF/PF), and more physiologic force distribution at slightly longer FU for the RG group than the arthrodesis group. Longer follow-up and broader clinical reporting are needed to identify the potential deficits of RG.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

First metatarsophalangeal arthrodesis outcomes for hallux rigidus versus hallux valgus

BACKGROUND

This study compared radiographic and functional patient outcomes of 1st MTP arthrodesis between hallux rigidus (HR) and hallux valgus (HV) cohorts.

METHODS

A retrospective review was conducted at an academic medical center on patients who underwent 1st MTP arthrodesis during 2009-2021. In total, 136 patients (148 feet: HR=57, HV=47, combined=44) met the inclusion criteria of minimum three-month follow-up (mean=1.25 years, range=0.25-6.14 years). Data collection included patient-reported outcome measures (PROMs), radiographic markers, and complication and reoperation rates.

RESULTS

PROMs improved overall, with HV patients significantly improving the least. The HR group had a significantly smaller improvement in HV angle (HR=-3.6, HV=-17, Combined=-15 p < .001), intermetatarsal angle (H=-0.16, HV=-2.8, Combined=-2.6 p < .001), and 1st-5th metatarsal width (HR=-0.98, HV=-4.6, Combined=-4.6, p < .001). Complication and reoperation rates did not differ by group.

CONCLUSION

Outcomes of 1st MTP arthrodesis does not appear to differ between diagnostic indications of hallux rigidus, hallux valgus, or both.

LEVEL OF EVIDENCE

Level III, Retrospective cohort study.

Gait analysis of foot compensation in symptomatic Hallux Rigidus patients

BACKGROUND

Compensatory motion of foot joints in hallux rigidus (HR) are not fully known. This study aimed to clarify the kinematic compensation within the foot and to detect whether this affects plantar pressure distribution.

METHODS

Gait characteristics were assessed in 16 patients (16 feet) with HR and compared with 15 healthy controls (30 feet) with three-dimensional gait analysis by using the multi-segment Oxford Foot Model, measuring spatio-temporal parameters, joint kinematics and plantar pressure.

RESULTS

HR subjects showed less hallux plantar flexion during midstance and less hallux dorsiflexion during push-off, while increased forefoot supination was detected during push-off. No significant differences in plantar pressure were detected. Step length was significantly smaller in HR subjects, while gait velocity was comparable between groups.

CONCLUSIONS

HR significantly affects sagittal hallux motion, and the forefoot compensates by an increased supination during push-off. Despite this kinematic compensatory mechanism, no significant differences in plantar loading were detected.

Average 4-Year Outcomes of Distal Oblique First Metatarsal Osteotomy for Stage 1 to 3 Hallux Rigidus

BACKGROUND

Hallux rigidus is the second most frequent pathology of the first ray. Surgical options for degenerative metatarsophalangeal joint disease are either joint destructive or conservative procedures. The hypothesis was that oblique distal shortening osteotomy of the first metatarsal is an effective conservative technique for the management of stage 1 to 3 hallux rigidus.

METHODS

We conducted a retrospective cohort study of 87 feet with Coughlin and Shurnas's stage 1-3 hallux rigidus, operated between 2009 and 2019. The cohort consisted in 72 patients (87 feet) with an average age of 57±9 (30/79) years; 22 of 87 (25.3%) feet had the first metatarsal surgery performed in isolation; 65 of 87 (74.7%) had concomitant forefoot procedures, including 31 of 87 (35.6%) with Akin phalangeal osteotomies and 34 of 87 (39.1%) with Moberg phalangeal osteotomies.We evaluated the American Orthopaedic Foot & Ankle Society (AOFAS) Scale, subjective satisfaction, joint amplitudes, shortening rate, and occurrence of postoperative complications with a mean follow-up of 51 months (16/134).

RESULTS

The AOFAS score increased from 54.2±11.3 (25/70) preoperatively to 92.2±7.8 (62/100) postoperatively (P < .001). Patients reported excellent or good outcome in 95.4% of cases. The 40-point self-reported pain subscale score improved from 19.6 (± 10.0) to 37.4 (± 5.4), P < .001.The overall range of motion increased from 61±21 (20/110) degrees to 69±17 (35/120) degrees (P < .001). The mean first metatarsal shortening rate (SR^po) was 9.6%. Neither the Coughlin grade, the metatarsal index, or the SR^po influenced the AOFAS score. At 6-month follow-up, 15 patients had transfer metatarsalgia compared with 5 at last follow-up without requiring another surgical procedure. The risk was not significantly different according to Coughlin's stage, preoperative metatarsal index, or SR^po.

CONCLUSION

Oblique distal osteotomy of the first metatarsal for stage 1-3 hallux rigidus, often in combination with other first ray procedures, performed well during our follow-up time period, with a high subjective satisfaction rate and few complications.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Finite Element Modelling of Planus and Rectus Foot Types for the Study of First Metatarsophalangeal and First Metatarsocuneiform Joint Contact Mechanics

Evaluating the contact mechanics of human joints is an important element in understanding the pathomechanics of orthopaedic diseases. Although physical testing is essential in the evaluation process, reliable computational models can augment these experiments by non-invasive predictions of biomechanical or surgical variables. The objective of this study was to perform verification of a framework for developing a medial forefoot finite element. Verification was conducted by comparing computational predictions to experimental measurements of first metatarsophalangeal and first metatarsocuneiform joint contact mechanics. A custom-built force-controlled cadaveric test-rig was used to derive measurements of contact pressure, force, and area. A quasi-static finite element was developed and driven under the same boundary and loading conditions. Calibration of cartilage moduli and mesh sensitivity analyses were performed. Mean errors in contact pressures, forces, and areas were 24%, 4%, and 40% at the first metatarsophalangeal joint and 23%, 12%, and 19% at the first Metatarsocuneiform joint, respectively. Verification of a medial forefoot finite element model development framework was presented and found to be within 30% for contact pressure and contact force of both joints. This study presents a method to verify and simulate realistic physiological loading to investigate orthopaedic diseases of the medial forefoot.

