Correlation of Hallux Rigidus Grade With Motion, VAS Pain, Intraoperative Cartilage Loss, and Treatment Success for First MTP Joint Arthrodesis and Synthetic Cartilage Implant

Cartiva interpositional arthroplasty versus arthrodesis in the treatment of Hallux rigidus: A retrospective comparative study with mean 2 year follow up

BACKGROUND

Hallux rigidus is a common condition characterised by first metatarsophalangeal joint (MTPJ) degeneration, pain and limited range of motion (ROM). The gold standard surgical treatment is arthrodesis, providing good pain relief, but sacrifices ROM. The Cartiva synthetic cartilage implant (SCI) has been utilised as an interpositional arthroplasty, aiming to reduce pain whilst preserving range of motion. Current evidence for Cartiva SCI is limited. The aim was to evaluate the clinical outcomes of Cartiva SCI compared to arthrodesis undertaken in our centre.

METHODS

A retrospective cohort study was conducted, enrolling all adult patients who underwent primary first MTPJ SCI arthroplasty or arthrodesis for the treatment hallux rigidus. The primary outcome was a validated patient-reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire (MOXFQ). Secondary outcomes included EQ-5D, complication rates, VAS Pain and FAAM (ADL).

RESULTS

Between 2017 and 2020 there were 33 cases divided into two groups (17 Cartiva SCI, 16 arthrodesis, mean age 59.0 ± 9.9 years) with a mean follow up of 2.3 years. There was no statistically significant difference in any of the MOXFQ, EQ-5D, VAS Pain or FAAM (ADL) outcome scores between the Arthrodesis and SCI groups (p > 0.05). The mean MOXFQ Index score was 7.2 ± 6.4 for the SCI group and 3.9 ± 5.8 for the Arthrodesis group at final follow up (p = 0.15). Although complications were high in both groups, the overall hallux reoperation rate was 29.4 % in the SCI cohort and 0.0 % for arthrodesis.

CONCLUSION

This retrospective comparative study found no significant superiority of Cartiva SCI over arthrodesis in terms of PROMs. Due to the higher rate of further surgical intervention in the SCI cohort, we recommend arthrodesis as the preferred surgical option for hallux rigidus.

LEVEL OF EVIDENCE

III.

Polyvinyl alcohol hydrogel implant for the treatment of hallux rigidus is associated with a high complication rate and moderate failure rate at short-term follow-up: a systematic review

PURPOSE

Moderate-to-severe hallux rigidus is a debilitating pathology that is optimally treated with surgical intervention. Arthrodesis produces reliable clinical outcomes but is limited by restriction in 1st metatarsophalangeal joint range of motion. The advent of polyvinyl alcohol hydrogel (PVA) implants have produced early promise based on initial trials, but more recent studies have called into question the efficacy of this procedure. The purpose of this systematic review was to evaluate the clinical and radiological outcomes following the use of PVA for hallux rigidus.

METHODS

The MEDLINE, EMBASE and Cochrane library databases were systematically reviewed using the preferred reporting items for systematic reviews and meta-analyses guidelines. 18 studies were included.

RESULTS

In total, 1349 patients (1367 feet) underwent PVA at a weighted mean follow-up of 24.1 ± 11.1 months. There were 168 patients (169 feet) included in the cheilectomy cohort and 322 patients (322 feet) included in the arthrodesis cohort. All 3 cohorts produced comparable improvements in subjective clinical outcomes. Postoperative imaging findings in the PVA cohort included joint space narrowing, peri-implant fluid, peri-implant edema and erosion of the proximal phalanx. The complication rate in the PVA cohort, cheilectomy cohort and arthrodesis cohort was 27.9%, 11.8% and 24.1%, respectively. The failure rates in the PVA cohort, cheilectomy cohort and arthrodesis cohort was 14.8%, 0.3% and 9.0%, respectively.

CONCLUSION

This systematic review demonstrated that PVA produced a high complication rate (27.9%) together with concerning postoperative imaging findings at short-term follow-up. In addition, a moderate failure rate (14.8%) and secondary surgical procedure rate (9.5%) was noted for the PVA cohort. The findings of this review calls into question the efficacy and safety of PVA for the treatment of hallux rigidus.

LEVEL OF EVIDENCE

IV.

Patient Satisfaction Following Hallux Rigidus Treatment With a Synthetic Cartilage Implant

BACKGROUND

There remains no clear consensus on patient satisfaction and functional outcomes following synthetic cartilage implant (SCI) implantation for hallux rigidus. The purpose of this study was to review our experience at a single academic institution using an SCI for treatment of hallux rigidus.

METHODS

A retrospective review was performed of patients who underwent the SCI procedure for treatment of hallux rigidus between January 2017 and May 2019. Functional outcomes were evaluated using Patient-Reported Outcome Measures Informational System (PROMIS)-10 scores as well as a survey investigating patient satisfaction, self-reported clinical improvement, and changes in sporting ability. Patients were divided into satisfied versus unsatisfied subgroups, and between-group differences in preoperative variables and complications were reviewed. A total of 90 patients (96 implants) were included in this study. The mean follow-up time was 26.4 months.

