Total Arthroplasty of the Metatarsophalangeal Joint of the Hallux

MIDTERM FUNCTIONAL OUTCOMES OF SYNTHETIC CARTILAGE IMPLANT (SCI) ARTHROPLASTY FOR HALLUX RIGIDUS

Hallux rigidus is a common degenerative condition of first metatarso-phalangeal joint most commonly affecting patients above 50 years of age. The aim of our study is to evaluate the five-year results of synthetic cartilage implant (Cartiva) arthroplasty for hallux rigidus. A retrospective study of 70 patients who underwent synthetic cartilage implant interpositional arthroplasty were collected and analysed. Patients with Grade 3 to 4 hallux rigidus and who had failed conservative management were included. Patients who had previous forefoot surgery, hallux varus or valgus deformity of more than 250 and neuromuscular disease were excluded. Mean age at the time of operation was 63.4 years (range 42-84 years). The mean follow-up was 62.6 months. The functional evaluation was done using Manchester-Oxford Foot Questionnaire (MOxFQ). EQ-5D and EQVAS. 86 patients were matriculated in the study with 70 patients being assessed at five years. The average preoperative MOxFQ score improved from 35.74 (31.44-40.04) to 19.11 (11.31- 26.91) at one year after surgery. The EQ-5D scores improved from preoperative average of 9.40 (8.14-10.66) to 4.26 (2.09-6.43) at one year. The preoperative EQVAS was 61.66 (51.25-72.07) to 71.45 (60.87-82.03 at one year. At five years follow up the average MOxFQ score was 17.6 (9.92-24.38), EQ-5D - 4.8 (2.26- 6.45) and EQVAS - 72.48 (62.40-82.56). Three patients had revision to first MTP fusion due to ongoing pain. Synthetic cartilage implant has demonstrated clinical efficacy and good functional outcomes at the end of five years for the treatment of Hallux rigidus. Level of Clinical Evidence: 4.

Surgical Management of Failed First Metatarsophalangeal Joint Arthroplasty

This article describes the etiology, clinical presentation, surgical management, and outcomes for treatment of the failed first metatarsophalangeal (MTP) joint arthroplasty. Failure following implant arthroplasty typically creates large osseous deficits and surgical management can be difficult. Salvage arthrodesis provides reliable joint stability while maintaining hallux length. Outcomes following conversion of a failed MTP joint arthroplasty to MTP joint arthrodesis have demonstrated consistent pain relief and high satisfaction: however, high rates of complication and nonunion have been reported. Bone graft may be necessary to fill large voids in the joint. Other revision options for failed arthroplasty have been described, but outcomes remain inconsistent and varied. Ultimately, conversion to MTP joint arthrodesis is the recommended intervention for treatment of the failed MTP arthroplasty implant, providing sufficient stability and pain relief.

Arthrodesis using Iliac Crest autograft in revision surgery of the first metatarsophalangeal joint total arthroplasty for the treatment of Hallux Rigidus: a retrospective study

PURPOSE

The treatments for hallux rigidus (HR) encompass a wide spectrum, including conservative methods and surgical approaches such as arthroplasty and arthrodesis. This study aims to evaluate the outcomes of revision with arthrodesis following the failure of the first metatarsophalangeal joint total arthroplasty (MTPJ1TA).

MATERIALS AND METHODS

Patients who had surgery at two advanced orthopedic centers between January 1, 2020, and January 1, 2024, were reviewed. Those with at least 6 months of postoperative follow-up were assessed for demographics (gender, age, side), reoperation rates, complications, Visual Analogue Scale (VAS) scores, Foot and Ankle Disability Index (FADI) scores, and American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal and Interphalangeal Scale (AOFAS-HMI) scores. Radiological evaluations included hallux valgus angle (HVA), intermetatarsal angle (IMA), dorsiflexion angle (DFA), and first ray length (FRL) in anteroposterior and lateral views.

