First Metatarsophalangeal Arthrodesis After Failed Distal Chevron Osteotomy for Hallux Valgus

Comparison of the outcomes of first metatarsophalangeal joint arthrodesis by locking plate and compression screw in patients with severe hallux valgus or hallux valgus revision

INTRODUCTION

Arthrodesis of the first metatarsophalangeal joint (MTP1) is indicated for hallux rigidus, septic arthritis, severe hallux valgus (HV) or HV revision. Few studies have compared the functional and radiographic outcomes between indications. The goal of this study was to compare the results of MTP1 arthrodesis in patients with severe HV or HV revision at 6 months postoperative. The hypothesis was that there are no differences in the fusion rate, functional scores and radiological correction between the two groups.

MATERIALS AND METHODS

This was a retrospective, observational, single-center study conducted between January 1, 2018 and July 31, 2021. The inclusion criteria were patients treated for severe HV or HV revision by MTP1 arthrodesis with a compression screw and locking plate who were at least 18 years of age. The exclusion criteria were a history of septic arthritis of MTP1 without prior HV surgery, primary hallux rigidus, rheumatoid arthritis, incomplete medical record. The functional outcomes consisted of the Foot Function Index (FFi-f) and the European Foot and Ankle Society (EFAS) score. Radiographs were made to evaluate preoperative and postoperative deformity, the correction and the fusion rate. These outcomes were compared between two groups: severe HV and HV revision.

RESULTS

An analysis was done of 58 cases of MTP1 arthrodesis: 45 severe HV and 13 HV revisions. The mean patient age was 66 years, and the mean follow-up was 15.7 months. There were no significant differences between the two groups in the postoperative functional scores: EFAS (p = 0.85) and FFI-f (p = 0.14). At the final review, there were no significant differences between the two groups in the foot angle measurements (hallux valgus angle, p = 0.08 and intermetatarsal angle, p = 0.15) and fusion rate (p = 0.89) with a 93% fusion rate in patients with severe HV and 92% in patients with HV revision.

CONCLUSION

Given the good radiographic and functional outcomes, MTP1 arthrodesis by locking plate and compression screw is indicated as a first line surgical treatment for patients with severe HV or for patients undergoing HV revision. There is no evidence of a significant difference in the functional scores, fusion rate and radiographic correction between these two indications.

LEVEL OF PROOF

IV; retrospective case series.

Primary Isolated Arthrodesis of the First Metatarsophalangeal Joint for Hallux Rigidus: Clinical, Radiologic, and Pedobarographic Evaluation

Background

Arthrodesis of the first metatarsophalangeal joint is an effective treatment of advanced hallux rigidus. Numerous options have been described for performing this intervention. The aim of this study was to evaluate the outcomes following a consistent surgical technique of joint preparation with hand tools and fixation with 2 crossed screws and a dorsal compression plate.

Methods

Thirteen patients (16 feet) who underwent primary isolated arthrodesis of the first metatarsophalangeal joint between March 2019 and June 2021 were available for clinical, radiologic, and pedobarographic evaluation at a minimum of 12 months after surgery. American Orthopaedic Foot & Ankle Society scores, numerical pain rating scale, the radiologic hallux valgus and intermetatarsal 1-2 angles as well as the distribution of plantar pressure during gait were compared between the pre- and postoperative conditions.

Results

After an average follow-up period of 26 months, union was achieved in all cases and the mean AOFAS score raised significantly by 39 points. All the patients were satisfied with the result. Only 1 patient complained of mild residual pain at walk. Hardware removal was performed in 2 cases. The mean hallux valgus angle dropped from 12.3 to 6.3 degrees. The mean postoperative dorsiflexion angle was 21.6 degrees. After the procedure, peak pressure was significantly higher beneath the first metatarsal head and heel, whereas pressure-time integral was significantly lower beneath the hallux and medial lesser toes.

Conclusion

Arthrodesis of the first metatarsophalangeal joint with 2 crossed screws and a dorsal compression plate is a safe and effective treatment of advanced hallux rigidus. This procedure provides adequate pain relief and functional improvement of gait.

Level of Evidence

Level IV, therapeutic, retrospective case series.

[Translated article] Better results in consolidation of hallux metatarsophalangeal arthrodesis with dorsal plate and interfragmentary compression screw

BACKGROUND AND AIMS

The first metatarsophalangeal joint arthrodesis is indicated for the treatment of various pathologies as a technique to reduce pain and improve the support of the first radius. Numerous surgical techniques and fixation methods have been described, with the combination of a dorsal plate and an interfragmentary screw being the one that has shown to be the most stable construct in biomechanical studies. Our aim is to analyze the radiological results after metatarsophalangeal arthrodesis of the hallux using a dorsal plate associated or not with an interfragmentary screw. The differences in terms of consolidation rates and complications in patients diagnosed with hallux rigidus, hallux valgus, hallux varus and failure of previous surgeries were evaluated.

