Revision MTP arthrodesis for failed MTP arthroplasty

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.

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 Hemiarthroplasty of First Metatarsophalangeal Joint Hallux Rigidus

Background Hallux rigidus (HR) is the most common arthritic condition of the foot. Although first metatarsophalangeal joint (MTPJ) arthrodesis has been the historical gold-standard treatment, polyvinyl alcohol (PVA) hydrogel implants have gained popularity as a joint-sparing technique. However, recent studies have shown variable failure rates of PVA hydrogel implants. The purpose of this study was to report the five-year experience with PVA hydrogel implants performed by a single surgeon. Methodology Health records were queried from August 2016 to 2021 for patients who underwent primary PVA hydrogel implant hemiarthroplasty for symptomatic late-stage HR. Patient demographics and postoperative outcomes variables were evaluated. Kaplan-Meier analysis was used to evaluate implant survival. A total of 146 PVA hydrogel implant procedures were performed with a minimum six-month follow-up. Results The majority of patients were female (n = 103, 70.5%), with a mean age of 58.1 (±10.1) years, body mass index of 27.3 (±5.2) kg/m2, and American Society of Anesthesiologists score <3 (n = 131, 89.7%). The majority had stage II or III disease (n = 115, 78.8%). Patients experienced significant improvement in visual analog scale score (p < 0.0001) and hallux dorsiflexion (p = 0.0005). There were 22 (15.1%) complications, including implant subsidence (n = 15, 10.3%), deep infection (n = 6, 4.1%), and hypertrophic ossification (n = 1, 0.7%). Revision surgeries were required in 12.3% (n = 18) of patients at an average of 9.4 (±9.2) months postoperatively. This included nine (6.2%) revision PVA hydrogel implant procedures and nine (6.2%) first MTJP arthrodesis. The one- and two-year survival rates for MTPJ arthrodesis (n = 9) were 95.9% and 86.3%, respectively. Conclusions In the largest single-surgeon series reported, first MTPJ hemiarthroplasty with a PVA hydrogel implant significantly improved pain and hallux dorsiflexion at an average of 14.5 months postoperatively. There was a high two-year survivorship of 86.3% until failure which required first MTPJ arthrodesis. Future studies should be performed to refine the indications for PVA hydrogel implants and identify risk factors.

Incidence of Nonunion of the First Metatarsophalangeal Joint Arthrodesis After Failed Implant Arthroplasty: A Systematic Review

Joint arthroplasty of the first metatarsophalangeal (MTP) joint is an accepted surgical option for patients with hallux rigidus. However, this procedure has been reported to have a high complication rate and unpredictable survivorship. Implant arthroplasty failure is a devastating complication that results in significant osseous defect with altered biomechanics of the foot. Commonly, salvage options are limited to arthrodesis with bone grafting. However, outcomes are rarely reported. The purpose of this study is to investigate the fusion rates of first metatarsophalangeal joint arthrodesis after conversion from failed implant arthroplasty. A systematic review of electronic databases to find reports of conversion arthrodesis after failed implant arthroplasty was performed. Six studies involving a total of 76 patients with a weighted mean age of 54.9 met the inclusion criteria. Out of the 6 included articles, the nonunion rate was 16.5% at a weighted mean follow-up of 48.1 months. The nonunion rate in the current report is higher than reported nonunion rates of primary arthrodesis. More prospective studies with consistent and standard outcome measures are needed to further determine the success rate of this salvage procedure.Levels of Evidence: 4, Systematic Review of Level 4 Studies.

Clinical, Radiographic, and Patient-Reported Outcomes of First Metatarsophalangeal Interposition Arthrodesis Using Porous Titanium Wedges

BACKGROUND

First metatarsophalangeal (MTP) arthrodesis is a common surgical procedure for addressing hallux MTP pathology. In the setting of revision procedures with significant bone loss, porous titanium wedges may provide an alternative to structural bone autograft or allograft.

OBJECTIVE

The purpose of this study is to report the clinical and radiographic outcomes achieved in first MTP interposition arthrodesis using porous titanium wedges.

METHODS

A retrospective analysis of 9 patients with a mean age 65.4 years (45-82 years) who underwent first MTP interposition arthrodesis with the use of porous titanium wedges from February 2014 to September 2017 was performed. Outcomes were assessed using both plain-film radiographs and computed tomography (CT) scans, as well as patient-reported outcome measures, including Foot and Ankle Ability Measure (FAAM) (Sports and Activities of Daily Living), pain Visual Analogue Scale (VAS), and 36-Item Short Form Survey (SF-36). Average follow-up time was 34.2 months (14-72 months).

RESULTS

At final follow-up, the average FAAM score was 91.1 ± 14.7 (75.1 ± 5.3 FAAM Activities of Daily Living; 17.9 ± 9.9 FAAM Sports). Average pain VAS score was 1.9 ± 1.7. Postoperative computed tomography (CT) imaging was obtained for 5 patients, all of which demonstrated good bony apposition or osseous integration of the wedge. Four patients underwent subsequent surgical procedures, including 3 isolated dorsal fixation revisions, and 1 complete MTP arthrodesis revision.