RESULTS

Of 27 patients, 4 were male (15%) and 23 female (85%), with an average age of 56.18 ± 7.49 years (range 41-72). Arthrodesis was performed in 26 patients, with one requiring reoperation due to implant failure. Average VAS scores were 7.14 preoperatively and 3.55 postoperatively (p < 0.05). Average FADI scores were 50.51 preoperatively and 71.51 postoperatively (p < 0.05). Average AOFAS-HMI scores were 51.22 preoperatively and 70.59 postoperatively (p < 0.05). Average HVA was 19.7° preoperatively and 6.29° postoperatively (p < 0.05). Average IMA was 10.66° preoperatively and 11.37° postoperatively (p = 0.406). Average DFA was 34.14° preoperatively and 22.33° postoperatively (p < 0.05). Average anteroposterior FRL was 10.17 cm preoperatively and 10.77 cm postoperatively (p < 0.05). Average lateral FRL was 10.12 cm preoperatively and 10.42 cm postoperatively (p < 0.05). None of the patients in the study exhibited postoperative donor site complications or transfer metatarsalgia, while a 100% rate of bone union was observed.

CONCLUSION

We think that revision of MTPJ1TA with arthrodesis is a safe treatment option. Additionally, the use of an iliac crest autograft can be a viable option to restore bone stock and create a biological environment conducive to fusion. This study evaluates revision surgery with arthrodesis in the largest patient group with failed MTPJ1TA, highlighting its significance in the field. However, further studies are needed to determine the ideal surgical procedure.

Silicone Arthroplasty as an Alternative to Arthrodesis in the Metatarsophalangeal Degenerative Disease of Hallux Valgus-A 5-Year Observational Study

Background: Arthroplasty is gaining more and more popularity in the treatment of osteoarthritis (OA) of the metatarsophalangeal I joint (MTP1). The aim of our study was to evaluate the early and long-term objective clinical and radiographic results, as well as the subjective results, of MTP1 arthroplasty in comparison to MTP1 arthrodesis among patients with OA and a valgus deformity of their MTP 1 joint. Methods: Patients with OA MTP1 were examined before surgery and in the 5-year period after surgery. The inclusion criteria for the study were OA of the MTP1 joint and a non-axial position of the toe in valgus between 20 and 40 degrees. Prostheses were created for the patients with higher demands for mobility of their MTP 1 joint and arthrodesis was carried out for those with lower expectations. The treatment outcomes were assessed by clinical examination, radiography, the AOFAS scale, the SEFAS scale, and using patient-related outcome measures (PROM). Results: A total of 39 people, 37 women and 2 men, aged 55 to 67 years old (average, 61 years old) participated in the study. During the follow-up period, there were no complications in the form of infection or a loosening of the implant after both arthroplasty and arthrodesis. The follow-up examination 60 months after the surgery showed an improvement in scores (>20 points) on both the AOFAS and SEFAS scales. All patients, after surgery, reported reduced pain. Conclusions: The use of a silicone prosthesis in the surgical treatment of degenerative changes in the MTPI joint, with appropriate indications and excluding cases with large hallux valgus, gives better results than arthrodesis.

Republication of "Current Concepts Review: Hallux Rigidus"

Arthritis of the first metatarsophalangeal (MTP) joint, hallux rigid, is a common and disabling source of foot pain in the adult population. Hallux rigidus is characterized by diseased cartilage and large, periarticular osteophytes that result in a stiff, painful joint. Activity modification, sensible shoes, orthotics, anti-inflammatory medications and occasional intra-articular steroid injections can be attempted to alleviate the discomfort associated with hallux rigidus. A number of surgical options exist for the treatment of recalcitrant hallux rigidus. Cheilectomy is a useful treatment for dorsal impingement pain seen in mild hallux rigidus. A new polyvinyl alcohol hemi-arthroplasty implant has shown promising early and midterm results in the treatment of advanced hallux rigidus; however, arthrodesis of the first MTP joint remains the gold standard treatment for advanced hallux rigidus because of unpredictable outcomes after early-generation joint replacement implants.

Assessment and Management of Atraumatic First Metatarsophalangeal Joint Pain

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, case-control study.