RESULTS

In all, 81.2% of patients reported that their foot was "much improved" (55.2%) or "improved" (26.0%) since undergoing the SCI procedure, whereas a slightly lower percentage, 74.0%, stated that they were "extremely satisfied" (41.7%) or "satisfied" (32.3%) at final follow-up. Patients were able to tolerate higher impact sporting activities after the procedure, and 75.0% of patients stated they would have the same surgery again. PROMIS-10 T-scores averaged 54.2 points for physical health and 57.4 points for mental health. Only 2.1% of patients required conversion to arthrodesis. Significant differences between the satisfied versus unsatisfied subgroups were found in preoperative corticosteroid injection use (21.1% vs 41.1%, respectively; P = .029) and preoperative VAS pain score (8.2 vs 7.1, respectively; P = .036).

CONCLUSION

The SCI procedure can be a viable option for treating hallux rigidus with high satisfaction overall, increased sport activity levels, and a very low revision rate. However, maximizing patient satisfaction may require more careful consideration of preoperative prognosticators and extensive patient counseling to ensure realistic expectations for recovery time and individual outcome.

LEVEL OF EVIDENCE

Level IV: Retrospective case series.

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.

Synthetic cartilage implant hemiarthroplasty versus cheilectomy for the treatment of hallux rigidus

Degenerative arthritis of the first metatarsophalangeal joint, hallux rigidus, is the most common type of arthritis of the foot, affecting nearly 2.5% of the population over the age of 50. Hallux rigidus can be treated surgically with either Cheilectomy or Synthetic cartilage implant (SCI) hemiarthroplasty. The purpose of this study is to compare outcomes from a single institution on the treatment of hallux rigidus using cheilectomy and SCI hemiarthroplasty. Between 2012 and 2020, 49 patients underwent either a SCI (Polyvinyl alcohol hydrogels) hemiarthroplasty or Cheilectomy for the treatment of hallux rigidus. Functional scores were assessed pre and postoperatively using the American Orthopedic Foot and Ankle scoring System (AOFAS) and the Foot and Ankle Outcome Score survey (FAOS). Plantar and Dorsal range of motion was also assessed pre and postoperatively. Outcomes, complications, and any reoperations were recorded for all patients. Mean pre-op AOFAS for Cheilectomy and SCI were 49.6 and 54.8, respectively, compared to 85.3 and 89.7, respectively, after surgery (p value < 0.05). Mean pre-op Dorsal range of motion (ROM) for Cheilectomy and SCI were 24.0 and 26.0 degrees, respectively, compared to 38.0 and 42.6 degrees, respectively, after surgery (p value < 0.05). SCI hemiarthroplasty patients had higher AOFAS and dorsal ROM at the latest follow up (p value < 0.05). Synthetic cartilage implant (SCI) hemiarthroplasty and cheilectomy both offer promising results and remain viable treatment options to decrease pain, improve function, and maintain motion for hallux rigidus. SCI hemiarthroplasty may offer superior range of motion and functional outcomes than cheilectomy for hallux rigidus. LEVEL OF CLINICAL EVIDENCE: 3.

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.

Autologous matrix induced chondrogenesis plus peripheral blood concentrate (AMIC+PBC) in chondral defects of the first metatarsophalangeal joint - 5-year follow-up

BACKGROUND

The aim of the study was to assess the 5-year-follow-up (5FU) after Autologous Matrix Induced Chondrogenesis plus Peripheral Blood Concentrate (AMIC+PBC) in chondral defects at the first metatarsophalangeal joint (MTP1).

MATERIAL AND METHODS

In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral lesion at MTP1 that were treated with AMIC+PBC from July 17, 2016 to May 31, 2017 were included. Size and location of the chondral lesions, the Visual-Analogue-Scale Foot and Ankle (VAS FA) and the EFAS Score before treatment and at 5FU were analysed and compared with previous 2-year-follow-up (2FU). Peripheral Blood Concentrate (PBC) was used to impregnate a collagen I/III matrix (Chondro-Gide, Wolhusen, Switzerland) that was fixed into the chondral lesion with fibrin glue.

RESULTS

One hundred and ninety-eight patients with 238 chondral defects were included. In 21 % of patients no deformities in the forefoot were registered. The average degree of osteoarthritis was 2.2. The chondral defect size was 1.0 cm² on average. The most common location was metatarsal dorsal (33 %), and in most patients one defect was registered (74 %). Corrective osteotomy of the first metatarsal was performed in 79 %. 176 (89 %)/164 (83 %) patients completed 2FU/5FU. VAS FA/EFAS Score were preoperatively 46.8/11.9 and improved to 74.1/17.1 at 2FU and 75.0/17.3 at 5FU on average. No parameter significantly differed between 2FU and 5FU.

CONCLUSIONS

AMIC+PBC as treatment for chondral defects at MTP1 as part of joint preserving surgery led to improved and high validated outcome scores at 2FU and 5FU. The results between 2FU and 5FU did not differ.

One-year Follow-Up Results with Hydrogel Implant in Therapy of Hallux Rigidus: Case Series with 44 Patients

BACKGROUND

The Cartiva implant (CI) is being increasingly used in the surgical therapy of hallux rigidus. Despite a growing number of studies, numerous questions regarding patient selection remain unanswered.