CONCLUSION

To our knowledge, this study represents the first reported clinical and radiographic outcomes in patients undergoing first MTP interposition arthrodesis with use of porous titanium wedges. While we found this technique to be a viable alternative to bone grafting for this difficult problem, further research should focus on comparative data with other commonly performed operative techniques.

LEVEL OF EVIDENCE

Level IV: Case series.

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.

Surgical Outcomes of Synthetic Cartilage Implant Hemiarthroplasty for Metatarsophalangeal Arthropathy

Introduction Metatarsophalangeal joint (MTPJ) arthropathy in the great toe causes considerable pain and debilitation, severely impacting quality of life. Traditional management options included conservative measures, steroid injections, and arthrodesis. New options include Cartiva, a synthetic cartilage hemiarthroplasty for the MTPJ. This prosthesis has evidence of improved pain and function without the sacrifice of joint movement seen with arthrodesis. However, the implant itself has mixed reviews. This study aims to identify the pre-, peri, and short-term post-surgical outcomes of Cartiva surgery and review the literature for existing reported outcomes. Methods We retrospectively reviewed a cohort of 22 consecutive Cartiva procedures between 2016 and 2022 in a single UK institution. Hospital records were analyzed for peri-operative complications, implant survival, additional operative interventions, patient-reported outcomes, and functional improvement. Results Twenty-one patients underwent Cartiva for the first MTPJ pathology and one for the third MTPJ pathology. Prior to surgery, 40.9% of patients had undergone alternative therapies, including MTPJ steroid injections (seven patients), cheilectomy (four patients), and bunionectomy (one patient). Total complication rates, inclusive of medical, surgical, and implant complications were 45.5% (10/22). Total reoperation rates were 18.2% (4/22) including two revisions to arthrodesis and two manipulations under anesthesia (MUA) with local anesthetic injection. At the final follow-up, 55% were still experiencing pain, 15% neurovascular symptoms, 10% swelling, and 50% stiffness or reduced range of movement. However, 85% of patients returned to usual activities of daily living within two years. Conclusion Cartiva surgery for metatarsophalangeal arthropathy has demonstrated outcomes of persistent pain, limited range of movement, and restricted function at short-term follow-up. Rates of reoperation and revision to arthrodesis were comparable with similar studies.

Staged reconstruction of the hallux for infected non-union using bulk autograft and a customized implant: Case report

This case report illustrates the outcome of a deep infection following internal fixation of a fracture of the big toe. Hallux amputation could be avoided through staged salvage procedure. This paper can assist readers on how to effectively and safely recognize and treat this type of injury.

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.

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.

Radiographic Outcomes of Titanium Augment vs Bone Graft in Lateral Column Lengthening for Adult-Acquired Flatfoot Deformity

Background

Lateral column lengthening (LCL) is a surgical procedure used to manage forefoot abduction and, in theory, also increases the longitudinal arch by plantarflexion of the first ray through tensioning the peroneus longus for patients with stage IIB adult acquired flatfoot deformity (AAFD). This procedure utilizes an opening wedge osteotomy of the calcaneus, which is then filled with autograft, allograft, or a porous metal wedge. The primary aim of this study was to compare the radiographic outcomes of these different bone substitutes following LCL for stage IIB AAFD.

Methods

We conducted a retrospective review of all patients who underwent LCL from October 2008 until October 2018. Preoperative weightbearing radiographs, initial postoperative radiographs, and 1-year weightbearing radiographs were reviewed. The following radiographic measurements were recorded: incongruency angle, talonavicular coverage angle (TNCA), talar-first metatarsal angle (T-1MT), and calcaneal pitch.

Results

A total of 44 patients were included in our study. The mean age of the cohort was 54 (range, 18-74). The study cohort was divided into 2 groups. There were 17 (38.7%) patients who received a titanium metal wedge and 27 (61.5%) that received autograft or allograft. Patients that underwent LCL with the autograft/allograft group were significantly older (59 vs 47 years old, P = .006). Patients who underwent LCL with a titanium wedge had a significantly higher preoperative talonavicular angle (32 vs 27 degrees, P = .013). There were no significant differences in postoperative TNCA, incongruency angle, or calcaneal pitch at 6 months or 1 year.

Conclusion

At 6 months and 1 year, no radiographic differences were found between autograft/allograft bone substitutes vs titanium wedge in LCL.

Level of Evidence

Level III, retrospective cohort study.

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.

Metatarsophalangeal HAPY® spherical pyrocarbon implant: Technical note

We present a new arthroplasty concept for the first metatarsophalangeal joint (MTP1) involving the HAPY® pyrocarbon interposition implant. This is a spherical implant that does not integrate into bone. Instead, the goal is to achieve gliding of the implant on the bone/cartilage to maintain the function and mobility of the MTP1 joint. We describe the surgical technique used for its implantation. Since the implant is not anchored into bone, it is stabilized in a spherical cavity hollowed out in the metatarsal head. In a preliminary study of 22 cases with a mean follow-up of 36 (20-79) months, the mean AOFAS score improved from 64 (35-72) preoperatively to 91 (47-100) postoperatively (p<0.05). At the final assessment, no subchondral cyst or osteolysis was visible.

