Arthroscopy of the first metatarsophalangeal joint in 59 consecutive cases

First metatarsophalangeal joint arthroscopy: Unearthing clinical evidence - A systematic review

PURPOSE

Arthroscopy of the first metatarsophalangeal joint (1 MTP) has gained increasing attention in the last two decades. Despite numerous studies describing the surgical technique, only a few provide clinical or radiological outcome data. This systematic review aimed to analyze studies presenting objectively measurable clinical outcomes of patients who underwent 1 MTP arthroscopy as the primary procedure, categorizing results by indication pathology.

METHODS

Following PRISMA guidelines, PubMed and Cochrane databases were searched for studies reporting outcomes of primary 1 MTP arthroscopy, regardless of underlying pathology. The selected articles were thoroughly assessed to extract data regarding the demographics of included patients, pathology, preoperative and postoperative clinical and radiological outcomes, complications, and reinterventions.

RESULTS

Fourteen articles, involving 405 patients (419 halluces), were included. Common indications were hallux valgus and hallux rigidus. Notably, Hallux Valgus Angle improved from 28.9° to 12.7°, and Intermetatarsal Angle improved from 13.8° to 9.2°, where reported. In hallux rigidus patients, range of motion increased from 25.15° to 71.3° post-surgery. Temporary or permanent sensory loss occurred in 3% of treated halluces, with 4.28% requiring reoperation.

CONCLUSIONS

Evidence on 1 MTP arthroscopy as the primary procedure is limited. It is most effective for hallux rigidus, while in hallux valgus cases, it can achieve satisfactory angular corrections but has a relatively high recurrence and reoperation rate. Although this technique is generally safe, further research should compare it with traditional surgical approaches to provide comprehensive insights.

LEVEL OF EVIDENCE

IV.

Back in Action: High Return to Pre-Injury Level of Sports after Arthroscopic Bone Marrow Stimulation for Osteochondral Lesions of the First Metatarsophalangeal (MTP-1) Joint

OBJECTIVE

The primary aim was to assess the return to sports outcomes of patients with symptomatic osteochondral lesions (OCLs) to the first metatarsophalangeal (MTP-1) joint treated by arthroscopic bone marrow stimulation (BMS). Secondary aims were to present patient-reported outcome measures (PROMs) on pain scores as well as surgery-related complications or reoperations to the MTP-1 joint.

DESIGN

All patients with MTP-1 OCLs treated by arthroscopic BMS with a minimum follow-up of 12 months were included. Outcomes included return to sports and work outcomes, satisfaction outcomes with the performed treatment, PROMs, as well as postoperative complications and reoperations. Medical records were screened by 2 independent reviewers and patients were contacted by phone to partake in an in-depth interview. Complications, reoperations, and revision surgeries were additionally assessed.

RESULTS

Nine patients (median age: 22 years with interquartile range (IQR) 20-29 years) were included with a median follow-up time of 47 (IQR: 23-92) months. Six (86%) out of 7 patients who participated in sports preoperatively returned to sports at any level at a median of 4 (IQR: 2.6-5.8) months. Five patients (71%) returned to pre-injury level of sport and eventually returned to performance at a median of 4 (IQR 2.8-7.5) and 8 (IQR: 4.0-10.5) months, respectively. The median Numeric Rating Scale for pain during walking was 1 (IQR 0-2.5) and all (100%) patients were able to return to work at a median of 4 (IQR: 2-17) weeks. Eighty-nine percent of the patients were very or fairly satisfied with the result of their treatment. No complications, reoperations, or revision surgeries were reported.

CONCLUSIONS

Arthroscopic BMS for patients with symptomatic OCLs to the MTP-1 joint can be considered safe and yields an 86% return to sport at any level and a 71% return to pre-injury and performance level, with good clinical, return to work, as well as satisfaction outcomes.