Functional Capabilities After First Metatarsal Phalangeal Joint Arthrodesis Using a Locking Plate and Compression Screw Construct

Arthrodesis of the first metatarsal phalangeal joint (MTPJ) is a widely utilized surgical procedure for a wide array of metatarsal pathologies. This study aims to explore the functional limitations following first MTPJ arthrodesis, overall satisfaction and patient's abilities to achieve activities of daily living (ADL). This prospective cohort study assessed functional limitations as well as footwear and lifestyle restrictions using several questionnaires. One hundred and three participants who had a first MTPJ arthrodesis under the care of a single surgeon were recruited. Pre- and postoperative patient-reported outcome measures were recorded. The American Orthopaedic Foot and Ankle Score (AOFAS) and the Manchester-Oxford Foot Questionnaire were also used to further examine functional status. Hallux valgus angle (HVA) and intermetatarsal angle (IMA) were compared using preoperative and postoperative weightbearing radiographs and successful fusion was recorded. Complications were documented and are discussed in detail. The duration of follow-up was more than 12 months. There was one nonunion in the cohort while 2 patients experienced delay to fusion. Approximately 97% of patients were very satisfied with the procedure and their ability to achieve ADLs post operatively. A further 82.5% of patients were able to return to wearing nonadaptive footwear. The mean reduction in HVA and IMA was 21.78° and 6.84°, respectively. This study demonstrates the safe and successful use of a compression screw/locking plate construct for arthrodesis of the first MTPJ. Furthermore, the study provides clear evidence of high levels of functionality after the procedure with statistically significant differences (p value <.05) in all 4 facets of the AOFAS questionnaire as well as several notable differences in activity levels and footwear restrictions pre and postoperatively.

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 systematic review of total arthroplasty and arthrodesis for end-stage hallux rigidus: A biomechanical perspective

BACKGROUND

Both arthrodesis and total arthroplasty are acceptable surgical options for end stage hallux rigidus without significant angular deformity. Total arthroplasty preserves first metatarsophalangeal joint (MTPJ) motion, which may help restore a more physiological gait pattern.

RESEARCH QUESTION

Is there a difference in the findings of gait studies after 1st MTPJ total arthroplasty or arthrodesis for end-stage hallux rigidus?

METHODS

PRISMA guidelines were followed to conduct a systematic review of literature for studies reporting gait analysis after the above procedures. Predetermined criteria were used to select papers and evaluated the findings of kinematic (spatial-temporal and dynamic motion), kinetic and foot pressure (pedobarographic) studies.

RESULTS

12 titles were short-listed for synthesis. There was 1 randomized controlled trial comparing the two procedures. Among the remaining cohort studies, 5 reported on total arthroplasty and 6 on arthrodesis of the 1st MTPJ. Due to significant heterogeneity, a narrative synthesis was undertaken. No studies in the arthroplasty group reported spatial-temporal or kinetic parameters. Only 2 papers, 1 in each group, recorded motion within the foot. One of them showed preserved dynamic motion at the 1st MTPJ after total arthroplasty. Pedobarographic studies had discordant findings in studies within both groups regarding restoration of weight bearing through the medial forefoot and the pulp of the great toe during gait.

CONCLUSION

Currently available studies are heterogenous and report inconsistent findings, which do not convincingly answer our research question. Prospective comparative studies with a large sample size, using standardized methodology in accredited laboratories with detailed reporting of kinetic, kinematic and pedobarographic components of gait analysis are required in order to draw concrete conclusions.

First Metatarsophalangeal Joint Arthrodesis Using Memory Staples: Clinical and Functional Results

Background. We present clinical and functional results of first metatarsophalangeal joint (MTPJ) arthrodesis using Memory staples. Methods. This retrospective observational study reviewed MTPJ arthrodesis with Memory staples from 2012 to 2016. Results. The mean age of 50 patients (55 feet) was 63 years (range 41-77 years). Forty-one feet were in women. Indication was hallux rigidus (n = 49) and hallux valgus (n = 6). The overall union rate was 98.2% (n = 54 of 55), including delayed healing in 3 (5.5%). The average time to union was 12 weeks. At a mean follow-up of 38 months (range 12-73 months), the mean Foot and Ankle Ability Measure score (47 out of 55, 86% response rate) was 87% (interquartile range 78%-100%). Complications included partial laceration of extensor hallucis longus (n = 1), wound infection (n = 4), wound-related (n = 2), lesser metatarsalgia (n = 3), cock up deformity (n = 1), and pain (n = 3). Conclusions. The high union rate, good patient satisfaction scores, and low rate of complications support our use of Memory staples.Levels of Evidence: Therapeutic, Level IV.

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.

Severe Hallux Valgus Angle Attended With High Incidence of Nonunion in Arthrodesis of the First Metatarsophalangeal Joint: A Follow-Up Study

The incidence of nonunion after first metatarsophalangeal joint (MTP-1) arthrodesis was found to be high in our clinic. By raising awareness for the problem, making a uniform surgical treatment protocol, banning the commonly used convex-concave reamers, and promoting solely the use of hand instruments to prepare the joint for arthrodesis, we tried to decrease the numbers of nonunion. This prospective cohort study included all patients who underwent MTP-1 fusion between January 2018 and March 2019. Patients were treated according to a standardized protocol, using hand instruments to prepare the joint for fusion. Anthropometric and therapy-related data were collected and compared with an earlier 2015-2016 cohort that was retrospectively assessed. Furthermore, the frequency of nonunion between convex-concave reamers and hand instruments was compared. A total of 53 patients underwent MTP-1 fusion surgery. The incidence of nonunion was 3.8%, significantly lower than the 24.1% in 2015 to 2016 (p = .002). Multivariate regression analysis showed a 7.11 times higher risk of nonunion in 2015 to 2016 compared with 2018 to 2019 (95% confidence interval [CI] 1.55 to 32.55) (p = .012). Furthermore, an increase of 10° in HVA showed a 1.52 risk of occurrence of nonunion (95% CI 1.07 to 2.17) (p = .021). The use of convex/concave reamers was univariately associated with a 3.61 times higher risk of nonunion (95% CI 1.14 to 11.43) (p = .029); however, after correction for preoperative HVA, the preparation method was no longer associated with the occurrence of nonunion (p = .108). Patients suffering from severe hallux valgus had nonunion in 32.1% of cases. Incidence of nonunion after MTP-1 arthrodesis was significantly reduced by raising awareness and by standardizing the treatment protocol. There was no significant difference in nonunion frequency between the methods of joint surface preparation. Severe hallux valgus is prone to nonunion, and more research into this indication for MTP-1 fusion and outcome is needed.

Adverse events involving hallux metatarsophalangeal joint implants: Analysis of the United States Food and Drug Administration data from 2010 to 2018

BACKGROUND

The prevalence of osteoarthritis of the hallux metatarsophalangeal joint (MTPJ) is 1 in 40 people over the age of 50. Surgical treatment options for MTPJ arthritis include joint preservation, joint resurfacing, and arthrodesis. Hallux MTPJ implants have evolved over the past several decades, but are associated with various complications. The aim of this study was to examine the MAUDE database to determine reported adverse events for hallux MTPJ implants.