A Novel Technique to Treat Hallux Rigidus in Athletic Patients With Central Osteochondral Defects: Preliminary Report on 12 Cases

Osteochondral defects, often caused by traumatic injuries, are focal areas of articular damage resulting in joint pain and stiffness ultimately leading to degenerative joint disease. This has not been well studied in the first metatarsal head, but is an often encountered problem in the active population in other joints. In this study, we prospectively evaluated the results of 12 patients who received autogenous bone grafting for repair of osteochondral defects of the first metatarsal head. Clinical outcomes were evaluated by the visual analog scale for pain and the Roles and Maudsley (RM) score. Between the years of 2009 and 2016, 12 patients received treatment for this particular surgical intervention and their outcomes were measured. The patients' average age was 43.5 ± 10.6 years and were followed from 52.3 ± 26.7 months postoperatively. Average return to activity was 4.7 ± 1.1 months. The average preoperative RM score was 4.0 ± 0.0 and postoperative RM score was 1.4 ± 0.7 (p = .0001). The encouraging outcomes of this study suggest that autogenous bone grafting for osteochondral defects of the first metatarsal head is an effective treatment to help restore the function of the first metatarsophalangeal joint.

Mid-Term Functionality and Survival of 116 HemiCAP® Implants for Hallux Rigidus

Hallux rigidus can be treated with a proximal hemiarthroplasty (HemiCAP®) to preserve the motion in the first metatarsophalangeal joint and reduce pain. This study examines the functionality, and survival rates of HemiCAP® implants, with or without a dorsal flange. One hundred and five patients were treated with a HemiCAP® (N = 116 HemiCAPs®) between 2006 and 2014. Revision rates, arthrosis score, hallux valgus (HV), intermetatarsal (IM), distal metaphyseal articular angle (DMAA), visual analog scale (VAS) (1-10 points), American Orthopaedic Foot and Ankle Score (AOFAS) MTP-IP (AOFAS 0-100 points), SF-12, range of motion (ROM), and radiographs were analyzed pre- and postoperatively. Statistics: Kaplan-Meier survival analysis, Cox-regression, and paired t tests. At 2, 4, and 6 years, the implant survival was 87%, 83%, and 81%, respectively. All revised due to pain. Dorsal flange, gender, arthrosis, HV, IM, and DMAA did not influence the results. At the mean 5-year follow-up (n = 47) median (range) dorsal ROM was 45° (10°-75°), AOFAS was mean 87.2 ± 10.8, VAS was 2 ± 1.6, and SEFAS was 42 ± 6 points. The dorsal flange made no significant difference for ROM or patient-reported outcome measures compared to the HemiCAP® with no dorsal flange. Twenty-three patients with preoperative data were re-examined, and preoperative dorsal ROM mean difference (confidence interval [CI]) increased 20.7° (13.9°-27.4°), VAS decreased with a mean difference (CI) of -4.7 (-5.8 to 3.5), and AOFAS increased with a mean difference (CI) 26.2 (20.2-32.2) (for all p < .001). The 6-year survival rate of the HemiCAP® implant was 81%. The design change to dorsal flange was not evident clinically. Unrevised patients had significantly less pain, greater ROM, and better foot and ankle function than preoperatively.

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.

Does the length of the plate affect the failure rate of hallux MTP joint arthrodesis for severe hallux valgus?

PURPOSE

The purpose of this study was to investigate the effect of the length of the dorsal locking plate on the failure rate of first MTP joint arthrodesis for severe hallux valgus deformities.

METHODS

A retrospective review was conducted for all patients who underwent first MTP joint arthrodesis using solely a specific locked plating system (Depuy-Synthes, Raynham, MA) for severe hallux valgus deformities between January 2014 to June 2017. Patients were divided into subgroups according to the length of the plate and the failure rate was investigated. Furthermore, radiographic parameters including intermetatarsal angle (IMA) and hallux valgus angle (HVA) were evaluated in weightbearing AP foot radiographs.

RESULTS

A total of 25 patients were included in this study. There were 16 (64%) patients in the medium-sized plate cohort and 9 (36%) patients in the small-sized plate cohort. We found a significant difference in the failure rate between the two groups; only 1 (6.25%) failure case occurred in the medium-sized plate cohort while 4 (44.44%) failure cases occurred in the small-sized plate cohort (P = .040, Odds ratio (OR) = 12.000, 95% Confidence Interval (CI) = 1.074, 134.110). The mean postoperative IMA and HVA were significantly improved in both cohorts. However, significant differences were found between the two cohorts in final follow-up IMA and HVA (P = .002 and P < .001, respectively).

CONCLUSIONS

For severe hallux valgus deformities, the use of longer plates to gain additional purchase in the diaphyseal bone may help mitigate the increased stresses placed on the fixation constructs for first MTP joint arthrodesis and decrease failure rate.

LEVEL OF EVIDENCE

Level III, case control study.