Complications of Hallux Rigidus Surgery

Hallux rigidus can be treated with a variety of surgical procedures, including joint preserving techniques, arthrodesis, and arthroplasty. The most commonly reported complications for joint preserving techniques consist of progression of arthritis, continued pain, and transfer metatarsalgia. Although good outcomes have been reported for arthrodesis overall, careful attention must be paid to technique and positioning of the toe to avoid nonunion or malunion. Arthroplasty preserves motion but in the case of failure can present the additional challenge of bone loss. In these scenarios, the authors recommend distraction bone block arthrodesis with structural autograft.

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

BACKGROUND

This paper compares long term success rate of MTP joint replacement for hallux rigidus. We provide long term results of MTP joint replacement with the use of the ToeFit Plus™ System.

MATERIALS AND METHODS

Our group consisted of 19 total joint replacements and 12 hemiarthroplasties in 18 and 11 patients respectively, performed between 2005-2009. The average follow-up period was 12.2 years (range 9.8-13.7, SD 1.1) for total arthroplasty group and 11.1 years (range 9.5-13.9, SD 1.7) for hemiarthroplasty group. In all followed patients AOFAS score was calculated along with the range of motion assessment.

RESULTS

Average AOFAS score improved from 37 preoperatively to 79 at the time of last follow-up in total arthroplasty group and from 45 to 86 in the hemiarthroplasty group, with consideration to the statistically considerable difference of both groups. The total range of motion improved on average from 14° to the current 32° in patients with total arthroplasty and from 15° to 32° with hemiarthroplasty. The total number of cases that required surgical revision was 7 (37%) in total arthroplasty group and 2 (17%) in hemiarthroplasty group.

CONCLUSION

Due to the high percentage of failure that was shown in our long term results, we no longer utilise the ToeFit Plus™ System.

Modern approaches to the treatment of hallux rigidus

The number of patients with degenerative joint pathology is steadily increasing. Arthrosis of the 1st metatarsophalangeal joint (hallux rigidus) is no exception, it occurs in 20-35 % of young and working people who lead a mobile lifestyle and is manifested by a symptom complex, including pain and a significant restriction of the function of the entire lower limb. The leading cause of the pathology development is degenerative-dystrophic changes in the joint, leading to pain syndrome and restriction of movement. Today, there are a large number of treatment options, both conservative and surgical. The choice of a specific surgical intervention from the entire variety of options is a difficult task, it is strictly individual and requires consideration of various clinical manifestations of the disease and a number of other factors. So, if 10 years ago arthrodesis was considered a gold standard for the HR treatment, today most authors recommend organ-sparing treatment, in particular, shortening osteotomies of the metatarsal bone with a possible use of scaffolds for the regeneration of articular cartilage. The article analyzes the main results of the HR surgical treatment presented in the publications of national and foreign specialists. In some cases, our own recommendations on the choice of the method are suggested.

The efficacy of shoe modifications and foot orthoses in treating patients with hallux rigidus: a comprehensive review of literature

Hallux rigidus (HR) is a degenerative disease of the first metatarsophalangeal (MTP1) joint and affects about 2.5% of people older than 50 years. The real etiology of this condition remains under debate. Clinical symptoms, physical exam, and instrumental evidence are important in assessing and grading the disease. The anatomy of the first metatarsal is unique and its configuration may play a significant role in the HR development. The first approach in the early stages of the disease usually begins with shoe modifications and foot orthoses, designed to limit irritation from the dorsal osteophytes, reducing motion and the mechanical stresses on the joint. To prevent or delay the development of HR, shoes should be sufficiently long, comfortable, with high toe box and broad toe-boxed, and should bear an allowed space for the orthotic device. The ideal orthotic appears to require a 3-mm thickness with a correct stiffness, and also increasing and extending the medial metatarsal arch just proximal to the metatarsal head, raising the first metatarsal and allowing the proximal phalanx to rest in a more plantarflexed position, decompressing the dorsal aspect of the joint. The increased foot pronation moment with medial column overload, when present, should be corrected. In addition, the maximum follow-up found by the analyzed studies was of 14.4 years, so the Authors cannot conclude how long conservative care can keep a patient free from pain and able to perform normal daily activities. However, the use of shoe modifications and foot orthoses may be considered a safe treatment and then should be always offered to patients, before any surgical management. (www.actabiomedica.it)

Valenti resection arthroplasty for hallux rigidus: A systematic review

BACKGROUND

Valente Valenti proposed in 1976 a "V" resection of the first metatarsophalangeal joint (MPT1) on the sagittal plane for advanced stages of hallux limitus/rigidus, preserving length of the first ray, flexor hallux brevis and sesamoid function. The available literature concerning correct indications, management and clinical outcomes of the Valenti procedure (VP) and its modifications in patients affected by hallux limitus/rigidus was systematically analyzed.