MATERIALS AND METHODS

The US Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was reviewed from 2010 to 2018 to review voluntary reported adverse event reports for approved implants within the United States. We recorded the type of adverse event and excluded duplicate reports and those extracted from already published literature.

RESULTS

Among 64 reported hallux MTPJ implant adverse events, the most common modes of adverse events were component loosening (34%), infection (14.1%), component fracture (9.4%), inflammation (9.4%), and allergic reaction (7.8%). Regarding implant type, Cartiva SCI had the highest percentage of adverse events (23.4%), followed by Arthrosurface ToeMotion (20.3%), Ascension MGT (12.5%), Arthrosurface HemiCAP® (10.9%), Futura primus (9.4%), and Osteomed Reflexion (6.3%). There was an increase in reported adverse events after 2016. The MAUDE database does not report the total incidence of implant insertion.

CONCLUSION

Our study of the MAUDE database demonstrated that component loosening and infection are the most common modes of adverse events for hallux MTPJ implants. Cartiva accounted for one-fourth of the implant-related adverse events during our study period, followed by ToeMotion, and Ascension MGT implants. Continued reporting of adverse events will improve our understanding on short and long-term complications of various hallux MTPJ implants.

LEVEL OF EVIDENCE

Level IV; Case Series from Large Database Analysis; Treatment Study.

[Evaluation of therapeutic efficacy of arthroplasty with Swanson prosthesis in the surgical treatment of 2-5 metatarsophalangeal joint diseases]

OBJECTIVE

Metatarsophalangeal joint is an important joint for daily weight-bearing walking. Osteoarthritis, osteochondrosis of the metatarsal head, rheumatoid arthritis can often cause the destruction of 2-5 metatarsophalangeal joint, leading to pain, limited joint movement and toe deformities, severely affecting the forefoot function. The purpose of this study is to report the results of middle-long term follow-up after performing Swanson double-stem silicon implant arthroplasty in patients with diseases of 2-5 metatarsophalangeal joint.

METHODS

From January 2010 to October 2015, 21 patients with 2-5 metatarsophalangeal joint replacement were performed with Swanson double-stem silicone prosthesis. In the study, 16 cases were successfully followed up, 2 men and 14 women with an average age (66.7±5.5) years. There were 9 cases diagnosed with rheumatoid arthritis, 5 cases with severe osteoarthritis and 2 cases with osteochondrosis of the metatarsal head. The American Association of foot and ankle surgery Maryland foot scoring system and visual analogue score (VAS) were used to evaluate the walking function, metatarsophalangeal joint mobility and pain degree before and after surgery.

RESULTS

The follow-up time ranged from 17 months to 5 years, with an average of 3.2 years. According to Maryland foot scoring system of the American Association of foot and ankle surgery, the preoperative score was (60.69±6.12) points and postoperative score was (88.13±5.84) points. Range of motion of metatarsophalangeal joint: preoperative: back extension 5.4°±3.1°, plantar flexion 4.4°±2.7°; postoperative: back extension 15.7°±4.5°, plantar flexion 12.2°±4.3°, the motion of 2-5 metatarsophalangeal joint after operation was significantly improved compared with that before operation (P < 0.01). The preoperative VAS was (6.8±0.9) points and the last follow-up was (2.3±0.8) points, the pain symptom of metatarsophalangeal joint was improved obviously after operation. The postoperative score was significantly higher than the preoperative score according to Maryland foot scoring system (P < 0.01), the excellent rate was 81.3%.

CONCLUSIONS

With the advantages of alleviating pain, preserving the length and alignment of metatarsophalangeal joint, improving the function of walking, and correcting the deformity, Swanson double-stem silicon implant arthroplasty is a reproducible and safe option for the reconstruction of the 2-5 metatarsophalangeal joint. However, there is still some probability of adverse reactions and still room for improvement.

Analysis of the effects of arthrodesis of the hallux metatarsophalangeal joint on gait cycle: results of a GAITRite® treadmill test

INTRODUCTION

Approximately 80% of patients are satisfied with the outcome of arthrodesis of the hallux metatarsophalangeal (MTP) joint. The hypothesis of this study was that MTP arthrodesis does not influence the walking cycle. The aim of this study was to evaluate the effect of MTP arthrodesis on gait cycle and to measure the functional outcome of MTP arthrodesis after a minimum of two year follow-up.

METHOD

This was an observational prospective cohort study performed at a single centre that included 26 patients (32 ft) who underwent unilateral or bilateral MTP arthrodesis during the period 2004-2014. An X-ray assessment based on the American Orthopaedic Foot and Ankle Society score was performed pre-operatively and at the last follow-up (average follow-up duration 8.3 years). The walking cycle was analysed at the final follow-up using a GAITRite^® treadmill test.

RESULTS

Twenty unilateral and six bilateral MTP arthrodeses were included in this study. The average age of the patients was 70 years. No significant difference was found in the walking cycle between the operated and non-operated sides for unilaterally MTP arthrodesis. However, we observed a non-significant increase in the percentage of contact time after MTP arthrodesis (65% on the operated side vs. 63% on the non-operated side). We also observed a significant decrease in the average walking rate, and a decrease in walking speed, in cases of bilateral MTP arthrodesis compared with normal walking cycle data from a laboratory study.

CONCLUSIONS

MTP joint arthrodesis does not appear to have any effect on the walking cycle, but reduced patient pain and increased the walking distance. The patients reported satisfaction with the surgical outcomes and would recommend it to a relative with the same pathology.

Arthrodesis versus Arthroplasty of the First Metatarsophalangeal Joint in the Treatment of Hallux Rigidus - A Comparative Study of Appropriately Selected Patients

Objective  Historical results of arthroplasty of the first metatarsophalangeal joint (1MTP) are relatively poor; however, improvements in the understanding of the normal foot biomechanics, implant materials and design currently make arthroplasty a reasonable option in appropriately selected patients. The present study aimed to compare the clinical and radiographic results of 1MTP arthrodesis and arthroplasty in the treatment of hallux rigidus and to present a rationale for patient selection for arthroplasty.

Methods  A total of 36 patients (38 feet) with hallux rigidus submitted to surgery (12 arthrodesis and 26 arthroplasties) were prospectively included in the study. Pain was assessed using the visual analogue scale (VAS) and the functional status was assessed using the American Orthopedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal (AOFAS-HMI) scale. Complications and radiographic results were also analyzed, and survival rates were calculated for both procedures.