First Metatarsophalangeal Joint Distraction Arthrodesis With Bicortical Calcaneal Autograft

First metatarsophalangeal joint (MTPJ) arthrodesis is a surgical treatment option for failed first MTPJ procedures. In cases of failed MTPJ arthroplasty, removal of failed implants and necrotic bone can cause shortening and biomechanical insufficiency of the first ray. Distraction arthrodesis with bone grafting can be used to maintain first ray length. We describe a technique of autograft harvest from the ipsilateral calcaneus. We present a retrospective case series of clinical and radiographic outcomes of distraction arthrodesis with bicortical calcaneal autograft in patients with failed procedures of the first MTPJ. We achieved a 100% osseous union rate. There was an insignificant change in first ray length from preoperative to postoperative (P = .2402). First ray length was maintained with a median autograft length of 10 (range 5 to 14) mm. We were able to correct first ray deformity with a significant reduction in preoperative to postoperative intermetatarsal angle and hallux abduction angle (P = .0156, P = .0068, respectively). Seven (88%) of 8 patients with available subjective follow-up were satisfied with the outcome of the procedure and would undergo the procedure again. Our results indicate that first MTPJ distraction arthrodesis with calcaneal autograft is a viable option for failed first MTPJ procedures. Surgeons who implement our techniques can expect high rates of osseous union, deformity correction, and patient satisfaction.

Early Failures of Polyvinyl Alcohol Hydrogel Implant for the Treatment of Hallux Rigidus

BACKGROUND

The purpose of this study was to evaluate the clinical and radiological outcomes following a polyvinyl alcohol hydrogel implant in the treatment of hallux rigidus.

METHODS

A retrospective cohort study investigating patients treated with a polyvinyl alcohol hydrogel implant for hallux rigidus was performed. Clinical outcomes were evaluated with the Foot and Ankle Outcomes Score (FAOS) and visual analog scale (VAS) score at the final follow-up. Plain radiographs were assessed postoperatively. Eleven patients (11 feet) with a mean follow-up of 20.9 months (range, 14-27 months) were included. The mean age was 60.3 years.

RESULTS

All FAOS subscales showed pre- to postoperative improvements, but there was no statistical significance in all subscales. The mean VAS score showed improvement from 4.1 to 3.0 (P = .012). On postoperative plain radiographs, implant subsidence was observed 60% (6/10) at 4 weeks after surgery and 90% (9/10) at the final follow-up. Fifty percent (5/10) showed radiologic lucency around the implant. Forty percent (4/10) had erosion of the proximal phalanx of the great toe. Four patients (36%) reported no improvement following surgery at the final follow-up, which were considered as failures. Three patients required additional surgery related to the implants. An additional patient is waiting to revise the implant.

CONCLUSION

Our current cohort study demonstrated a high failure rate with the polyvinyl alcohol hydrogel implant in patients with hallux rigidus. Significant radiologic subsidence with lysis around the implant, erosion of the proximal phalanx countersurface, and implant wear are harbingers for concern in the long term.

LEVEL OF EVIDENCE

Level IV, case series.

[Mini implants in foot and ankle surgery: an alternative to total joint replacement or joint fusion]

Mini implants are increasingly used in foot and ankle surgery. They preserve the joints' functions, are easy to insert and easy to convert to an alternative treatment. Early surgical attempts using silastic implants did not bring the expected success. First achievements where reached with modern metallic mini implants in the first metatarsophalangeal (MTP) joint and the ankle joint. For a few years now, a polyvinyl alcohol implant has been used to treat the arthritic first MTP joint. Even severe arthritic joints can be treated with an implant made of polylactide. This implant can also be used in the treatment of Lisfranc joint pathologies. To address severe osteochondral defects of the talus, an innovative hemiarthroplasty implant has been suggested. This article gives a summary of currently used mini implants. Their application as possible alternatives to total joint replacement or joint fusion are critically reviewed in the light of the current literature.

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.

First Metatarsal Phalangeal Joint Arthrodesis without the Use of Hardware after Failed Arthroplasty: A Case Report

Introduction

First metatarsal phalangeal joint (MTPJ) arthroplasty has a high failure rate due to aseptic loosening, which leads to bone loss. The salvage procedure is conversion to an arthrodesis, but bone loss can make obtaining screw fixation difficult. Herein, we report a unique case of revision first-metatarsal arthrodesis without the use of hardware after a failed arthroplasty.

Case Report

A 60-year-old women presented to us with first MTPJ pain in the setting of failed arthroplasty. We performed an arthrodesis; however, intraoperatively, hardware fixation could not be obtained due to bone loss. We utilized allograft bone struts to maintain first ray length and to hold the correct hallux position during arthrodesis maturation.

Conclusion

Bone loss is a frequently encountered problem in revision surgery to a first MTPJ arthrodesis. An arthrodesis can be obtained without the use of hardware in scenarios where bone loss precludes screw fixation.

Joint sparing management of hallux rigidus: Cartiva SCI vs cheilectomy a comparative review

BACKGROUND

Hallux rigidus, or first metatarsophalangeal joing arthritis, is a very common condition which causes pain and loss of motion in the joing which can be debilitating.

METHODS

Patient reported outcome measures were utilised to study the difference in day to day functionality between two common surgical management options for hallux rigidus.

RESULTS

55 Cartiva and 23 Cheilectomy patients were included in this study. The Manchester Oxford Foot and Ankle Questionnaire revealed statistically significant improvements in the cheilectomy patients when compared to Cartiva SCI.Foot and Ankle Ability Measure found no statistical difference was found between the two surgical treatments.