PATIENTS AND METHODS

As part of a retrospective case series with prospective follow-up (average follow-up period: 12 months), a total of 44 patients (male/female = 16/28; mean age at the time of surgery: 55.4 years) with 44 CI were analysed (VAS, EFAS-, AOFAS-score). Using a correlation analysis and a machine learning algorithm, risk factors for therapy failure were investigated.

RESULTS

The overall survival rate of the CI was 93% at 12 months. The VAS, EFAS and AOFAS scores showed a significant improvement in comparison to the preoperative condition. The mobility of the metatarsophalangeal joint showed no increase. Patients with a medium osteoarthritis grade and a medium level of clinical restraint showed the greatest improvement in relation to their preoperative condition.

CONCLUSION

The CI can be seen as an effective therapy for hallux rigidus. Nonetheless, realistic patient expectations must be communicated.

Adverse Events Related to Cartiva Hemiarthroplasty of First Metatarsal: An Analysis of Reports to the United States Food and Drug Administration

Background: The results supporting Cartiva, a synthetic cartilage implant (Wright Medical) in hallux rigidus have come from limited institutions creating observational bias. Complications experienced in community centers are not routinely included in the published literature. To look at a broader range of potential complications, we reviewed the United States Food and Drug Administration's (FDA) voluntary device database and compared that data with published literature. Methods: The Manufacturer and User Facility Device Experience (MAUDE) database of the FDA was retrospectively reviewed between July 2016 and October 2019 using the product code: PNW, assigned for Cartiva. Results: A total of 49 events have been reported and implant subsidence was the most common with 16 reports. Others include fragmentation (9), infection (4), bone erosion (3), foreign body reaction (1) and unspecified (16). Thirty-five events mentioned further surgeries at a mean interval of 4.75 months. Conclusions: The analysis of the MAUDE database disclosed certain device-related dysfunctions that have been underreported in the published literature. Because of the voluntary nature of reporting, the true incidence of each complication is unknown with this data representing a baseline. The MAUDE database could be further strengthened by a more robust reporting mechanism or mandatory reporting of device-related complications.Levels of Evidence: Level IV: Case series from large database analysis.

Management of Periprosthetic Polyvinyl Alcohol Synthetic Cartilage Implant Infection with Staged First Metatarsophalangeal Joint Arthrodesis

Surgical management of hallux rigidus using a polyvinyl alcohol synthetic cartilage implant has gained popularity among foot and ankle surgeons. Although uncommon, appropriate diagnosis and management of a periprosthetic implant infection is critical in limiting morbidity. We present a case report and staged technique for converting a first metatarsal synthetic cartilage hemiarthroplasty to arthrodesis in the setting of a periprosthetic joint infection.

Early Failure of a Polyvinyl Alcohol Hydrogel Implant With Osteolysis and Foreign Body Reactions in an Ovine Model of Cartilage Repair

BACKGROUND

Hemiarthroplasty using a polyvinyl alcohol (PVA) hydrogel synthetic implant has been suggested as a good alternative to arthrodesis for the treatment of hallux rigidus. However, failure rates as high as 20% have been recorded.

PURPOSE

To characterize the pathological processes in bone, cartilage, and the synovial membrane after PVA hemiarthroplasty in an ovine model with 6 months of follow-up.

STUDY DESIGN

Controlled laboratory study.

METHODS

A unilateral osteochondral defect (8-mm diameter × 10-mm depth) was made in the medial femoral condyle in 6 sheep. Animals were randomized to receive a PVA implant (n = 4) or to have an empty defect (n = 2) and were monitored for 6 months. Patellofemoral radiographs were obtained at monthly intervals, and quantitative computed tomography was performed at the end of the study. After death, the joints were macroscopically evaluated and scored. Osteochondral and synovial membrane histological findings were assessed using modified Osteoarthritis Research Society International (OARSI) and aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) scoring systems. Immunohistochemistry using Iba1 was performed to evaluate activated macrophage infiltration.

RESULTS

Overall, 2 sheep with PVA implants were euthanized at 1 and 5 months because of uncontrollable pain and lameness (failed implants). Quantitative computed tomography showed that sheep with failed implants had 2.1-fold more osteolysis than those with successful implants. The sheep with failed implants had osteoarthritis with extensive glycosaminoglycan loss and cartilage fibrillation of the condyle and opposing tibial surface on histological examination. A foreign body reaction with severe chronic lymphoplasmacytic and granulomatous inflammation with giant cells was detected surrounding the implant. The synovial membrane ALVAL score was 9 of 19 and 14 of 19 in failed implants with synovial hyperplasia and lymphoplasmacytic and macrophage infiltration. In contrast, the synovial membrane in successful implants and empty defects was normal (ALVAL score = 0/19). Immunolabeling for Iba1 in failed implants confirmed extensive and dense macrophage infiltration within the condyle and synovial membrane, with the highest immunoreactive score (9/9).

CONCLUSION

PVA hydrogel implants had a 50% failure rate with uncontrollable pain, severe osteolysis, inflammation, and foreign body reactions.

CLINICAL RELEVANCE

The failure rate and pathological characteristics of the PVA implants suggest that their use should not be continued in human patients without further in vivo safety studies.