METHODS

Titles and abstracts of all selected articles were independently screened by two authors to assess their suitability to the research focus.

RESULTS

Selection produced 8 articles as full-text, for a total of 347 patients, with a mean follow-up of 6±7.1 (range 0.2-17.5) years. Most common complication was transient sesamoiditis in 21 (7.4%) patients. No substantial differences in clinical outcomes were found between the original and modified techniques.

CONCLUSIONS

VP appears to allow an early recovery with few complications, if compared to fusion, interposition arthroplasties or osteotomies. The wide joint resection does not prevent, if necessary, further procedures such as fusion or implants.

LEVEL OF EVIDENCE

Level I, systematic review.

Salvage arthrodesis for failed first metatarsophalangeal joint arthroplasty: A network meta-analysis

BACKGROUND

We aim to provide an evidence-based literature review of salvage arthrodesis for failed first metatarsophalangeal joint arthroplasty with a network meta-analysis.

METHODS

A search of PubMed, Embase and Cochrane databases was conducted in December 2016 which identified 12 relevant articles out of 340 articles assessing the efficacy of salvage arthrodesis for failed joint arthroplasty of the first metatarsophalangeal joint. The 12 studies were assigned a level of evidence (I-V) and interventions were graded a level of recommendation (A-C, I) in support of or against the treatment modality.

RESULTS

There is fair evidence (grade B) to support salvage arthrodesis with structural bone graft. There is poor evidence (grade C) for salvage arthrodesis without bone graft. There was no good evidence (grade A) to recommend either intervention. Meta-analysis showed that salvage arthrodesis resulted in improved functional outcome over time.

CONCLUSIONS

Salvage arthrodesis showed good bone union rates and patient satisfaction.

LEVEL OF CLINICAL EVIDENCE

III - Systematic Review of Level III studies.

Motion Preservation in Hallux Rigidus After Failure of Hydrogel Implantation: Treatment Considerations and a Report of 2 Cases

Hallux rigidus is a common condition treated daily by surgeons worldwide. During the past decade, the standard treatment algorithm has been questioned by both patients and surgeons seeking alternatives to arthrodesis, which was previously considered the gold standard for advanced disease. Patients are living longer, and many have a more active lifestyle; thus, recreating and improving range of motion and achieving pain relief are increasingly desirable. The treatment spectrum and implant options for motion-preserving techniques in the metatarsophalangeal joint has been widened with the recent US Food and Drug Administration approval of a polyvinyl-alcohol hydrogel implant. In the controlled US Food and Drug Administration trial, the 2-year revision rate was 9.2% and all failures were revised to a first metatarsophalangeal arthrodesis. Outcomes comparison of these revisions to primary fusions showed less predictable pain relief and may warrant alternative treatment considerations, preferably those that allow for continuation of motion preservation. Revision of failed hydrogel implants to arthrodesis can be performed through various first metatarsophalangeal fusion techniques or, as introduced in this review, with a fourth-generation threaded hemiarthroplasty. Excellent 10-year results with primary hemiarthroplasty supported its use as revision procedure in 2 failed polyvinyl-alcohol implantations, preserving arthrodesis for future salvage if necessary. The purpose of this report was to outline a motion-preserving technique after failed hydrogel implants and describe preoperative, intraoperative, and postoperative considerations for optimized outcomes.

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.