Results  All of the patients reported significant improvement in pain and functional status after surgery. Patients submitted to arthroplasty had better functional results on the AOFAS-HMI scale (89.7 versus 65.7 points; p  < 0.001) and better pain relief (VAS 1.6 versus 3.9 points; p  = 0.002) when compared with the group submitted to arthrodesis. There was one case of infection in the arthroplasty group and 2 cases of pseudarthrosis in the arthrodesis group.

Conclusion  Arthrodesis provides pain relief and satisfactory results but alters the biomechanics of gait. Like arthrodesis, arthroplasty improves pain significantly, being a more physiological alternative to preserve the biomechanics of the foot. While the two surgical methods yielded good clinical results, selected patients submitted to arthroplasty had better clinical scores and lower revision rates.

Osteoarthritis in England: Incidence Trends From National Health Service Hospital Episode Statistics

Objective

It is typical in epidemiological research of osteoarthritis (OA) to collect data for the hand, hip, and knee. However, little population‐based data exist for this disease in the foot. Thus, we addressed patterns of OA for the foot compared with the hand, hip, and knee spanning 2000/2001 to 2017/2018 in England.

Methods

Secondary‐care data from 3 143 928 patients with OA of the foot, hand, hip, and knee were derived from the National Health Service (NHS) Hospital Episode Statistics (HES) database. Distribution, population prevalence, and incidence of joint‐specific OA were stratified by age and sex.

Results

OA incidence increased significantly at the foot [3.8% (95% confidence interval [CI] 3.0, 4.6)], hand [10.9% (10.1, 11.7)], hip [3.8% (2.9, 4.7)], and knee [2.9% (2.2, 3.6)] per year from 2000/2001 to 2017/2018. A higher proportion of women were diagnosed with OA, whereas greater incidence in men was estimated for the hand and hip. Foot OA presented comparable diagnosis numbers to the hand. More recently during 2012/2013 to 2017/2018, a significant rise in hip OA was estimated among younger adults, whereas knee OA decreased across all age groups. Incidence of OA in the foot and hand were particularly significant among the 75 or older age group, though bimodal age distributions were observed for both sites.

Conclusion

The significant increase in secondary care records for OA in England underscores the importance of exploring possible causative factors and identifying groups most at risk. Further detailed data may be particularly important for the hip, which represents significant incidence among younger adults. Greater incidence of OA in the foot compared with the knee emphasizes the need for well‐conducted epidemiological research in this area. Monitoring the performance of surgical outcomes at the population‐level for this frequently affected yet understudied site could have substantial potential to reduce the socioeconomic burden it represents to the NHS.

Long-Term Results of Hemiarthroplasty Compared With Arthrodesis for Osteoarthritis of the First Metatarsophalangeal Joint

If operative treatment is opted for grade 3 and 4 osteoarthritis of the first metatarsophalangeal joint, arthrodesis is considered the standard of care. However, if preservation of joint mobility is preferred, implant arthroplasty could be favored. Previous studies have suggested hemiarthroplasty might result in less pain, better function, and greater patient satisfaction compared with arthrodesis. However, these studies only evaluated short-term results (range 2.2 to 6.6 years). The aim of our study was to determine whether patients treated with hemiarthroplasty would show better postoperative outcomes compared with those treated with arthrodesis after ≥5 years after surgery. The American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal interphalangeal (AOFAS-HMI) scale score was used as the primary outcome measure. Secondary outcomes addressed satisfaction rates, patient procedure recommendation, and number of unplanned repeat surgical procedures. We also addressed the influence of the procedures on daily activities (work and sports), the influence of smoking on the postoperative results, and the costs for both procedures. A total of 47 primary arthrodeses and 31 hemiarthroplasties performed between January 2005 and December 2011 were evaluated. After a mean follow-up period of 8.3 (range 5 to 11.8) years, the mean AOFAS-HMI scale score after arthrodesis and hemiarthroplasty was 72.8 ± 14.5 and 89.7 ± 6.6, respectively (p = .001). The patients were significantly more pleased after hemiarthroplasty (p < .001), and this procedure was recommended more often (p < .001). The number of unplanned repeat surgical procedures did not differ between the 2 groups. Patients resumed sports activities significantly sooner after hemiarthroplasty (p = .002). The overall crude costs were similar for both procedures. Our results have shown more favorable postoperative outcomes for hemiarthroplasty compared with arthrodesis as operative treatment of osteoarthritis of the first metatarsophalangeal joint after a mean follow-up period of 8.3 years.

PRINCIPLES OF SURGICAL TREATMENT IN PATIENTS WITH OSTEOARTHRITIS OF THE FIRST METATARSOPHALANGEAL JOINT

At present, there is no general approach to choosing surgical tactics for hallux rigidus. Many surgical procedures are used to treat osteoarthritis (OA) of the first metatarsophalangeal joint (FMPJ), which are relevant at different stages of the disease. Nevertheless, this fact also suggests that all proposed methods have one or other disadvantages. At the same time, FMPJ arthrodesis that relieves pain and is functionally inferior to joint-sparing surgery remains the gold standard. However, due to the fact that not only persons over the age of 50 years, but also younger patients often suffer from FMPJ OA, the most non-damaging option of joint-sparing surgery is cheilectomy with chondroplasty of the FMPJ, which allows restoration of painless joint motions, thus sparing the anatomy of the foot. Chondroplasty using the authologous matrix-induced chondrogenesis (AMIC®) technique for knee, hip, and ankle cartilage defects is described. There are no reports on FMPJ chondroplasty with the AMIC method in either Russian or foreign literature.

Early results of Roto-glide joint arthroplasty for treatment of hallux rigidus

BACKGROUND

Traditionally severe hallux rigidus is treated with arthrodesis. Recently arthroplasty has been used in order to retain motion at the metatarsophalangeal joint.

AIM

To assess the early to mid-term functional and radiological outcomes in patients undergoing first metatarsophalangeal arthroplasty using the Rotoglide implant.

MATERIALS AND METHODS

A prospective review was undertaken to assess functional and radiological outcomes of all patients undergoing an un-cemented three-component first metatarsophalangeal arthroplasty for hallux rigidus. Thirty four implants were performed in 28 patients over a 2-year period. Mean age was 60.5 years (range 45-77 years). Mean follow-up was 27.7 months (range 7-44 months).

RESULTS

Mean AOFAS score improved from 41.2 pre-operatively to 89.1 at final follow-up (47.9; 95% CI=43.6-54.3; p<0.0001). The mean metatarsophalangeal (MTP) range of motion improved from 29.5° pre-operatively to 68.2° post-operatively (38.7; 95% CI=35.1-42.2; p<0.0001). The mean AOFAS pain scores improved from 8.8 preoperatively to 35.0 postoperatively (26.2; 95% CI=22.4-29.9; p<0.0001). Three patients required revision surgery. No radiological complications were observed in any other patients.