Needle Arthroscopy for Osteochondral Lesions of the First Metatarsophalangeal Joint: A Standardized Approach

Cartilage and osteochondral lesions of the first metatarsophalangeal (MTP-1) joint are characterized by pain during weight bearing and walking. The lesions often require surgical intervention(s). Arthroscopic bone marrow stimulation may be considered the preferred operative intervention for small lesions. Technological advances, patient preferences, and economic considerations combine to foster the development of minimally invasive needle arthroscopic procedures. This technical note presents and highlights our minimally invasive surgical technique for needle arthroscopic treatment through bone marrow stimulation for osteochondral lesions of the MTP-1 joint.

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.

The anatomy of the anconeus nerve redefined

The anconeus nerve is the longest branch of the radial nerve and suitable as a donor for the neurotization of the axillary nerve. The aim of this study was to map its topographical course with reference to palpable, anatomical landmarks. The anconeus nerve was followed in 15 cadaveric specimens from its origin to its entry to the anconeus. It runs between the lateral and the medial head of the triceps before entering the medial head and running intramuscularly further distal. Exiting the muscle, it lies on the periosteum and the articular capsule of the elbow, before entering the anconeus muscle. Two types of anconeus nerve in relation to branches innervating triceps were found: nine nerves also innervated the lateral triceps head, while the other six only contributed two branches to its innervation. The course of the anconeus nerve is important for harvesting as a donor nerve and to protect the nerve in surgical elbow approaches.

Percutaneous Lateral Release in Hallux Valgus: Anatomic Basis and Indications

In the last decade, minimally invasive or percutaneous surgery has evolved rapidly through the development of novel techniques. Treatment of hallux valgus deformity is one of the indications for percutaneous surgery, both for bony and soft tissue correction. The release of the structures on the lateral part of the first metatarsophalangeal joint (lateral release) is one of the best indications for percutaneous surgery in the forefoot. In this article, a detailed description of the anatomy of the metatarsophalangeal joint is provided, along with the indications and tips to perform a safe percutaneous lateral release.

Joint Preparation and Ray Shortening in Arthroscopic Versus Open First Metatarsophalangeal Fusion: A Cadaver Study

Purpose This study compares the amount of joint preparation and first ray shortening following first metatarsophalangeal (MTP) joint fusion utilizing open conical reaming versus arthroscopic technique. Methods Ten below-knee cadaver specimens were randomly assigned to undergo either open or arthroscopic first MTP fusion. Following fixation, first ray length measurements were obtained from pre-operative and post-operative radiographs and were used to determine first ray shortening. Additionally, the ratio of first ray length to second ray length was calculated both pre-operatively and post-operatively and compared between the two approaches. All ankles were then completely dissected, and prepared surface areas were demarcated. ImageJ photo analysis software (National Institutes of Health, Bethesda, MD, USA) was used to calculate the percentage of prepared and unprepared cartilage of each articular surface of each specimen.  Results Overall, the open approach resulted in 99.3% ± 1.6% joint surface preparation, whereas the arthroscopic approach yielded 92.9% ± 7.2% (p = 0.089). On average, the head of the first metatarsal was significantly more prepared with the use of the open approach (99.5% ± 1.1%) than with the arthroscopic approach (96.6% ± 1.5%) (p = 0.008). However, with respect to the base of the phalanx, the average difference in preparation between the arthroscopic approach and the open approach was not statistically significant (90.0% ± 12.8% vs. 99.0% ± 2.2%; p = 0.160). The average amount of first ray shortening in the arthroscopic approach was 2.2 ± 1.8 mm compared to 2.1 ± 3.2 mm in the open approach (p = 0.934). The average change in the first to second ray length ratio was 0.02 for both approaches (p = 0.891). Conclusion Arthroscopic first MTP fusion can be used to achieve joint preparation comparable to open technique while maintaining first ray length.