MATERIALS AND METHODS

A retrospective cohort study of 55 patients with a mean age of 65.10 years in whom a dorsal plate was used was performed. Patients were divided into two groups depending on whether or not an interfragmentary screw was used. The minimum follow-up was 6 months after surgery. The assessment of the pre and postoperative radiological results was based on the variation of the hallux angle, the intermetatarsal angle and the dorsal metatarsophalangeal angle of the hallux, as well as the cases of nonunion identified in each study group.

RESULTS

The radiological results, statistically significant differences (p<0.05) were only found in the dorsal metatarsophalangeal angle between both study groups. No statistically significant differences were found regarding the radiological evaluation of the pre and postoperative hallux angle and intermetatarsal angle. An equal decrease of each angles was observed in both study groups. Regarding the consolidation rate, statistically significant differences (p<0.05) were found between group A, which associated an interfragmentary screw, presenting a consolidation rate of 92%, and group B, which did not associate an interfragmentary screw, and that presented a union rate of 63%.

CONCLUSION

Hallux metatarsophalangeal arthrodesis of the hallux with a dorsal plate and interfragmentary screw show best results regarding consolidation rate and complications compared to those cases in which an interfragmentary screw was not used.

Better results in consolidation of hallux metatarsophalangeal arthrodesis with dorsal plate and interfragmentary compression screw

INTRODUCTION AND AIMS

The first metatarsophalangeal joint arthrodesis is indicated for the treatment of various pathologies as a technique to reduce pain and improve the support of the first radius. Numerous surgical techniques and fixation methods have been described, with the combination of a dorsal plate and an interfragmentary screw being the one that has shown to be the most stable construct in biomechanical studies. Our aim is to analyze the radiological results after metatarsophalangeal arthrodesis of the hallux using a dorsal plate associated or not with an interfragmentary screw. The differences in terms of consolidation rates and complications in patients diagnosed with hallux rigidus, hallux valgus, hallux varus and failure of previous surgeries were evaluated.

MATERIAL AND METHODS

A retrospective cohort study of 55 patients with a mean age of 65.10 years in whom a dorsal plate was used was performed. Patients were divided into 2 groups depending on whether or not an interfragmentary screw was used. The minimum follow-up was 6 months after surgery. The assessment of the pre and postoperative radiological results was based on the variation of the hallux angle, the intermetatarsal angle and the dorsal metatarsophalangeal angle of the hallux, as well as the cases of nonunion identified in each study group.

RESULTS

The radiological results, statistically significant differences (p<0.05) were only found in the dorsal metatarsophalangeal angle between both study groups. No statistically significant differences were found regarding the radiological evaluation of the pre and postoperative hallux angle and intermetatarsal angle. An equal decrease of each angles was observed in both study groups. Regarding the consolidation rate, statistically significant differences (p<0.05) were found between group A, which associated an interfragmentary screw, presenting a consolidation rate of 92%, and group B, which did not associate an interfragmentary screw, and that presented a union rate of 63%.

CONCLUSIONS

Hallux metatarsophalangeal arthrodesis of the hallux with a dorsal plate and interfragmentary screw show best results regarding consolidation rate and complications compared to those cases in which an interfragmentary screw was not used.

Effect of Obesity on Patient-Perceived Outcomes After First Metatarsophalangeal Joint Arthrodesis

BACKGROUND

While first metatarsophalangeal joint (MTPJ) arthrodesis is a common and effective procedure, there is a paucity of studies examining obesity's effect on outcomes of 1st MTPJ arthrodesis. This study's purpose was to evaluate patient-reported outcomes following 1st MTPJ arthrodesis in obese versus non-obese patients.

METHODS

A retrospective cohort study of 94 patients undergoing first MTPJ fusion over the age of 18 with a diagnosis of hallux valgus or hallux rigidus was performed. Surgical and postoperative outcomes were examined preoperatively and at 6 and 12 months follow-up via Visual Analog Pain scale (VAS), and Short Form 36 (SF-36) surveys, and data were stratified into 2 patient groups: BMI < 30 (n = 62, mean age 63.9 ± 9.1 and ≥ 30 (n = 32, mean age 61.9 ± 8.4).

RESULTS

Average overall VAS and SF-36 physical component scores improved significantly at 6 months (P < .001, .006) and 1 year postoperative visits (P < .001, .007) with no differences in survey scores, outcomes, or complications between weight groups.

CONCLUSION

Our study showed first MTPJ fusion improves short-term pain and physical quality-of-life in arthritic obese and non-obese patients without differences in nonunion, complications, or patient-reported measures.

LEVEL OF EVIDENCE

Level III, Prognostic, Case-Control Study.

High complication rates following revision first metatarsophalangeal joint arthrodesis: a retrospective analysis of 79 cases

BACKGROUND

The most common indications for revision of first metatarsophalangeal joint (MTPJ) arthrodesis are symptomatic failures of prior arthrodesis, failed hallux valgus correction, and failed MTPJ arthroplasty implants. However, the outcomes of revision MTPJ arthrodesis have rarely been studied. The purpose of this study was to compare the clinical, radiographic, and patient-reported outcomes of revision MTPJ arthrodesis following different primary procedures.