CONCLUSIONS

This un-cemented prosthesis provides pain relief, while maintaining range of motion of the joint. The authors have observed clinically and statistically significant improvement in functional outcomes, with a low early complication rate and high patient satisfaction levels.

Bone-block arthrodesis procedure in failures of first metatarsophalangeal joint replacement

BACKGROUND

The treatment for the failure of a first metatarsophalangeal joint (MTP1) prosthesis can be complex. There is no consensus regarding the ideal treatment. One of the main issues is the available bone stock after prosthesis removal. The aim of the study was to report the clinical and radiographic results for MTP1 arthrodesis with autologous calcaneus bone graft (bone-block fusion) as a revision procedure of a previous MTP1 implant failure.

METHODS

This study included 12 patients diagnosed with failure of a MTP1 prosthesis. All patients were treated with MTP1 arthrodesis using ipsilateral calcaneal bone graft. Patients were evaluated with the Foot Ankle Disability Index (FADI), the visual analogue pain scale (VAS) and AOFAS Hallux Metatarsophalangeal Interphalangeal scoring system (AOFAS-HMI), weight-bearing radiograph of the foot, and a computed tomography scan. The 1-2 intermetatarsal angle, hallux valgus angle, and first ray length were measured before surgery and at final follow-up.

RESULTS

Complications included 3 cases of arthrodesis nonunion, (1 symptomatic, 2 asymptomatic) with 2 of the 3 patients experiencing hardware failure and 1 superficial wound infection. The average FADI improved from 41.8 preoperatively to 84.6 at final follow-up (p<0.05); the average VAS improved from 8.5 preoperatively to 2 at final follow-up (p<0,05); the average AOFAS-HMI significantly improved from 50.7 preoperatively to 73.8 at final follow-up (p<0.05). The average length of the bone-block used was 14.3mm (range 11-19mm). The 1-2 intermetatarsal angle decreased from 9.5° preoperatively to 8.4° at final follow-up (p<0.05); hallux valgus angle improved from 19.7° preoperatively to 14.3° at final follow-up (p<0.05).

CONCLUSIONS

The management of a failed first metatarsophalangeal joint prosthesis remains controversial. Bone-block arthrodesis using ipsilateral calcaneal autograft appears to be a viable option restoring the bone loss, and avoiding hallux shortening. Nonunion is the most frequent complication with 25% of patients affected, but only 1/3 of patients with nonunion were symptomatic and required revision.

The Rotoglide™ total replacement of the first metatarso-phalangeal joint. A prospective series with 7-15 years clinico-radiological follow-up with survival analysis

BACKGROUND

The Rotoglide total replacement of the MTP-1 joint. 15 years survival analysis. The purpose of this prospective study was to evaluate the long-term performance clinico-radiographically of an uncemented three-component total replacement for the first metatarso-phalangeal joint (MTP-1) used for hallux rigidus (primary osteoarthritis grades 3 and 4). The follow-up was median 11.5 years (7-15).

METHODS

The AOFAS forefoot score was used preoperatively and at follow-up. Radiographs were taken weight-bearing in the AP-projection and in tip-toe standing in the lateral view. Arthrosis in the sesamoid junction, prosthetic loosening, subsidence (of prosthesis as well as sesamoids), and dorsiflexion were measured, recorded and subjected to multiple variance analysis. Survival analysis was performed for 15 years.

MATERIAL

Ninety implants in 80 patients (53 women and 27 men); median age 58 (41-76) were evaluated.

RESULTS

Six patients representing seven prostheses in situ had died from unrelated reason. The median preoperative AOFAS increased significantly from 40 to 95. The median gain was 45. Four replacements (4.4%) were extracted for other reasons than loosening. No aseptic loosenings were recorded. The survival rate at 15 years was 91.5% (83-100). Multiple variance analysis showed that arthrosis in the metatarso-sesamoid junction correlated with reduced AOFAS score.

CONCLUSION

The prosthesis has stood the test of time; the results justify its further use.

Mid-term outcomes of first metatarsophalangeal arthroplasty using the Primus FGT double-stemmed silicone implants

BACKGROUND

Silicone implants for first metatarsophalangeal (MTP-1) arthroplasty are regaining popularity, though most studies have long inclusion periods, or short follow-up. The authors aimed to report mid-term outcomes of a cohort that received a third-generation MTP-1 implant at minimum follow-up of 5 years.

METHODS

The authors evaluated 70 MTP-1 arthroplasties performed in 64 patients using the Primus™ Flexible Great Toe implant. The indications were hallux rigidus of grade II (10%) and grade III (87.1%) or revision surgery (2.9%).

RESULTS

All patients completed clinical and radiographic assessments at 83.5 months (range, 62-114). There were no revisions or reoperations and the AOFAS-HMI score was 88.9±9.1 (median, 90; range, 67-100). Metatarsalgia was 'absent' in 47.1%, 'mild' in 41.1%, 'moderate' in 7.1% and 'severe' in 1.4%.

CONCLUSION

This study reported excellent mid-term clinical outcomes and survival rates of a third generation MTP-1 arthroplasty design and confirmed findings of recent studies regarding efficacy of silicone double-stemmed implants.

LEVEL OF EVIDENCE

Level IV case series.

Long term results of the Toefit-Plus replacement for first metatarsophalangeal joint arthritis

Hallux rigidus is osteoarthritis affecting the metatarsophalangeal joint of the first toe. Patients often complain of pain and stiffness with pain being aggravated by walking, particularly during toe-off in the gait cycle. Osteoarthritis of the metatarsophalangeal joint is commonly treated with arthrodesis or resection arthroplasty. Metallic replacement of this joint is used sometimes but is not widely accepted. The use of silastic joints has problems with synovitis and implant failure. The authors used titanium implants, which can be screwed into the metatarsal and phalanx, allowing good fixation without the use of bone cement. Release of the tight plantar capsule and tissues is necessary to achieve better range of movement and correct implant positioning. Fifty five cases of arthritis of the first metatarsophalangeal joint were treated surgically with Toefit-Plus™ joint replacement. The implant consists of both metatarsal and phalangal components and a fixed-bearing polyethylene insert. All patients had a release of tight soft tissues on the plantar side. Follow up occurred at 84 to 144 months after surgery (mean of 134 months), and the results showed increasing numbers of implant failures and revisions (21%) of Toefit-Plus™ implants. 47 patients were available for review. Twenty four (51%) out of 47 patients reported satisfactory results with Toefit-Plus™ arthroplasty. Ten of these patients (21%) had removal of implants and further surgical procedures were needed due to implant failure. Eleven (23%) out of 47 patients still complained of pain despite having joint replacement with the Toefit-Plus ™ implant. There is a high rate of complications with the Toefit-Plus™ implant resulting in revision surgery. Patients should have the risks associated with arthroplasty clearly explained, including the risk of revision, and the option of arthrodesis should be discussed when planning surgery. Further trials and redesign of implants may help to improve results. The authors would not recommend the Toefit-Plus™ implant due to poor results seen in one third of patients.