Anatomical Study of Minimally Invasive Lateral Release Techniques for Hallux Valgus Treatment

BACKGROUND

Lateral release (LR) for the treatment of hallux valgus is a routinely performed technique, either by means of open or minimally invasive (MI) surgery. Despite this, there is no available evidence of the efficacy and safety of MI lateral release. Our aim was to study 2 popular techniques for MI LR in cadavers by subsequently dissecting the released anatomical structures.

METHODS

Twenty-two cadaveric feet were included in the study and allocated into 2 groups, 1 for each procedure: 1 group underwent a MI adductor tendon release (AR), and in the other group, an extensive percutaneous lateral release (EPLR) (adductor tendon, suspensory ligament, phalanx-sesamoid ligament, lateral head of flexor hallucis brevis, and deep transverse metatarsal ligament) was performed. Anatomical dissection was performed to identify neurovascular injuries and to verify the released structures.

RESULTS

Both techniques demonstrated to be effective in reproducing a MI LR. A satisfactory release of the adductor tendon was achieved equally in both techniques (P = .85), being partial in most EPLR cases and full in the majority of AR cases. The EPLR was successful in releasing the intended additional structures (P < .05). One case of inadvertent complete section of the flexor hallucis longus was identified in the percutaneous adductor tendon release group. No cases of dorsolateral nerve injury were seen with either of the techniques.

CONCLUSION

Percutaneous lateral release was a reliable and accurate technique in this cadaveric model. The MI AR proved to be more effective in fully releasing the adductor tendon while the ER was intended and able to release a number of other structures.

CLINICAL RELEVANCE

MI LR is a safe procedure that could obviate the need for open surgery to achieve the same surgical goal. It can be associated to either open or MI osteotomies in the correction of hallux valgus.

Intermediate-term results of isolated minimally invasive arthroscopic cheilectomy in the treatment of hallux rigidus

AIM

The aim of this study was to determine the intermediate-term results of minimally invasive cheilectomy of the first MTPJ using a high-torque low-speed burr and arthroscopic debridement.

METHODS

A consecutive series of patients who underwent isolated unilateral minimally invasive cheilectomy of the first MTPJ were contacted by telephone. A questionnaire was used to assess patient satisfaction and complications. Patients with less than 2 years of follow-up were excluded.

RESULTS

Thirty-six patients completed the study. Mean patient age at time of surgery was 50.0 years (range 24.5-67.0). Mean follow-up was 4.69 years (range 2.0-7.3). Thirty patients (83%) reported they would recommend the procedure. Mean postoperative improvement in pain was 69% (range 0-100). Twenty-seven (84%) of patients reported either no pain (28%) or mild pain (56%). For patients who reported any pain, the mean pain experienced was rated as 3.4 out of 10 (range 1-9). Twenty-nine (81%) patients reported they could wear a 'fashionable' shoe postoperatively. One patient experienced a delayed rupture of the extensor hallucis longus at 6 months postsurgery. One patient underwent further arthroscopic cheilectomy. No patient required conversion to fusion of the first MTPJ.

CONCLUSION

Minimally invasive cheilectomy of the first MTPJ using high-torque low-speed burr and arthroscopic debridement results in high patient satisfaction with a low rate of complications at intermediate follow-up.

Arthroscopy of the First Metatarsophalangeal Joint

Arthroscopic treatments for the first metatarsophalangeal joint have not spread fully owing to a number of factors. First, in the common arthroscopic view, the joint is observed from above, which makes the structures difficult to grasp and the dorsal aspect of the joint difficult to visualize and treat. Second, techniques for widening the view have not yet been reported. Third, the portals necessary for observation and treatment with hallux sesamoids have not yet been established. Finally, techniques for detecting the sesamoids have not been previously reported. We have developed a method for first metatarsophalangeal joint arthroscopy by treating 14 patients with hallux rigidus and 9 patients with hallux sesamoid disorders. We report a new method that combines a variety of arthroscopic techniques. Our study has 4 novel points. First, in our arthroscopic technique, the joint can be examined from the medial side because traction is directly and horizontally applied to the great toe using an adjustable traction device with the surgeon standing on the unoperated side. The technique enables observation of the dorsal aspect of the metatarsal head and proximal phalanx and makes the structures easier to grasp. Second, the coagulator technique as an arthroscopic aid is demonstrated. Third, all aspects of the joint, including the sesamoids, can be observed through our 4 portals. Finally, techniques for detecting the sesamoids are identified. We believe our novel method will ensure that arthroscopy of the first metatarsophalangeal joint is easier than previously described methods.