Hemiarthroplasty Versus Total Joint Arthroplasty for Hallux Rigidus: A Systematic Review and Meta-analysis

BACKGROUND

When surgery is indicated for hallux rigidus, toe arthroplasty is an alternative procedure to arthrodesis for patients who wish to preserve toe range of motion. Our study investigated midterm outcomes of first metatarsophalangeal joint (MTPJ) arthroplasty in an effort to discern whether or not partial or total joint replacement confers benefit in these patients.

METHODS

A systematic review of MTPJ arthroplasty was performed for the years 2000 to 2017. A Forest plot was created comparing preoperative and postoperative American Orthopedic Foot and Ankle Score (AOFAS), Visual Analogue Scale (VAS), and range of motion (ROM) results for both hemitoe and total-toe arthroplasty. Statistical analysis was performed.

RESULTS

Mean postoperative AOFAS scores in patients undergoing hemiarthroplasty improved by 50.7 points (95% CI = 48.5, 52.8), whereas the mean AOFAS score improvement in total joint arthroplasty patients was 40.6 points (95% CI = 38.5, 42.8). VAS outcomes were comparable. Mean postoperative MTPJ ROM improved by 43.0° (95% CI = 39.3°, 46.6°) in hemitoe patients, which exceeded the mean ROM improvement of 32.5° (95% CI = 29.9°, 35.1°) found in total joint arthroplasty cases. A meta-analysis revealed no significant difference.

CONCLUSION

Hemisurface implants in MTPJ arthroplasty may improve postoperative AOFAS and ROM results to a greater extent than total-toe devices.

LEVEL OF EVIDENCE

Level IV: Systematic review.

Outcomes Following Interposition Arthroplasty of the First Metatarsophalangeal Joint for the Treatment of Hallux Rigidus: A Systematic Review

Background:

Interposition arthroplasty of the first MTP joint has recently experienced renewed interest as a treatment for hallux rigidus. The purpose of this study was to systematically review the rapidly expanding literature on PRO following interposition arthroplasty of the first MTP joint.

Methods:

PubMed Central, Embase, and the Cochrane Central Register for Controlled Trials (CENTRAL) were searched. Inclusion criteria included length of time to follow-up, number of patients, outcome measure, and use of allogeneic or autogenous soft tissue or a synthetic matrix as interposition.

Results:

20 studies were included in the review, comprising 498 patients and 539 feet with mean time to follow-up of 4.5 years. The most common substance used for interposition in the included studies was autogenous first MTPJ capsular tissue, a technique reported on in 12 (60.0%) of the included articles. In studies reporting preoperative and postoperative outcomes by way of a standardized outcome scoring system, mean group improvements exceed minimal clinically important differences in the majority of studies. Eighty-five percent of the studies included in this review were of Level IV quality evidence, and of this subset of studies, 70.6% were of a retrospective nature. Progression to further surgery was observed in 3.8% of toes. The most common complication reported was transfer metatarsalgia of 1 or more lesser toes, observed in up to 57.9% of patients in one study.

Conclusion:

Interposition arthroplasty appears to be a viable option for the treatment of moderate to severe hallux rigidus in patients looking to salvage motion through the first metatarsophalangeal joint. A wide array of autogenous, allogeneic, and synthetic implant materials have surfaced in recent years, but long-term follow-up and prospective, comparative study designs with low risk of bias are limited.

Level of Evidence:

Level IV, systematic review of Level III-IV studies

Long-Term Results of Surgical Treatment of Valenti Procedures for Hallux Rigidus: A Minimum Ten-Year Follow-Up Retrospective Study

Few studies reporting long-term results of surgical treatment of hallux rigidus have been published. The aim of this study is to assess the clinical outcome of Valenti procedures in a series of patients with hallux limitus/rigidus with a minimum 10-year follow-up time. We retrospectively evaluated 38 patients (40 feet) who underwent a Valenti procedure with a mean follow-up of 132 ± 19.6 (range 114 to 184) months. All patients were clinically reassessed on the basis of the evaluation of pain (visual analogue scale), function (American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale Assessment and Foot & Ankle Disability Index), and subjective satisfaction. The scores before and after treatment, obtained from clinical recordings and clinical evaluation during the last follow-up visits, were compared. We found significant improvement of the mean values of the visual analogue score (p < .0001), Foot & Ankle Disability Index (p < .0001), and American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale Assessment (p < .0001) during the latest follow-up visits. The results suggest that the Valenti technique represents a safe, reproducible surgical procedure that allows satisfying long-term results. The few reported complications were essentially the progressive worsening of the joint stiffness, but no sesamoiditis, metatarsal overload, secondary surgeries, or failures were documented.