Long-Term Follow-up of Arthrodesis vs Total Joint Arthroplasty for Hallux Rigidus

BACKGROUND

The optimal operative management of hallux rigidus is still a matter for debate among surgeons. Despite arthrodesis widely considered to be the gold standard treatment, many surgeons advocate arthroplasty as a suitable alternative. There are, however, few long-term or high-quality studies evaluating these modalities. We present the 15-year follow-up of a randomized controlled trial.

METHODS

This data is the follow-up to the original study published in 2005. In the original study, 63 patients (77 toes) were recruited to and randomized to have either metatarsophalangeal joint (MTPJ) arthrodesis or arthroplasty. The primary outcome measure was a decrease in pain on a visual analog scale (VAS) at 24 months. In the present study, data were available for all surviving patients (52 patients, 66 toes). Data were collected in the form of satisfaction scores, VAS for pain, the VAS foot and ankle and survivorship data.

RESULTS

The results of the original study demonstrated that pain relief was greater following arthrodesis at 2 years. At 15 years, patients with an arthrodesis experienced less pain and were more satisfied compared to those with an arthroplasty. No functional differences were seen between these 2 groups. There were more revisions in the arthroplasty group.

CONCLUSION

Despite the hope of better function, less pain, and greater satisfaction from MTPJ replacement, this was not found in our patient population. The long-term results of our study showed that arthrodesis outperformed arthroplasty. If an arthroplasty failed, then salvage was likely to be technically difficult, with significant potential for complications.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Reduced Postoperative Functional Length Ratio Influences Patient Satisfaction in First Metatarsophalangeal Joint Replacement

Complications of first metatarsophalangeal joint metallic arthroplasty are well known. However, the resulting shortening of the metatarsals can lead to transverse metatarsalgia or medial column pain at the metatarsophalangeal joints by creating Morton's toe/foot, which increases pressure on the second metatarsal head. The effect of the functional length ratio of the first and second metatarsals on pain and patient satisfaction has not been rigorously evaluated. We evaluated the effect of the first/second metatarsal ratio on patient satisfaction with first metatarsophalangeal joint metallic arthroplasty. From October 2008 to February 2010, 34 patients (median age 66.2, range 55 to 70 years) with hallux rigidus were treated surgically using the Toefit-Plus(™) prosthesis. At a mean follow-up period of 27.5 (range 17 to 35) months, 30 patients (88.24%) underwent re-evaluation. The functional length of the first and second metatarsals and the lucency around the prosthesis were evaluated. Statistically significant (p ≤ .05) improvements were found for the mean modified American Orthopaedic Foot and Ankle Society score (from 44 to 80), pain (from 7 to 3 on a 10-cm visual analog scale), and mean total range of motion (from 42.2° to 59.4°). Also, 20 patients (58.82%) were fully satisfied with the procedure (scores of 8 to 10 on a 3-point Likert scale). Shortening the first metatarsal reduced the functional length ratio (r = 0.95; p < .001) and was associated with lower patient satisfaction (r = 0.66, p = .007). Preoperative consideration of the first/second metatarsal functional length ratio could be useful in preventing medial column pain due to a relatively short first metatarsal to a long second metatarsal axis in the transverse plane.

Fusion of the First Metatarsophalangeal Joint: Precontoured or Straight Plate?

Precontoured, low-profile plates with fixed dorsiflexion angles are becoming increasingly popular for first metatarsophalangeal joint fusion. We have concerns that the routine use of a precontoured plate can lead to excessive clinical dorsiflexion. The aim of our study was to investigate the relationship between the first metatarsophalangeal joint dorsiflexion intramedullary angle and the angle formed at the dorsal cortices where the plate is applied. We hypothesized that the dorsal cortical angle was significantly less dorsiflexed than the intramedullary angle. We measured both angles on lateral weightbearing radiographs of 40 consecutive individuals presenting with forefoot symptoms. The results demonstrated that the mean dorsal cortical angle was significantly smaller (mean 0.2° plantarflexion) compared with the intramedullary angle (mean 10.6° dorsiflexion; p < .001). The interobserver and intraobserver reliability of both the intramedullary and the dorsal cortical measurements was very good. In conclusion, the dorsal cortical angle is, on average, 10.8° smaller than the intramedullary angle, with a mean angle of almost 0°. This finding should be considered when selecting plates for first metatarsophalangeal joint fusion.

Operative Treatment for Osteoarthritis of the First Metatarsophalangeal Joint: Arthrodesis Versus Hemiarthroplasty

Controversy remains whether hemiarthroplasty or arthrodesis results in better postoperative outcomes for patients who request surgery for advanced osteoarthritis of the first metatarsophalangeal joint. Therefore, we tested the primary null hypothesis that the 2 treatment groups would not differ in the postoperative American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal interphalangeal scale scores after a follow-up period of ≥1 year. Secondary analyses addressed the satisfaction rates, percentage of patients who would recommend the procedure, and unplanned repeat operation rates. A total of 58 primary arthrodeses and 36 hemiarthroplasties performed from January 2005 to December 2010 were evaluated at ≥1 year postoperatively. At a mean average of 4 (range 1 to 7) years after surgery, the mean American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal interphalangeal scale score was 77.5 ± 18.5 in the arthrodesis group and 77.8 ± 12.0 in the arthroplasty group (p = .93). The number of repeat operations did not differ between these 2 groups, and patients treated with hemiarthroplasty reported greater mean satisfaction (p = .04). These results showed that the symptom intensity and magnitude of disability were similar at ≥1 year after arthrodesis or hemiarthroplasty for osteoarthritis of the first metatarsophalangeal joint, although the patients were subjectively more pleased with the results after hemiarthroplasty.

Outcome following first metatarsophalangeal joint replacement using TOEFIT-PLUS™: A mid term alert

BACKGROUND

We aim to evaluate the mid-term results of first metatarsophalangeal joint replacement for hallux rigidus using Toefit-Plus™ in a single surgeon series.

METHODS

We prospectively studied the outcomes of 86 toes in 73 patients using the AOFAS-HMI score and radiological follow up. The mean follow up was 33 months (2-72). Ten patients have been lost to follow up.