Physical Function and Pain Interference Levels of Hallux Rigidus Patients Before and After Synthetic Cartilage Implant vs Arthrodesis Surgery

BACKGROUND

Hallux rigidus is a common and painful degenerative condition of the great toe limiting a patient's physical function and quality of life. The purpose of this study was to investigate pre- and postoperative physical function (PF) and pain interference (PI) levels of patients undergoing synthetic cartilage implant hemiarthroplasty (SCI) vs arthrodesis (AD) for treatment of hallux rigidus using the Patient-Reported Outcomes Measurement Information System (PROMIS).

METHODS

PROMIS PF and PI t scores were analyzed for patients who underwent either SCI or AD. Postoperative final PROMIS t scores were obtained via phone survey. Linear mixed model analysis was used to assess differences in PF and PI at each follow-up point. Final follow-up scores were analyzed using independent sample t tests.

RESULTS

Total 181 (59 SCI, 122 AD) operatively managed patients were included for analysis of PROMIS scores. Final phone survey was performed at a minimum of 14 (mean 33, range, 14-59) months postoperatively, with 101 patients (40 SCI, 61 AD) successfully contacted. The mean final follow-up was significantly different for SCI and AD: 27 vs 38 months, respectively (P < .01). The mean age of the SCI cohort was lower than the AD cohort (57.5 vs 61.5 years old, P = .01). Average PF t scores were higher in the SCI cohort at baseline (47.1 and 43.9, respectively, P = .01) and at final follow-up (51.4 vs 45.9, respectively, P < .01). A main effect of superior improvement in PF was noted in the SCI group (+4.3) vs the AD group (+2) across time intervals (P < .01). PI t scores were similar between the 2 procedures across time points.

CONCLUSION

The SCI cohort reported slightly superior PF t scores preoperatively and at most follow-up time points compared with the arthrodesis group. No differences were found for PI or complication rates between the 2 treatment groups during this study time frame.

LEVEL OF EVIDENCE

Level IV, case series.

Treatment of hallux rigidus (HARD trial): study protocol of a prospective, randomised, controlled trial of arthrodesis versus watchful waiting in the treatment of a painful osteoarthritic first metatarsophalangeal joint

INTRODUCTION

Hallux rigidus is a common problem of pain and stiffness of the first metatarsophalangeal joint (MTPJ) caused mainly by degenerative osteoarthritis. Several operative techniques have been introduced for the treatment of this condition without high-quality evidence comparing surgical to non-surgical care. In this trial, the most common surgical procedure, arthrodesis, will be compared with watchful waiting in the management of hallux rigidus.

METHODS AND ANALYSIS

Ninety patients (40 years or older) with symptomatic first MTPJ osteoarthritis will be randomised to arthrodesis or watchful waiting in a ratio of 1:1. The primary outcome will be pain during walking, assessed using the 0-10 Numerical Rating Scale (NRS) at 1 year after randomisation. The secondary outcomes will be pain at rest (NRS), physical function (Manchester-Oxford Foot Questionnaire), patient satisfaction in terms of the patient-acceptable symptom state, health-related quality of life (EQ-5D-5L), activity level (The Foot and Ankle Ability Measure Sports subscale), use of analgesics or orthoses and the rate of complications. Our null hypothesis is that there will be no difference equal to or greater than the minimal important difference of the primary outcome measure between arthrodesis and watchful waiting. Our primary analysis follows an intention-to-treat principle.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Ethics Committee of Helsinki and Uusimaa Hospital District, Finland. Written informed consent will be obtained from all the participants. We will disseminate the findings of this study through peer-reviewed publications and conference presentations.

PROTOCOL VERSION

21 June 2021 V.2.0.

TRIAL REGISTRATION NUMBER

NCT04590313.

The Use of a Synthetic Cartilage Implant for Hallux Rigidus: A Systematic Review

Background. Hallux rigidus is a common pathology afflicting the foot, for which various joint salvage techniques have been described with a multitude of different implants. Recently, a synthetic cartilage implant composed of polyvinyl alcohol (PVA) received FDA premarket approval for the treatment of arthritis of the great toe. The purpose of this study was to (1) systematically review the clinical evidence supporting the use of a PVA implant in hallux rigidus and (2) determine the strength of the recommendation that can be made supporting the use of a PVA implant by evaluating the quality of evidence available. Methods. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Using the terms "cartiva OR polyvinyl alcohol OR synthetic cartilage OR hemiarthroplasty AND hallux rigidus OR great toe arthritis OR first toe arthritis" we searched the PubMed/Medline database. The quality of the included studies was evaluated using the American Academy of Orthopaedic Surgeons Clinical Practice Guideline and Systematic Review Methodology. Results. Seven studies met the inclusion criteria, 6 of these were derived from a single randomized controlled trial. A moderate recommendation can be given for the use of a PVA implant for hallux rigidus based on short-term outcomes. A limited recommendation can be given for the use of a PVA implant for hallux rigidus based on mid-term outcomes. Conclusion. There are limited studies available detailing the outcomes of a PVA implant for hallux rigidus; however, the results that are available demonstrate a high level of evidence.Levels of Evidence: Level I: Systematic review.

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.