Measuring Visualized Joint Surface in Hallux Metatarsophalangeal Arthroscopy

BACKGROUND

Arthroscopy has been increasingly used to evaluate small joints in the foot and ankle. In the hallux metatarsophalangeal (MTP) joint, little data exist evaluating the efficacy of arthroscopy to visualize the articular surface. The goal of this cadaveric study was to determine how much articular surface of the MTP joint could be visualized during joint arthroscopy.

METHODS

Ten fresh cadaveric foot specimens were evaluated using standard arthroscopy techniques. The edges of the visualized joint surface were marked with curettes and Kirschner wires; the joints were then surgically exposed and imaged. The visualized surface area was measured using ImageJ^® software.

RESULTS

On the distal 2-dimensional projection of the joint surface, an average 57.5% (range, 49.6%-65.3%) of the metatarsal head and 100% (range, 100%-100%) of the proximal phalanx base were visualized. From a lateral view of the metatarsal head, an average 72 degrees (range, 65-80 degrees) was visualized out of an average total articular arc of 199 degrees (range, 192-206 degrees), for an average 36.5% (range, 32.2%-40.8%) of the articular arc.

CONCLUSION

Complete visualization of the proximal phalanx base was obtained. Incomplete metatarsal head visualization was obtained, but this is limited by technique limitations that may not reflect clinical practice.

CLINICAL RELEVANCE

This information helps to validate the utility of arthrosocpy at the hallux metatarsophalangeal joint.

Arthroscopic treatment of focal osteochondral lesions of the first metatarsophalangeal joint

Background

Although arthroscopic surgical treatment of the first metatarsophalangeal (MTP) joint involves painful sesamoid excision, synovectomy, debridement, and partial cheilectomy, no gold standard treatment technique has been defined in the literature for hallux rigidus and focal osteochondral lesions. This study aimed to assess the arthroscopic treatment for early-grade focal osteochondral lesions of the first MTP joint and to determine the impact of arthroscopic microhole drill surgery on foot function and activities of daily living in a group of patients who failed conservative treatment.

Methods

This prospective study included 14 patients with hallux rigidus and focal osteochondral lesions of the first MTP joint who underwent surgery in 2014 and were followed on a regular basis thereafter.

Results

The patients had mean preoperative VPS (visual pain scale) and AOFAS (American Orthopedic Foot and Ankle Society)-Hallux scores of 8.14 ± 0.86 SD and 48.64 ± 4.27, respectively; the corresponding postoperative values of both scores were 1.86 ± 0.66 SD and 87.00 ± 3.70, respectively. Both VPS and AOFAS-Hallux scores changed significantly.

Discussion

In this prospective study, we explored the impact of arthroscopic microhole drill surgery on foot function and activities of daily living in patients with focal osteochondral lesions of the first MTP joint. Our results showed significant improvements in VPS and AOFAS scores with this treatment.

Conclusions

An arthroscopic microhole drill technique can be used with impressive functional scores and without any complications in patients who failed conservative therapy for hallux rigidus with focal chondral injury.