METHODS

A retrospective review of revision MTPJ arthrodesis cases between January 2015 and December 2019 was performed. The radiographic results, patient-reported outcomes, and rates of complications, subsequent revisions, and nonunions, were analyzed and compared preoperatively and postoperatively. A multivariate analysis was utilized to determine risk factors for complications and reoperations.

RESULTS

This study yielded a total of 79 cases of revision MTPJ arthrodesis. The mean follow-up time was 365 days (SD ± 295). The overall complication rate was 40.5%, of which the overall nonunion rate was 19.0%. Seven cases (8.9%) required further revision surgery. The multivariate analysis revealed that Diabetes mellitus was associated with significantly higher overall complication rates (p = 0.016), and nonunion was associated with "in-situ" joint preparation techniques (p = 0.042). Visual Analog Scale (VAS) significantly improved postoperatively (p < 0.001); However, PROMIS-10 physical health and PROMIS-10 mental health did not change significantly during the study period.

CONCLUSION

Treatment of MTPJ surgery failures is a clinical challenge in orthopedic surgery. In our study, revision of first MTPJ surgery resulted in higher nonunion rates and overall complication rates compared to typical outcomes from primary MTPJ arthrodesis. Diabetes, Tobacco use, and "in-situ" joint preparation technique were found to be independent risk factors for complications and reoperations.

LEVEL OF EVIDENCE

III-Retrospective Cohort Study.

First metatarsophalangeal arthrodesis outcomes for hallux rigidus versus hallux valgus

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, Retrospective cohort study.

Managing Complications of Foot and Ankle Surgery: Hallux Valgus

Hallux valgus deformity is nowadays one of the most common and symptomatic disorders affecting the foot. Surgical corrections of hallux valgus deformity are among the most common orthopedic procedures. Despite the general high success rate complications can occur. The treatment of complications start before the first incision has been performed by thorough preoperative planning and choice of the right procedure. Once the complication is evident, thorough planning is necessary to address the patient's individual needs. In this paper the treatment of recurrent hallux valgus, hallux varus, malunion, and avascular necrosis are discussed.

[Distal osteotomy of the first metatarsal bone with plantarization for the treatment of hallux limitus due to metatarsus primus elevatus]

OBJECTIVE

Joint-preserving procedure with plantarization of the 1st metatarsal and improvement of range of motion.

INDICATIONS

Mild and moderate arthrosis of the 1st metatarsophalangeal joint with pain and shoe discomfort due to elevation of 1st ray and failed conservative treatment.

CONTRAINDICATIONS

Severe degenerative conditions 1st metatarsophalangeal joint with significant loss of range of motion preoperatively. General contraindications for surgical treatment/anesthesia.

SURGICAL TECHNIQUE

Dorsomedial approach to 1st metatarsophalangeal joint, mild cheilectomy and arthrolysis, v‑shaped osteotomy of metatarsal 1 from dorsal with plantarization of the metatarsal head, screw fixation from proximal dorsal to distal plantar.

POSTOPERATIVE MANAGEMENT

Full weightbearing in rocker bottom shoe for 6 weeks.

RESULTS

Improvement of range of motion from 35° dorsal extension to 50° in all cases after 6 months. Reduction of painful movement from VAS 6-7 to VAS 2-3 in 80% of patients.

Effects of Short-Term Limitation of Movement of the First Metatarsophalangeal Joint on the Biomechanics of the Ipsilateral Hip, Knee, and Ankle Joints During Walking

BACKGROUND We analyzed the effect of limitation of movement of the first metatarsophalangeal joint (FMJ) on the biomechanics of the lower limbs during walking. MATERIAL AND METHODS Eight healthy college students completed walking under barefoot (BF) and FMJ constraint (FMJC) conditions. We synchronously collected kinematics and dynamics data, and calculated the torque, power, and work of hip, knee, and ankle joints. RESULTS Compared with normal conditions, when the FMJ is restricted from walking, the maximum ankle dorsiflexion angle is significantly increased (P<0.001), the maximum plantar flexion angle is significantly reduced (P<0.001), the maximum plantar flexion torque (P<0.001) and the maximum dorsiflexion torque (P<0.05) increased significantly, the maximum power increased significantly (P<0.001), the minimum power decreased significantly (P<0.001), and the negative work increased significantly (P<0.001). The torque of hip and knee joints increased significantly (P<0.05). CONCLUSIONS After the movement of the FMJ is restricted, the human body mainly compensates and transfers compensation by increasing the angle of dorsiflexion, increasing work and the activity level of surrounding muscles through the ankle joint, thereby increasing the torque load of the knee and hip joints to maintain the dynamic balance of kinematics. FMJC condition increases the energy consumption of the human ankle, knee, and hip joints during walking. The load is compensated by the gradual attenuation of the ankle, knee, and hip. Long-term limitation may cause damage to the posterior calf muscles and increase the incidence of knee arthritis.