Early Catastrophic Failure of a Synthetic Cartilage Implant for Hallux Rigidus

Hallux rigidus is a common arthritic disorder of the foot. Surgical treatments are varied, from isolated cheilectomy to arthrodesis. A synthetic cartilage implant has been embraced recently as a joint-sparing alternative to arthrodesis, with good early and midterm outcomes. However, early clinical failures have been described relating to implant subsidence. This case report focuses on another mode of failure consisting of early catastrophic wear resulting in conversion to a lengthening arthrodesis at short-term follow-up.Levels of Evidence: Level V.

Effect of Age on Complication Rates and Outcomes Following First Metatarsophalangeal Arthrodesis for Hallux Rigidus

BACKGROUND

Hallux rigidus is one of the most common toe pathologies in patients greater than 50 years old. Although metatarsophalangeal (MTP) arthrodesis is used to improve pain and function, older patients are often considered to be higher-risk operative candidates. There are minimal data on outcomes of MTP fusion and no studies comparing outcomes between geriatric and younger patients.

METHODS

This is a single-center, prospective study of all patients who underwent MTP fusion between August 1, 2015, and July 1, 2018. Patient-reported outcomes were assessed using the Short Form Health Survey (SF-36), Life-Space Assessment survey (LSA), and visual analog scale (VAS) for pain administered preoperatively as well as 6 months and 1 year postoperatively. Baseline characteristics and operative outcomes were collected from the electronic medical record. Clinical and patient-reported outcomes were compared between patients <65 years old and ≥65 years old. Of 143 included patients, 79 were in the younger group (mean of 56.5 years) and 64 were in the older group (mean of 72.0 years).

RESULTS

Compared with the younger group, the older group was more predominantly female (95.3% older group, 77.2% younger group, P = .002). More patients in the older group had hypertension (73.4% older group, 50.6% younger group, P = .005) and coronary artery disease (9.4% older group, 0.0% younger group, P = .005). Both age groups had similar rates of postoperative wound complications requiring operative irrigation and debridement, deep vein thrombosis, deformity recurrence, and revision surgery. No differences were detected in SF-36, LSA, and VAS surveys administered at baseline, 6 months postoperation, or 1 year postoperation between younger and older patients.

CONCLUSION

Despite more comorbidities, older patients had similar rates of postoperative complications and reported similar outcomes for pain, function, and mobility following MTP fusion. These findings support increased implementation of MTP fusion surgery for older patients with hallux rigidus.

LEVEL OF EVIDENCE

Level II, prospective cohort.

Comparison Between Polyvinyl Alcohol Implant and Cheilectomy With Moberg Osteotomy for Hallux Rigidus

BACKGROUND

In 2016, the US Food and Drug Administration (FDA) approved the use of a polyvinyl alcohol (PVA) hydrogel implant for the surgical management of hallux rigidus. Though recent studies have evaluated the safety and efficacy of the implant, no study has compared outcomes following PVA implantation with those following traditional joint-preserving procedures for hallux rigidus, such as cheilectomy with Moberg osteotomy. The purpose of this study was to compare clinical and patient-reported outcomes for patients undergoing cheilectomy and Moberg osteotomy, with or without PVA implant, at a single multisurgeon academic center. Our hypothesis was that the addition of the PVA implant would result in superior clinical and patient-reported outcomes.

METHODS

In total, 166 patients were identified who underwent cheilectomy and Moberg osteotomy with (PVACM; n = 72) or without (CM; n = 94) a PVA implant between January 2016 and December 2018 by 1 of 8 foot and ankle fellowship-trained orthopedic surgeons at our institution. Of these patients, 60 PVACM and 73 CM patients had both baseline and minimum 1-year postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores. The average time to survey follow-up was 14.5 months for PVACM patients and 15.6 months for CM patients. Retrospective chart review was performed to assess the incidence of postoperative complications and reoperations, with an average clinical follow-up of 27.7 (range, 16.0-46.4) months for PVACM patients and 36.6 (range, 18.6-47.8) months for CM patients.

RESULTS

Both PVACM and CM cohorts demonstrated significant improvement in the PROMIS Physical Function, Pain Interference, Pain Intensity, and Global Physical Health domains when comparing preoperative and postoperative scores within each group (P < .01). When comparing scores between the PVACM and CM cohorts, preoperative scores were similar, while CM patients demonstrated significantly higher postoperative Physical Function (51.8 ± 8.7 vs 48.8 ± 8.0; P = .04) and significantly lower Pain Intensity (39.9 ± 8.3 vs 43.4 ± 8.7; P = .02) scores. The pre- to postoperative change in Physical Function was also significantly greater for CM patients (7.1 ± 8.5 vs 3.6 ± 6.2; P = .011). In the PVACM group, there were 3 revisions (5%), 1 reimplantation, 1 conversion to arthrodesis, and 1 revision to correct hyperdorsiflexion. In the CM group, there was 1 revision (1.4%), a conversion to arthrodesis (P = .21). Other postoperative complications included persistent pain (7 out of 60 PVACM patients [11.7%] and 8 out of 73 CM patients [11.0%]; P = .90) and infection in 3 PVACM patients (5%) and no CM patients (P = .05).