RESULTS

Eight patients sustained intraoperative fractures or impending fractures requiring circlage wiring. Eighteen joints have either been revised or listed for revision giving a revision rate of 24%; this occurred at a mean of 33 months post-surgery.

CONCLUSIONS

First MTPJ replacement is an option in hallux rigidus and patients who are not revised experience significant improvement in AOFAS scores in the medium term. We have previously published satisfactory results with this prosthesis. However the revision rate is unacceptably high and we have discontinued its use completely. Future design evolutions should address the issue of osteointegration on the phalangeal side.

Short-Term Clinical Outcome of Hemiarthroplasty Versus Arthrodesis for End-Stage Hallux Rigidus

Few data are available to compare the outcomes of first metatarsophalangeal joint (MTPJ) hemiarthroplasty and arthrodesis. We included 46 patients who had undergone BioPro(®) first MTPJ hemiarthroplasty and 132 who had undergone arthrodesis, with a minimum follow-up duration of 12 months. The primary outcome was patient satisfaction, which was determined using binominal questions. The Foot and Ankle Outcome Score, Foot Function Index, and Numerical Rating Scale for pain and limitations questionnaires were also used. The secondary outcome was treatment failure. No differences were found in the satisfaction rate (p = .54) after a median period of 38.4 (range 12 to 96) months and 39.8 (range 12 to 96) months in the hemiarthroplasty and arthrodesis patients, respectively. Furthermore, no differences were found in the failure rates (p = .93) or the interval to failure (p = .32).The results of the present study showed no significant differences in the short-term clinical outcomes and failure rates for BioPro(®) first MTPJ hemiarthroplasty and arthrodesis. Prospective comparative studies are required to determine whether BioPro(®) first MTPJ hemiarthroplasty is a good alternative for first MTPJ arthrodesis in the long term.

Design of a first metatarsophalangeal joint simulator

BACKGROUND

The use of total first metatarsophalangeal joint (MPJ) arthroplasty to treat patients in which the pain, due to a pathological joint, has not been relieved with a conservative method or for which the disease or disorder is at an advanced stage, is popular. Although meta-analysis of clinical results indicates that this surgical option is efficacious, there are problems with implant failure due to wear of the components. Although there is a plethora of designs of this type of implant in clinical use, there are no literature reports on total first MPJ simulators, which may be used to evaluate, for example, the wear rate of a total first MPJ implant.

METHODS

We designed such a simulator, guided by the biomechanics of the joint. Thus, for example, the implant under test will be articulated at least 40° dorsiflexion, under a 600 N loading, at 1 Hz. Furthermore, the testing stations will be configured to allow testing of any type of first MPJ implant. We also performed a finite element analysis (FEA) study of a model of an articulating station, subjected to a quasi-static load of 1200 N.

RESULTS

For an articulating station, (1) the highest von Mises stress occurred at the implant-fixture interface; and (2), for the other parts, the minimum factor of safety, against elastic failure, is approximately 9.

CONCLUSIONS

The designed joint simulator is mechanically sound and may be used for wear testing of any type of first MPJ implant.

First metatarsophalangeal joint arthrodesis in the treatment of hallux valgus

First metatarsophalangeal joint arthrodesis is a reliable procedure with predictable outcomes in the treatment of moderate-to-severe hallux valgus with degenerative changes of the joint. It offers better functional outcome compared to arthroplasty with or without prosthesis in appropriate patient populations. Recent studies have shown that with appropriate fixation, early weight bearing may be initiated without an increase in nonunion.

Early results of first metatarsophalangeal joint replacement using the ToeFit-Plus™ prosthesis

The aim of the present study was to investigate the outcomes of first metatarsophalangeal replacement for hallux rigidus using the Smith & Nephew ToeFit-Plus™ implant. We assessed the outcomes of 69 first metatarsophalangeal joint replacements using the American Orthopaedic Foot and Ankle Society score preoperatively and annually postoperatively, with retrospective radiologic review. All operations were performed by the same surgeon within 2 centers. A total of 69 arthroplasties were performed within the study period (57 patients). The median American Orthopaedic Foot and Ankle Society score at 1 year was 100 (interquartile range 100 to 100), at 2 years was 100 (interquartile range 95 to 100), at 3 years was 100 (interquartile range 87.5 to 100), and at 4 years, it was 100 (interquartile range 91.25 to 100). Radiolucencies around the phalangeal component were seen in 23 cases; however, this was symptomatic in only 2 patients, who required revision surgery. Our early results have shown that first metatarsophalangeal joint replacement surgery with the ToeFit-Plus™ prosthesis results in significant improvements in the American Orthopaedic Foot and Ankle Society scores for most patients; however, longer term follow-up is required to monitor the clinical effect of radiolucency around the phalangeal component.

Revision MTP arthrodesis for failed MTP arthroplasty

INTRODUCTION

Although the gold standard to address hallux rigidus that fails conservative treatment is an arthrodesis, some surgeons have attempted to use arthroplasty to improve range of motion and to simulate a normal joint. When these implants do fail, a salvage MTP arthrodesis is the only surgical option for these patients. This research aims to outline various methods to arthrodese the MTP joint in salvage situations.

METHODS

We retrospectively looked at patients who underwent a first-MTP fusion after failure of an implant arthroplasty. All fusions involved either bone allograft or autograft and internal fixation. The patients were assessed clinically, radiographically, and with the Ankle Society Hallux Metatarsophalangeal-Interphalangeal (AOFAS MTP-IP) clinical questionnaire preoperatively and postoperatively.

RESULTS

In all, 11 patients met the inclusion criteria. The average age of patients at the time of the salvage MTP arthrodesis was 57 years. The interval time between primary surgery and revision arthrodesis was on average 84.2 months. There was a high reoperation rate, with 7 operative procedures occurring per 12 arthrodeses (58%). The average time to radiographic fusion was 6.9 ± 4.8 months; 41.7% of patients had a delayed union (>6 months to fusion). Two patients had symptomatic nonunions (16.7%). All the patients had an improvement in their AOFAS MTP-IP score.

CONCLUSION

Although salvage arthrodeses for failed arthroplasties generally have favorable satisfaction rates and are a powerful tool in treating this painful condition, they are fraught with complications. They unite slower, have a significantly higher reoperation rate, and have lower AOFAS scores than primary fusions.

Conversion arthrodesis for failed first metatarsophalangeal joint hemiarthroplasty

BACKGROUND

Arthrodesis is currently the most commonly performed surgical procedure for the treatment of arthritis of the first metatarsophalangeal (MTP) joint. Hemiarthroplasty of the first MTP joint has been shown to have inferior clinical results and higher revision rates. The objective of this study was to assess the clinical outcome of the salvage of failed hallux phalangeal hemiarthroplasty with conversion to arthrodesis.