Arthroscopic treatment of focal osteochondral lesions of the first metatarsophalangeal joint

Background

Although arthroscopic surgical treatment of the first metatarsophalangeal (MTP) joint involves painful sesamoid excision, synovectomy, debridement, and partial cheilectomy, no gold standard treatment technique has been defined in the literature for hallux rigidus and focal osteochondral lesions. This study aimed to assess the arthroscopic treatment for early grade focal osteochondral lesions of the first MTP joint and to determine the impact of arthroscopic microhole drill surgery on foot function and activities of daily living in a group of patients who failed conservative treatment.

Methods

This prospective study included 14 patients with hallux rigidus and focal osteochondral lesions of the first MTP joint who underwent surgery in 2014 and were followed on a regular basis thereafter.

Results

The patients had mean preoperative VPS (visual pain score) and AOFAS (American Orthopedic Foot and ankle Society)-Hallux scores of 8.14 ± 0.86 SD and 48.64 ± 4.27, respectively; the corresponding postoperative values of both scores were 1.86 ± 0.66 SD and 87.00 ± 3.70. Both VPS and AOFAS-Hallux scores changed significantly.

Discussion

In this prospective study, we explored the impact of arthroscopic microhole drill surgery on foot function and activities of daily living in patients with focal osteochondral lesions of the first MTP joint. Our results showed significant improvements in VPS and AOFAS scores with this treatment.

Conclusions

An arthroscopic microhole drill technique can be used with impressive functional scores and without any complications in patients who failed conservative therapy for hallux rigidus with focal chondral injury.

Turf Toe and Disorders of the Sesamoid Complex

A turf toe injury encompasses a wide spectrum of traumatic problems that occur to the first metatarsophalangeal joint. Most of these injuries are mild and respond well to nonoperative management. However, more severe injuries may require surgical management, including presence of diastasis or retraction of sesamoids, vertical instability, traumatic hallux valgus deformity, chondral injury, loose body, and failed conservative treatment.

First Metatarsophalangeal Joint Arthroscopy for Osteochondral Lesions

Small-joint arthroscopy has supplanted open procedures because it offers the potential for improvement in joint visualization, reduced scarring, and accelerated recovery. Despite these advantages, arthroscopy of the first metatarsophalangeal joint is not commonly performed and reports of its use are lacking. The reason for this is not clear but may be because of perceived technical complexity and poorly defined indications. In our experience, however, arthroscopy of the first metatarsophalangeal joint is a versatile procedure that facilitates treatment of many different pathologic processes through a minimally invasive approach with few complications. We present our technique for arthroscopic management of osteochondral lesions of the hallux.

Open, Arthroscopic, and Percutaneous Cheilectomy for Hallux Rigidus

Cheilectomy consists of excision of the dorsal exostosis and part of the metatarsal head. It is typically performed for patients in the earlier stages of hallux rigidus presenting with dorsal pain and dorsiflexion stiffness in the absence of through-range symptoms, rest pain, and plantar pain and with negative result on grind test. If joint motion-preserving surgery is appropriate, then cheilectomy is generally considered to be the first-line surgical choice. In addition to the standard open technique, minimally invasive surgery in the form of either percutaneous or arthroscopic surgery is available. The indications, surgical techniques, and outcomes are discussed.

Extended indications for foot and ankle arthroscopy

Advances in foot and ankle arthroscopy have allowed surgeons to diagnose and treat a broadening array of disorders that were previously limited to open procedures. Arthroscopy of the posterior ankle, subtalar joint, and first metatarsophalangeal joint and tendoscopy can be used to address common foot and ankle ailments, with the potential benefits of decreased pain, fast recovery, and low complication rates. Posterior ankle and subtalar arthroscopy can be used to manage impingement, arthrofibrosis, synovitis, arthritis, fractures, and osteochondral defects. First metatarsophalangeal joint arthroscopy can address osteophytes, chronic synovitis, osteochondral defects, and degenerative joint disease. Tendoscopy is a minimally invasive alternative for evaluation and débridement of the Achilles, posterior tibial, flexor hallucis longus, and peroneal tendons.