CONCLUSION

Cheilectomy offers good post-operative functional and sporting outcomes after surgery for the management of hallux rigidus at 5 years.

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.

Cartiva case series: The efficacy of the cartiva synthetic cartilage implant interpositional arthroplasty at one year

Background

The Cartiva synthetic cartilage implant (SCI) is licenced for use in management of symptomatic hallux rigidus in several countries including the UK. As of now, there are no independent series for treatment of hallux rigidus utilising polyvinyl alcohol implants.

Methods

Patients at a single centre with symptomatic hallux rigidus who underwent Cartiva implant interpositional arthroplasty were identified. First metatarsophalangeal joint arthritis was radiographically graded according to the Hattrup and Johnson (HJ) classification. Pre-operative and post-operative patient-reported outcomes (PROMs) were evaluated using the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale and the Manchester-Oxford Foot Questionnaire (MOXFQ).

Results

55 patients (14M, 41F) (37R and 18L) were followed up for an average of 21 months (min = 12, max = 38). 14 patients suffered from HJ2/moderate arthritis and 41 patients with grade HJ3/severe arthritis.Post-operative mean FAAM scores showed statistically significant improvement (p < 0.0001). Patients reported a 40% increase in functionality during activities of daily living.All 3 MOXFQ Domain scores improved significantly (p < 0.02). The Index score improved by 34 points (p < 0.0001).There was no correlation between length of follow up or age and PROMs (r = 0.129). No statistical difference was demonstrated between sexes. Clinically, however, males and older patients exhibited better outcomes.

Conclusions

Our study shows excellent results with statistically significant improvements in functional outcomes, and promising short-term follow-up with low early revision rates. Durability and survivability of the implant will continue to be studied in this cohort.

Is adjunction of advanced platelet-rich fibrin (A-PRF) useful in first metatarsophalangeal joint arthrodesis? A retrospective cohort study

PURPOSE

First metatarsophalangeal (MTPJ1) fusion represents the gold standard treatment for end-stage hallux rigidus (HR). The aim of this study was to assess efficacy and safety of A-PRF in promoting union after MTPJ1 arthrodesis. Our hypothesis was that the use of A-PRF may reduce the non-union rate and the time to fusion in the treatment of HR.

METHODS

14 patients that had undergone MTPJ1 arthrodesis with A-PRF adjunction with 21 standard MTPJ1 fusions were retrospectively reviewed. The fusion rate and time to fusion (clinically and radiographically) were assessed at 6, 12 weeks and at the longest follow-up; the clinical status at final follow-up through forefoot AOFAS, EQ5d, SEFAS and VAS-pain scores; the complication rate.

RESULTS

At 6-weeks, bony union was achieved in 100% of patients in the A-PRF group compared to 70% in the control group, but this difference was not statistically significant (p=0.22). At final follow-up (41 months), union rate in the control group reached 92% (one non-union). AOFAS, VAS and EQ-5d scores showed similar results for the two groups (p=0.86, p=0.12 and p=0.61, respectively); only SEFAS score revealed a difference favoring the A-PRF group (p=0.04). No revision surgery or complication was recorded in any group.

CONCLUSIONS

A tendency for increased union rate was mainly found at 6 weeks in patients treated with MTPJ1 fusion associated to A-PRF compared to isolated fusion. The use of A-PRF was not associated with an increased complication rate at final follow-up.

LEVEL OF EVIDENCE

Level 3, therapeutic study, retrospective comparative study.

Silastic first metatarsophalangeal joint arthroplasty for the treatment of end-stage hallux rigidus

AIMS

Arthroplasty for end-stage hallux rigidus (HR) is controversial. Arthrodesis remains the gold standard for surgical treatment, although is not without its complications, with rates of up to 10% for nonunion, 14% for reoperation and 10% for metatarsalgia. The aim of this study was to analyze the outcome of a double-stemmed silastic implant (Wright-Medical, Memphis, Tennessee, USA) for patients with end-stage HR.

METHODS

We conducted a retrospective review of 108 consecutive implants in 76 patients, between January 2005 and December 2016, with a minimum follow-up of two years. The mean age of the patients at the time of surgery was 61.6 years (42 to 84). There were 104 females and four males. Clinical, radiological, patient reported outcome measures (PROMS) data, a visual analogue score (VAS) for pain, and satisfaction scores were collected.

RESULTS

The survivorship at a mean follow-up of 5.3 years (2.1 to 14.1) was 97.2%. The mean Manchester Oxford Foot and Ankle Questionnaire (MOXFQ) scores improved from 78.1 to 11.0, and VAS scores for pain from 7/10 to 1.3/10. The rate of satisfaction was 90.6%. Three implants (2.8%) required revision; one for infection, one-month postoperatively, and two for stem breakage at 10.4 and 13.3 years postoperatively. There was a 1.9% reoperation rate other than revision, 23.1% of patients developed a minor complication, and 21.1% of patients had non-progressive and asymptomatic cysts on radiological review.

CONCLUSION

We report a 97.2% survivorship at a mean follow-up of 5.3 years with this implant. We did not find progressive osteolysis, as has been previously reported. These results suggest that this double-stemmed silastic implant provides a predictable and reliable alternative with comparable outcomes to arthrodesis for the treatment of end-stage HR. Cite this article: Bone Joint J 2020;102-B(2):220-226.