METHODS

A retrospective review of patients who underwent salvage of the first MTP joint hemiarthroplasty with conversion to arthrodesis was performed. Preoperative assessment included the visual analog pain (VAP) scale and AOFAS Hallux Metatarsophalangeal Interphalangeal scoring system (AOFAS-HMI). Postoperative outcomes were graded via AOFAS-HMI, VAP, and Foot and Ankle Ability Measure (FAAM).

RESULTS

Twenty-one hemiarthroplasties were converted to arthrodesis in 21 patients, with 18 available for follow-up included in the study. There were 13 women and 5 men. Local autologous bone graft was used in 12 cases, while 6 patients required tricortical iliac crest bone graft for the treatment of extensive bone loss. At final follow-up, at a mean of 4.3 years, the average VAS pain score had diminished to 0.75 from 7.8 preoperatively out of 10, while the mean AOFAS-HMI improved from 36.2 out of 100 preoperatively to 85.3 out of 90 (modified to exclude first MTP motion). The mean FAAM ADL/sports were 97.3/91.3, respectively. All patients achieved fusion although at a longer interval than primary fusions.

CONCLUSIONS

Conversion from a failed hallux phalangeal hemiarthroplasty to arthrodesis showed similar success to primary arthrodesis which was achieved in the majority of cases with the use of regional bone graft for small defects. However, the time to fusion was longer than that of primary arthrodesis, and it sometimes required structural bone graft for augmentation.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

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.

A retrospective review of the primus first MTP joint double-stemmed silicone implant

Implant arthroplasty has been a surgical alternative for correction of hallux rigidus for many decades. A study is presented reviewing the authors' experience using the (Tornier/Futura) Primus double-stemmed silicone implant. A total of 144 patients representing 201 implants were identified and invited to participate in the study. The postoperative period ranged from 32 to 108 months, with an average of 66.4 months. Chart review was performed on all cases. This review revealed that there were 2 implants that had been removed, each for reasons other than implant breakdown. Several indications in addition to hallux rigidus were found, including hallux valgus with arthritis, geriatric bunion, rheumatoid arthritis, and iatrogenic and traumatic arthritis. The outcomes are presented for all patients, with additional breakdown by their indication for surgery. In all, 54 patients involving 70 implants responded and were clinically evaluated. This study included a Visual Analogue Scale, Foot and Ankle (VAS FA) patient outcome and satisfaction questionnaire, clinical examination, and X-ray evaluation. Patients with hallux rigidus had an average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score of 88.2, and those with hallux valgus with arthritis had an average score of 88.6. The average AOFAS score for all patients was 87.4. The average VAS patient satisfaction for all patients was 8.5 (with 10 being highest satisfaction). Implant arthroplasty continues to be a viable alternative for surgical correction of hallux rigidus as well as other degenerative conditions of the first MTP joint. This procedure is particularly effective in older, less-active patients with lower functional demand.

LEVELS OF EVIDENCE

Therapeutic, Level IV, Retrospective case series.

Nineteen-year follow-up of the silastic double stemmed hinge prosthesis of the first metatarsophalangeal joint

BACKGROUND

The purpose of this retrospective study is to evaluate patient-related outcome and reoperation rate of the Swanson prosthesis in patients with and without grommets.

METHODS

Between 1981 and 1999, 98 Swanson MTP-1 prostheses were implanted in 84 patients (14 bilateral). The average follow-up was 19 years. Patients were asked to fill in the Foot and Ankle Outcome Score (FAOS) questionnaire and were asked if they had undergone reoperations. In addition, medical records where searched.

RESULTS

36 patients (mean age 71 years) returned the questionnaire. All median FAOS sub scores were 100. There were no differences in FAOS sub scores between patients who had a prosthesis with or without grommets, except for FAOS "activities in daily living" which was lower for patients without grommets. Reoperation rate was 4%.

CONCLUSION

The Swanson silastic double stemmed hinge prosthesis showed good to excellent patient-related outcome and reoperation rate at long-term follow-up.

Hállux Rígidus: prospective study of joint replacement with hemiarthroplasty

OBJECTIVE:

To report the results of medium-term follow-up after deploying Arthrosurface-HemiCap^(r) in patients with diagnosis of Hállux Rigidus (HR).

METHOD:

Eleven patients underwent partial Arthroplasty of the first metatarsal-phalangeal joint. Six women and five men with an average age 51.9 years (46 to 58 years) and average postoperative follow-up of 3.73 years (3-4 years); were classified through the Kravitz system and evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) scales for hállux, Visual Analogical Scale (VAS) - analog functional pain - and range of motion in the first metatarsal joint in preoperative, postoperative after six months and present post-operative.

RESULTS:

The results show significant improvement of the three analyzed parameters, both for overall analysis and for pre and post-operative comparisons individually. The comparative analysis of each variable in the six months and the current postoperative periods do not show statistically significant differences, indicating maintenance of parameters during this interval.

CONCLUSION:

hemiarthroplasty of first metatarsophalangeal joint is a reproducible and safe option for the surgical treatment of hállux rigidus II and III, with significant improvement of the evaluated parameters for the studied population. Level of Evidence IV, Case Series.

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.

A retrospective comparison of first metatarsophalangeal joint arthrodesis using a locked plate and compression screw technique

INTRODUCTION

The historic primary treatment for end-stage first metatarsophalangeal (MTP) joint arthritis has been fusion. Traditionally, this has been accomplished by metaphyseal apposition between the proximal phalanx and metatarsal using crossed compression screws. Recently, locked plates have been introduced that help support this technique by offering added stability. We present our experience with 45 first MTP fusions in 45 feet using a locked plate and compression screw.

METHODS

A retrospective review of 45 patients who met the study criteria with a hallux rigidus correction using a locked plate with a compression screw was performed. Charts and radiographs were independently reviewed by 2 authors not involved in the index procedures to assess outcomes.

RESULTS

There was a 93% fusion rate (42/45 feet) with 3 nonunions. The mean time to union was 51.1 days (range = 29-116 days, SD = 24.4). The mean patient age was 58.1 years (range = 29-80 years, SD = 10.1). The mean time to partial weight bearing was 7.0 days (range = 0-53 days, SD = 13.8) and the mean time to full weight bearing was 62.0 days (range = 29-57 days, SD = 17.9).

DISCUSSION

We report on the results of first MTP fusion using a compression screw and locked plate technique. The results show that this is an effective means of creating a first MTP joint arthrodesis.

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.