Current Concepts Review

Arthritis of the first metatarsophalangeal (MTP) joint, hallux rigid, is a common and disabling source of foot pain in the adult population. Hallux rigidus is characterized by diseased cartilage and large, periarticular osteophytes that result in a stiff, painful joint. Activity modification, sensible shoes, orthotics, anti-inflammatory medications and occasional intra-articular steroid injections can be attempted to alleviate the discomfort associated with hallux rigidus. A number of surgical options exist for the treatment of recalcitrant hallux rigidus. Cheilectomy is a useful treatment for dorsal impingement pain seen in mild hallux rigidus. A new polyvinyl alcohol hemi-arthroplasty implant has shown promising early and midterm results in the treatment of advanced hallux rigidus; however, arthrodesis of the first MTP joint remains the gold standard treatment for advanced hallux rigidus because of unpredictable outcomes after early-generation joint replacement implants.

Clinical and Radiologic Outcomes of Metatarsophalangeal Hemiarthroplasty: A Review of 12 Consecutive Cases

This study examined function, pain, satisfaction, and radiologic outcomes among patients treated with first metatarsophalangeal hemiarthroplasty. Patients were invited to participate in an outcome study conducted with questionnaires on subjective and objective outcomes and clinical and radiographic follow-up. A total of 12 patients (12 feet; mean patient age, 58.8±12.3 years) agreed to participate. Mean follow-up was 22.3±19.8 months. Of these patients, 7 were satisfied with the postoperative result. The mean visual analog scale pain score decreased significantly from 7.0±2.3 preoperatively to 3.5±3.3 postoperatively (P=.024). Mean passive range of motion of the first metatarsophalangeal joint was 32°±10° preoperatively, 93°±18° intraoperatively after implantation of the prosthesis and closure of the joint capsule, and 38°±19° at final follow-up (P=.26). Mean American Orthopaedic Foot and Ankle Society forefoot score increased significantly from 47.3±14.7 preoperatively to 71.8±15.2 at last follow-up (P=.033). During the follow-up period, 6 patients underwent additional procedures: 5 therapeutic joint infiltrations and 1 arthrodesis. No patients had radiologic loosening of the implant at final follow-up. Osseous dysplastic changes at the base of the proximal phalanx were noted among 6 of 11 patients (12 total cases) at final follow-up. Although first metatarsophalangeal hemiarthroplasty provided significant pain reduction at mean follow-up of 22.3 months, range of motion of the first metatarsophalangeal joint was not restored to anticipated levels and there were high rates of patient dissatisfaction and secondary interventions. [Orthopedics. 2018; 41(1):e64-e69.].

Hallux rigidus: How do I approach it?

Hallux rigidus is a degenerative disease of the first metatarsalphalangeal (MTP) joint and affects 2.5% of people over age 50. Dorsal osteophytes and narrowed joint space leads to debilitating pain and limited range of motion. Altered gait mechanics often ensued as 119% of the body force transmit through the 1^st MTP joint during gait cycle. Precise etiology remains under debate with trauma being often cited in the literature. Hallux valgus interphalangeus, female gender, inflammatory and metabolic conditions have all been identified as associative factors. Clinical symptoms, physical exam and radiographic evidence are important in assessing and grading the disease. Non-operative managements including nonsteroidal antiinflammatory drugs, intra-articular injections, shoe modification, activity modification and physical therapy, should always be attempted for all hallux rigidus patients. The goal of surgery is to relieve pain, maintain stability of the first MTP joint, and improve function and quality of life. Operative treatments can be divided into joint-sparing vs joint-sacrificing. Cheilectomy and moberg osteotomy are examples of joint-sparing techniques that have demonstrated great success in early stages of hallux rigidus. Arthrodesis is a joint-sacrificing procedure that has been the gold standard for advanced hallux rigidus. Other newer procedures such as implant arthroplasty, interpositional arthroplasty and arthroscopy, have demonstrated promising early patient outcomes. However, future studies are still needed to validate its long-term efficacy and safety. The choice of procedure should be based on the condition of the joint, patient’s goal and expectations, and surgeon’s experience with the technique.