Radiographic and Magnetic Resonance Imaging of the Symptomatic Synthetic Cartilage Implant

BACKGROUND

Synthetic Cartilage Implantation (SCI; Cartiva) is a treatment of hallux rigidus associated with mixed clinical outcomes in the United States. Patients with persistent pain typically undergo diagnostic imaging for evaluation. We aimed to characterize the radiologic findings of SCI and surrounding tissues.

METHODS

This is a retrospective review of patients treated using SCI who underwent magnetic resonance imaging (MRI) for persistent pain. Metatarsophalangeal (MTP) joint spaces were compared on plain radiographs of the foot immediately postoperatively and at most recent follow-up. MRI of the foot were assessed for dimensions of the implant, bony channel, and presence of peri-implant fluid. Clinical follow-up, including Patient-Reported Outcome Measures Informational System (PROMIS) scores, satisfaction rating, and revision surgery, was collected. Eighteen cases of symptomatic SCI from 16 patients (13 females, 3 males) were included. All but 1 case involved a 10-mm implant.

RESULTS

Mean satisfaction rating was 2.25 (1-5 Likert scale). PROMIS scores indicated moderate physical dysfunction (41) and moderate pain interference (63). Six of 16 patients (37.5%) underwent revision surgery at average 20.9 months of follow-up. Plain radiographs over a 13.3-month interval showed joint space narrowing of 2 mm medially and 1.6 mm laterally (P < .001). One hundred percent of cases had radiographic evidence of osteoarthritis (OA) progression. MRI studies were obtained on average 11.5 months postoperatively. The implant diameter averaged 9.7 mm, which mismatched the bony channel diameter of 11.2 mm (P < .001). Fourteen of 18 cases had peri-implant fluid. All cases had edema in the metatarsal, proximal phalanx, and soft tissues.

CONCLUSION

Radiographic loss of MTP joint space and progression of arthritis were present for all cases studied. MRI revealed bony channel widening and a smaller implant, with peri-implant fluid suggesting instability at the implant-bone interface. Persistent edema was observed in soft tissues and bone. Diagnostic imaging of SCI in symptomatic patients demonstrated concerning findings that merit further correlation with patient outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

First Metatarsophalangeal Joint Space Area Decreases Within 1 Month After Implantation of a Polyvinyl Alcohol Hydrogel Implant: A Retrospective Radiographic Case Series

In 2016, the U.S. Food and Drug Administration approved the first and only polyvinyl alcohol hydrogel implant for the treatment of hallux rigidus. The implant functions as a bumper to maintain first metatarsophalangeal joint space to prevent contact of the phalangeal base with the first metatarsal head. Short-term and intermediate outcomes with this implant have reported positive outcomes with no radiographic outcomes of implant wear or subsidence. We performed a retrospective radiographic review of 27 consecutive patients who received the implant and measured preoperative and postoperative joint space area (JSA). We found a significant improvement in JSA (p < .001) between the preoperative JSA and JSA at the first postoperative visit at 1 to 2 weeks. We also found a significant decrease in JSA (p < .001) between the first postoperative visit and the second postoperative visit at 5 to 12 weeks. This information could have further implications for implant design as well as how we can better achieve functional improvements in the first metatarsophalangeal joint in patients with hallux rigidus.

Is interposition arthroplasty a viable option for treatment of moderate to severe hallux rigidus? - A systematic review and meta-analysis

INTRODUCTION

When conservative therapy for hallux rigidus fails, surgical options such as arthrodesis and interposition arthroplasty can be considered. Although arthrodesis of MTP joint is the gold standard treatment. However patients desiring MTP joint movement may opt for either interposition arthroplasty or implant arthroplasty to avoid the movement restrictions of arthrodesis. The purpose of this systematic review was to investigate clinical outcomes and complications following interposition arthroplasty for moderate to severe hallux rigidus, for patietns who would prefer to maintain range of motion in the MTP joint.

METHODS

A systematic search on MEDLINE, EMBASE and Cochrane library database was performed during February 2018. Demographics, surgical techniques, clinical outcomes, radiological outcomes and complications were recorded from each included study. Pooled statistics performed for variables with homogenous data across the studies. A linear regression model used to compare the clinical outcomes between autogenous vs allogenous material interposition arthroplasty.

RESULTS

Fifteen articles were included in the systematic review. Mean AOFAS scores improved from preoperative 41.35 to postoperative 83.17. Mean pain, function, and alignment score improved from preoperative values of 14.9, 24.9, and 10 to postoperative values of 33.3, 35.8, and 14.5. Mean dorsiflexion increased from 21.27° (5-30) to 42.03° (25-71). Mean ROM improved from 21.06° to 46.43°. Joint space increased from 0.8mm to 2.5mm. The most common postoperative complications included metatarsalgia (13.9%), loss of ground contact (9.7%), osteonecrosis (5.4%), great toe weakness (4.8%), hypoesthesia (4.2%), decreased push off power (4.2%), and callous formation (4.2%).

CONCLUSION

Interposition arthroplasty is an effective treatment option with acceptable clinical outcomes in patients with moderate-severe hallux rigidus who prefer to maintain range of motion and accept the risk of future complications.