CONCLUSION

Though our results generally support the safety and utility of the PVA implant as previously established by the clinical trial, at 1 to 2 years of follow-up, CM without a PVA implant may provide equivalent or better relief compared with a PVACM procedure, while avoiding potential risks associated with the implant.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Clinical Outcomes of the Polyvinyl Alcohol (PVA) Hydrogel Implant for Hallux Rigidus

BACKGROUND

Hallux rigidus is a common arthritic condition that has been addressed surgically with a range of techniques, from an isolated cheilectomy to first metatarsophalangeal (MTP) joint fusion. Recently, hemiarthroplasty with polyvinyl alcohol (PVA) hydrogel implant has been used as an alternative treatment to relieve pain while preserving motion of the first MTP joint. We retrospectively reviewed patient-reported outcome scores and clinical outcomes for patients treated for hallux rigidus with PVA hydrogel implant at an academic, multisurgeon center.

METHODS

A total of 103 patients who underwent first MTP hemiarthroplasty with PVA hydrogel implant between January 2017 and October 2018 were retrospectively reviewed (average, 26.2 months). Eight surgeons were represented. Baseline Patient-Reported Outcomes Measurement Information System (PROMIS) scores for the Physical Function, Pain Interference, Pain Intensity, Global Physical Health, Global Mental Health, and Depression domains were collected prospectively and compared with PROMIS scores collected at a minimum of 1 year postoperatively (average, 13.9 months). Seventy-three patients had both preoperative and postoperative scores. Ten of these patients had undergone a prior procedure of the first MTP, and 52 underwent concurrent Moberg osteotomy at the time of PVA hydrogel implantation.

RESULTS

For patients with baseline and postoperative PROMIS scores, significant pre- to postoperative improvement was detected for the Physical Function, Pain Interference, Pain Intensity, and Global Physical Health domains (P < .05). Patients who had undergone a prior procedure of the first MTP had significantly higher postoperative Pain Intensity scores compared with those who did not undergo a prior procedure. Patients undergoing concurrent Moberg osteotomy had significantly lower postoperative Pain Interference and Pain Intensity scores compared with those who did not undergo a Moberg. Two patients underwent revision procedures in the first 2 years postoperatively, one with revision hemiarthroplasty and one with conversion to arthrodesis.

CONCLUSION

On average across our entire cohort, physical function and pain scores improved significantly pre- to postoperatively; however, postoperative pain scores were significantly higher for patients who had undergone a prior procedure of the first MTP and significantly lower for patients who underwent concurrent Moberg osteotomy. The implant displayed excellent survivorship in the first 2 years postoperatively, with only 2 revision procedures.

LEVEL OF EVIDENCE

Level III, comparative series.

Patient-Reported Outcomes and Early Complications After Synthetic Cartilage Device Implantation

Background:

Previous Level I studies show promising results for the use of a hydrogel synthetic cartilage implant (SCI) for the treatment of hallux rigidus. A recent independent retrospective review has put those results into question, however. The purpose of this article is to report patient-reported outcomes and early complications using this implant so as to add to the paucity of data in the literature regarding this implant.

Methods:

This was a retrospective chart review of patients undergoing hydrogel synthetic cartilage implant for the treatment of hallux rigidus from July 2017 to November 2018. Data collected included patient demographics, radiographic grading, and outcomes: Veterans Rand 12 Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), visual analog scale (VAS), patient satisfaction, and complications. Fifty-four patients (59 feet) with an average age of 57.6 (range, 39-78) years were analyzed. The average latest follow-up was 18.9 (range, 3-31.3) months. Body mass index was 26.7 (range, 18.7-35.2). None were diabetic and 5 were smokers.

Results:

The mean outcome improvements were 6.5 points (VR-12 Physical), 17.2 points (FAAM ADL), 27.4 points (FAAM Sport), and 18.4 points (VAS) (P < .01 for each). Scores were significantly improved from preoperatively to most recent follow-up for FAAM ADL (71.0 vs 88.2 points), FAAM Sports (44.6 vs 72.0 points), and VAS (49.4 vs 31.0) (P < .01). Overall, 72.5% patients would definitely or probably have the operation again. Ten patients (18.5%) went on to have revision surgery. Of these, 7 patients were revised to an arthrodesis, and 1 metal hemiarthroplasty and 2 implants were removed because of infection.

Conclusion:

Synthetic cartilage implantation for the treatment of hallux rigidus demonstrated improved pain and outcome scores at short-term follow-up. Reoperation and conversion to fusion rates were comparable to prior studies.

Level of Evidence:

Level IV, case series.

The use of polyvinyl alcohol hydrogel implants in the lesser metatarsal heads. Is it safely doable? A cadaveric study

BACKGROUND

The use of synthetic polyvinyl alcohol hydrogel (PVAH) implants for treatment of lesser toe metatarsophalangeal joint (MTPJ) arthritis is promising and currently limited by the size of implants available. The primary objective of this cadaveric study was to investigate the maximum drilling size and largest PVAH implant dimension that could be safely introduced while still preserving an intact bone rim of the lesser metatarsal heads.