Midterm Outcomes of Polyvinyl Alcohol Hydrogel Hemiarthroplasty of the First Metatarsophalangeal Joint in Advanced Hallux Rigidus

BACKGROUND

Hallux rigidus is the most common arthritic condition of the foot. A randomized clinical trial of first metatarsophalangeal (MTP) joint hemiarthroplasty with a polyvinyl alcohol (PVA) hydrogel implant (Cartiva) demonstrated pain relief and functional outcomes equivalent to first MTP arthrodesis at 2 years postoperation, with no cases of implant fragmentation, wear, or bone loss. We prospectively determined 5-year outcomes of first MTP hemiarthroplasty with the PVA hydrogel implant.

METHODS

Patients who underwent first PVA hydrogel MTP hemiarthroplasty in the previously reported trial were evaluated at 5 years postoperatively. Patients underwent physical examination and radiographic evaluation and completed a pain VAS, the Short-Form-36 (SF-36), and the Foot and Ankle Ability Measure (FAAM) sports subscale and activities of daily living (ADL) subscale. At the time of this study, 29 patients had reached 5 years' follow-up. Two were lost to follow-up, leaving 27 patients with mean age 56.1 (range, 40.1-71.9) years. Mean follow-up was 5.4 (range, 4.9-6.4) years.

RESULTS

Postoperative active MTP natural joint dorsiflexion and peak MTP dorsiflexion were mean 18.2 (range, 10.0-30.0) and 29.7 (range, 10.0-45.0) degrees, respectively. Pain VAS, SF-36 PCS, FAAM ADL, and FAAM Sports scores demonstrated clinically and statistically significant improvements. Radiographically, no patient demonstrated changes in implant position, implant loosening or subsidence, or implant wear. One implant was removed because of persistent pain and converted to fusion 2 years postoperation.

CONCLUSION

Five years following first MTP hemiarthroplasty with a PVA hydrogel implant, functional outcomes improved significantly, pain was reduced significantly, and the implant demonstrated excellent survivorship.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Mid-term functional outcome of a total arthroplasty of the first metatarsophalangeal joint

BACKGROUND

Arthroplasty of the first metatarsophalangeal joint is an alternative treatment option for end-stage hallux rigidus to the current gold standard of arthrodesis. The aim of this study was to investigate the mid-term functional outcome of an anatomically shaped prosthesis for the first metatarsophalangeal joint using pedobarography.

METHODS

Ten patients (12 affected feet; age at surgery: 62.1 (SD: 7.2) years) were investigated preoperatively and 52 (SD: 3) months postoperatively using pedobarography (EMED, novel GmbH, Munich, Germany). Two patients were excluded at follow-up because their prosthesis was converted to an arthrodesis. Peak force and plantar pressure under the five metatarsal heads and the hallux were analyzed and correlated with the clinical outcome (pain, American Orthopaedic Foot and Ankle Society forefoot score and radiographic maximum first metatarsophalangeal dorsiflexion). Differences between pre- and postoperative data were analyzed using paired t-tests (alpha=0.05).

FINDINGS

Postoperatively, forefoot peak forces under the fourth (+40.9%; P=0.018) and fifth metatarsal (+54.9%; P=0.037) and plantar pressures under the fifth metatarsal (+38.7%; P=0.027) increased significantly, while peak plantar pressures and forces under the hindfoot, medial forefoot and hallux did not change. While maximum passive dorsiflexion was not significantly greater at the 4-year follow-up compared to preoperatively, overall greater passive dorsiflexion was associated with higher first metatarsal peak pressure.

INTERPRETATION

Despite of patients reporting less pain, the functional results indicate an altered and potentially non-physiological postoperative gait pattern with a lateralization of the load during walking, especially in patients with limited passive dorsiflexion.