LEVEL OF EVIDENCE

IV.

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.

Midterm Outcomes of a Synthetic Cartilage Implant for the First Metatarsophalangeal Joint in Advanced Hallux Rigidus

BACKGROUND:

A prospective, randomized, noninferiority clinical trial of synthetic cartilage implant hemiarthroplasty for hallux rigidus demonstrated functional outcomes and safety equivalent to first metatarsophalangeal (MTP) joint arthrodesis at 24 months. We prospectively assessed safety and efficacy outcomes for synthetic cartilage implant hemiarthroplasty at a minimum of 5 years.

METHODS:

Of 135 eligible patients from the original trial, 112 (83.0%) were enrolled (mean age, 58.2 ± 8.8 years; 87 females). Pain visual analog scale (VAS), Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL), and FAAM Sports subscales were completed preoperatively and 2 and 5 years postoperatively. Great toe active dorsiflexion, weightbearing radiographs, secondary procedures, and safety parameters were also evaluated.

RESULTS:

At 24 months, 14/152 (9.2%) patients had undergone implant removal and conversion to arthrodesis. In years 2 to 5, 9/119 (7.6%) patients underwent implant removal and conversion to arthrodesis. At mean 5.8 ± 0.7 (range, 4.4-8.0) years' follow-up, pain VAS, FAAM ADL, and FAAM Sports scores improved by 57.9 ± 18.6 points, 33.0 ± 17.6 points, and 47.9 ± 27.1 points, respectively, from baseline. Clinically significant changes in VAS pain, FAAM ADL, and FAAM Sports were reported by 103/106 (97.2%), 95/105 (90.5%), and 97/104 (93.3%) patients, respectively. Patient-reported outcomes at 24 months were maintained at 5.8 years in patients who were not revised. Active MTP joint peak dorsiflexion was maintained. Ninety-nine of 106 (93.4%) patients would have the procedure again.

CONCLUSION:

Clinical and safety outcomes for synthetic cartilage implant hemiarthroplasty observed at 2 years were maintained at 5.8 years. The implant remains a viable treatment option to decrease pain, improve function, and maintain motion for advanced hallux rigidus.

LEVEL OF EVIDENCE:

Level IV, case series.

Long-Term Outcomes of Corrective Osteotomies Using Porous Titanium Wedges for Flexible Flatfoot Deformity Correction

Common corrective osteotomies used in flexible flatfoot deformity reconstruction include Cotton and Evans osteotomies, which require structural graft to maintain correction. Auto-, allo-, and xenografts are associated with a number of limitations, including disease transmission, rejection, donor site morbidity, technical challenges related to graft fashioning, and graft resorption. Porous titanium is a synthetic substance designed to address these flaws; however, few studies have been reported on the efficacy, safety, and long-term outcomes. A multicenter retrospective cohort of 63 consecutive preconfigured porous titanium wedges (PTWs) used in flexible flatfoot reconstructions from June 1, 2009 to June 30, 2015 was evaluated. The primary outcome measure was the pre- to postdeformity correction efficacy. The secondary outcomes included maintenance of correction at a minimum follow-up point of 12 months, complications, graft incorporation, and graft safety profile. Multivariate linear regression found a statistically significant improvement in all radiographic parameters from preoperatively to the final weightbearing radiographs (calcaneocuboid 18.850 ± 4.020 SE, p < .0001; Kite's, 7.810 ± 3.660 SE, p = .04; Meary's 13.910 ± 3.100 SE, p = .0001; calcaneal inclination, 5.550 ± 2.140 SE, p = .015). When restricted to patients with >4 years of follow-up data, maintenance of correction appeared robust in all 4 measurements, demonstrating a lack of bone or graft resorption. No patients were lost to follow-up, no major complications or implant explantation or migration occurred, and all implants were incorporated. Minor complications included hardware pain from plates over grafts (8%), 1 case of scar neuritis, and a 5% table incidence of transfer pain associated with the PTWs. These results support the use of PTWs for safety and degree and maintenance of correction in flatfoot reconstruction.

Allograft Tendon Interposition Arthroplasty of the Hallux Metatarsophalangeal Joint: A Technique Guide and Literature Review

The "anchovy" interpositional arthroplasty technique can be used as a salvage option for failed hallux rigidus procedures. The operative technique utilized by the senior author is described. Careful soft-tissue handling, meticulous joint space and graft preparation, and interposition graft stabilization using a bone tunnel and suture anchors are unique aspects of this technique, which in the authors' experience have contributed to improved outcomes. Current literature regarding indications and outcomes is limited and controversial. The proposed benefits of soft-tissue interposition arthroplasty of the hallux metatarsophalangeal joint for patients with prior failed implant arthroplasty are improved pain scores and preservation of range of motion. Level of Evidence: Level V, technique guide.