METHODS

Height and width of all lesser metatarsals were measured on CT and during anatomic dissection. Sequential reaming of the second to fourth metatarsals was performed. Maximum reaming size, largest implant inserted, and failure of the metatarsal head were recorded. Metatarsal head sizes were compared and a multiple regression analysis evaluated measurements that influenced maximum drilling and implant size.

RESULTS

CT and anatomical measurements demonstrated significant correlation (ICC range, 0.-0.85). Mean values for height and width of the metatarsal heads were respectively: second (14.9 mm and 9.9 mm), third (14.8 mm and 8.8 mm), fourth (14.0 mm and 8.7 mm) and fifth (12.3 mm and 9.3 mm). All the second, third and fourth metatarsal heads could be safely drilled up to 7.5 mm, preserving an intact bone rim. At 80% of the time, the heads could be safely drilled up to 8.0 mm. Height of the metatarsal heads was the only factor to significantly influence the size of maximum reaming and implant introduced. In respectively 20%, 40% and 50% of the second, third, and fourth metatarsal heads, neither 8 mm nor 10 mm PVAH implants could be used.

CONCLUSIONS

Our cadaveric study found that the even though the majority of the lesser metatarsal heads could be safely drilled up to 8 mm, the smallest PVAH implant size currently available in most countries (8 mm) could be inserted in most of the second, but only in about half of the third and fourth metatarsal heads. The remaining bone rim around inserted implants was considerably thin, usually measuring less than 1 mm. In order to optimize the use PVAH in lesser metatarsal heads, smaller implant options are needed.

Comparison of Complication and Reoperation Rates for Minimally Invasive Versus Open Cheilectomy of the First Metatarsophalangeal Joint

BACKGROUND

Dorsal cheilectomy of the first metatarsophalangeal joint is an accepted treatment to alleviate dorsal impingement, pain, and reduced dorsiflexion in hallux rigidus. Traditionally performed via an open incision, this procedure has more recently been performed using minimally invasive techniques despite limited supportive published evidence.

METHODS

From December 2012 through December 2017, a retrospective analysis of all cheilectomies performed in our institution was done. The surgical technique was recorded along with any subsequent procedures performed for either persistent or recurrent pain, and complications were also noted. A comparison between open and minimally invasive outcomes was performed. In total, 171 cheilectomies were performed during this period. There were 38 open and 133 minimally invasive procedures.

RESULTS

At a mean 3-year follow-up, the reoperation rates of the 2 groups were different with only 1 (2.6%) of the open group requiring a fusion, while 17 (12.8%) of the minimally invasive surgical (MIS) group required further surgery (relative risk, 4.86; P = .059). In the open group, there was 1 (2.6%) complication, compared with 15 (11.3%) in the minimally invasive group (relative risk, 4.29; P = .076).

CONCLUSION

While patients may opt for MIS cheilectomy with a proposed faster recovery time and better cosmesis, they should be counseled about the risks and benefits of both methods, and that the technique of MIS cheilectomy utilized in this study appears to have an increased relative risk of requiring a further procedure.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Early Outcomes and Complications of Synthetic Cartilage Implant for Treatment of Hallux Rigidus in the United States

BACKGROUND

The aim of this study was to determine the early outcomes and complications following the implantation of a hydrogel synthetic cartilage implant (SCI, Cartiva) for the treatment of hallux rigidus by a single surgeon.

METHODS

A retrospective chart review was performed of consecutive patients who underwent treatment for hallux rigidus with an SCI between August 2016 and April 2018 by a single surgeon. Demographic information, radiographic assessment, and concomitant operative procedures performed were evaluated for all patients. Postoperatively, PROMIS physical function (PF) and pain interference (PI) scores, patient satisfaction, reoperation, conversion to arthrodesis, and need for further clinical treatment were collected. Sixty-four SCIs were implanted in 60 patients. Follow-up averaged 18.5 months (range 12-30 months).

RESULTS

14% (9/64) of patients were very satisfied, 28% (18/64) satisfied, 20% (13/64) neutral, 11% (7/64) unsatisfied, and 27% (17/64) very unsatisfied with their outcome. In addition, 45% of patients underwent additional procedures at the time of SCI, and 23% had a history of surgery on the hallux before implantation. PROMIS PF scores averaged 42 and PROMIS PI scores averaged 60. Overall, 63% completed PROMIS PI, 66% completed PROMIS PF, and 100% completed a satisfaction survey. In addition, 30% (19/64) underwent magnetic resonance imaging (MRI) postoperatively due to pain. There was a 20% reoperation rate, which included an 8% rate of conversion to arthrodesis.

CONCLUSION

Synthetic cartilage implantation yielded neutral patient satisfaction, mild pain, and physical dysfunction at early follow-up. We believe patient selection and counseling regarding early postoperative limitations are important before proceeding with SCI.

LEVEL OF EVIDENCE

Level IV, case series.

First Metatarsophalangeal Joint Implant Options

Evidence-based medicine continues to guide our treatment of patients. Owing to the unique characteristics of the first metatarsophalangeal joint (1^st MTPJ) with its small surface area and the significant amount of multiplanar force that affects it, finding the perfect implant to allow motion and alleviate pain is still the ultimate goal. While some of the older metallic implants and silastic spacers may still be providing pain relief and function to patients, the majority have failed and caused significant bone loss along the way. The HemiCap implants have shown some promise in select patients and may still be a viable option in patients desiring maintenance of 1st MTPJ motion.

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

Patient-Perceived Recovery and Outcomes After Silastic Implant Arthroplasty

In some chronic musculoskeletal conditions, patients with persistent pain and disability have still achieved recovery through behavioral adaptations (readjustment) or cognitive coping (redefinition). Although the pendulum shift from physician-reported clinical indicators to patient-reported outcomes measures (PROMs) has recently focused on quantifying residual pain and disability to determine recovery (resolution), whether patients are capable of coping with any ongoing deficits and achieving other forms of recovery has not been considered. We performed a retrospective case series to assess patient-perceived recovery and outcomes after silastic implant arthroplasty for hallux rigidus. From July 2006 to July 2016, 28 patients at a single institution were enrolled. PROMs were prospectively obtained and compared between patients considering themselves recovered without or with residual deficits (recovered-resolved, recovered-not resolved) and those not recovered. Holistic satisfaction, procedure-specific satisfaction, complications, reoperations, and failure rates were recorded. Overall, 50.0% perceived themselves as recovered-resolved, 43% as recovered-not resolved, and 7% as not recovered. The mean modified Foot Function Index was 17.26, the verbal analog scale for pain score was 2.03, and implant survivorship 100% at a median of 67 (interquartile range 28.4 to 103.5) months. Although only 50% of patients reported complete symptom resolution, satisfaction was high, and most perceived themselves as recovered, suggesting recovery in hallux rigidus might not always be predicated by the complete resolution of all symptomatology. Although PROMs relying on pain inference and functional disability will continue to be utilized with increasing frequency, foot and ankle surgeons should be cognizant of their inherent limitations in assessing other forms of recovery.

Clinical Outcomes Following Minimally Invasive Dorsal Cheilectomy for Hallux Rigidus

BACKGROUND:

Following failure of conservative treatment, a dorsal cheilectomy can be performed for patients in early stages of hallux rigidus by a traditional open approach or by a minimally invasive technique. We report our clinical outcomes following minimally invasive dorsal cheilectomy (MIDC).

METHODS:

Eighty-nine patients (98 feet) with symptomatic hallux rigidus treated between 2011 and 2016 were included in this study. The average age was 54 years. Manchester-Oxford Foot Questionnaire (MOxFQ) scores and visual analog scale (VAS) pain scores were collected. The mean follow-up was 50 months.

RESULTS:

The average VAS score improved from 8.0 preoperatively to 3 postoperatively. The mean MOxFQ summary index score decreased from 58.6 preoperatively to 30.5 postoperatively. All 3 MOxFQ domains also improved. Swelling took an average of 5.3 weeks to settle. There were 2 wound infections and 2 delayed wound healings. Two patients had transient nerve paraesthesia, while 2 patients had permanent numbness in the dorsomedial cutaneous nerve distribution. Twelve patients (12%) underwent reoperation, of which 7 had a first metatarsophalangeal joint arthrodesis for ongoing pain, 4 had repeat cheilectomy for residual impingement, and 1 had an open removal of loose bone.

CONCLUSION:

Our results suggest that MIDC resulted in improvement in patient-reported outcome measures and was a safe technique with minimal complications. The complications were similar to open cheilectomy. There was an associated learning curve as 5 of our reoperations were due to incomplete cheilectomy. Coughlin grade 1 did well with MIDC as with open cheilectomy as none went onto an arthrodesis. However, 10% (7/65) of our grade 2 and 3 cases went on to an arthrodesis.

LEVEL OF EVIDENCE:

Level IV, retrospective case series.

Implant Arthroplasty versus Arthrodesis for the Treatment of Advanced Hallux Rigidus: A Meta-analysis of Comparative Studies

Implant arthroplasty and arthrodesis of the first metatarsophalangeal joint are the main surgical treatment options for advanced hallux rigidus. The superiority of each modality continues to be debated, because there are few high-quality evidence-based studies, such as randomized controlled clinical trials or meta-analyses of comparative studies. The purpose of this study was to identify whether implant arthroplasty or arthrodesis is superior for the treatment of advanced hallux rigidus through meta-analysis of comparative studies. A comprehensive search of the MEDLINE, EMBASE, and Cochrane library databases was conducted. Only retrospective or prospective comparative studies were included in this meta-analysis. The literature search, data extraction, and quality assessment were conducted by 2 independent reviewers. The primary outcomes were clinical scores and patient satisfaction. The rate of reoperation and complication were also investigated. Seven comparative studies were included (2 prospective and 5 retrospective studies). There were no significant differences between the 2 groups in the American Orthopedic Foot and Ankle Society-Hallux Metatarsophalangeal Interphalangeal score, patient satisfaction rate, reoperation rate, or complication rate. The visual analogue scale for pain was significantly lower in the arthrodesis group than the implant arthroplasty group. This meta-analysis revealed that implant arthroplasty and arthrodesis of the first metatarsophalangeal joint led to similar clinical outcomes, patient satisfaction, reoperation rates, and complication rates, whereas pain was significantly lower in arthrodesis. Further studies of high methodological quality are required to confirm these conclusions.

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.