Titanium Scaffolding: An Innovative Modality for Salvage of Failed First Ray Procedures

Shortening of the first ray is a potential complication associated with first metatarsal procedures. Correction of this deformity conventionally has required the use of a tricortical bone graft to lengthen the bone. Graft complications, including donor site morbidity, poor graft stability, and graft resorption, have revealed a need for an alternative procedure. The present report shows that titanium cage scaffolding has lower extremity applications beyond its previous uses in the ankle and spine. Two patients underwent surgical correction for failed first ray procedures using a titanium cage apparatus with a calcaneal autograft and other biologic agents. The scaffolds were appropriately sized to fill the defect. Patients remained non-weightbearing until radiographic evidence of healing appeared. Success was determined by diminished pain, a return to activity, ambulation, and patient satisfaction. Patients exhibited faster-than-anticipated healing, including a return to protected weightbearing activities and increased stability within 6 weeks. Titanium cage implants provide long-term stability and resistance to stress and strain in the forefoot. The implant we have described, newly applied to the first ray, is analogous to a system used in salvage of failed ankle replacements. In addition to reducing reliance on the iliac crest bone graft, the titanium cage apparatus is advantageous because it is customized to fill a defect using computed tomography scanning, thereby reducing graft failure secondary to an improper shape. These cases demonstrate the potential beneficial applications for titanium cages in failed first ray reconstruction.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A prospective 24 months follow-up of a three component press-fit prosthesis for hallux rigidus

BACKGROUND

The aim of this study was to evaluate the results following total first metatarsophalangeal (FMTP) joint replacement arthroplasty using a modular three component press fit prosthesis at two year follow up.

METHODS

All patient data was collected in a prospective way in four study centres. Both preoperative and postoperative evaluation consisted of an assessment using the AOFAS-HMI score, visual analogue scale for pain, evaluation of the range of motion and patient satisfaction scores. Postoperative X-rays were reviewed for loosening and radiolucency up to two years.

RESULTS

Fifty-five feet were available for analysis at 24 months. Two implants were removed during the study. Six more feet had additional surgery due to stiffness or malalignment. Postoperative AOFAS-HMI scores improved significantly by 32.4 points at two year follow-up (p<0.001). The visual analogue scale for pain improved significantly from 6.8 (std 1,6) preoperatively to 1.6 (std 1,9) postoperatively (p<0.0001). Mean dorsiflexion improved from 12.6 (std 10,1) degrees preoperatively to 31.2 (std 16,8) degrees postoperatively. Eighty-seven percent of patients were moderately to well satisfied with the end result. Eighteen prostheses showed radiolucency at 24 months.

CONCLUSION

Implantation of a Metis^® modular three component press fit prosthesis for the metatarsophalangeal joint in hallux rigidus shows significant improvement in AOFAS-HMI scores and a decrease in pain. Concerns remain with regard to early reoperation rate (14.5%) and long term survival of the implant. Future studies will have to address these aspects.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV case series.

First Metatarsal-Phalangeal Joint Arthrodesis: Primary, Revision, and Salvage of Complications

Arthrodesis of the first metatarsal-phalangeal joint has been proposed for treatment of severe hallux valgus, end-stage hallux rigidus, rheumatoid arthritis, and revision of failed surgery due to the perceived safety and efficacy. This article discusses the principles of first metatarsal-phalangeal joint arthrodesis in primary and revision situations, joint preparation, configurations of osteosynthesis, and common complications, including salvage of nonunion and revision of malunion with realignment osteotomy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Distraction First Metatarsophalangeal Arthrodesis With Tricortical Calcaneus Autograft: Technique Tips

First metatarsophalangeal joint arthritis can stem from a biomechanical imbalance as in hallux abducto valgus, metabolic arthritidies such as rheumatoid or gout, and even in posttraumatic cases. Advanced arthritis in the foot and ankle can often become debilitating. Surgical intervention is often necessary. Revision of failed first metatarsophalangeal joint arthroplasty is often in the setting of bony erosion and lysis, cystic changes, and loss of bone stock. In this article, we describe first metatarsophalangeal distraction arthrodesis technique using tricortical calcaneus autograft with the aim of simplifying donor site graft harvesting and decreasing donor site morbidity while attaining successful osseous union.

LEVELS OF EVIDENCE

Level V.

Total Toe Replacement in the United States: What Is Known and What Is on the Horizon

Arthritis of the first metatarsophalangeal is a common problem of the forefoot. The gold standard surgical treatment has been fusion of the first metatarsophalangeal joint. Many patients are unwilling to accept pain relief at the expense of loss of motion and the corresponding loss of shoe wear choices and activities requiring dorsiflexion of the hallux. Early implants were plagued with loosening and continued pain but implants have evolved. Current implants use modern bearing surfaces with press-fit fixation. These implants have renewed optimism for total toe arthroplasty. This article reviews the literature for implants currently available and describes the surgical techniques.

Prospective, Randomized, Multi-centered Clinical Trial Assessing Safety and Efficacy of a Synthetic Cartilage Implant Versus First Metatarsophalangeal Arthrodesis in Advanced Hallux Rigidus

BACKGROUND

Although a variety of great toe implants have been tried in an attempt to maintain toe motion, the majority have failed with loosening, malalignment/dislocation, implant fragmentation and bone loss. In these cases, salvage to arthrodesis is more complicated and results in shortening of the ray or requires structural bone graft to reestablish length. This prospective study compared the efficacy and safety of this small (8/10 mm) hydrogel implant to the gold standard of a great toe arthrodesis for advanced-stage hallux rigidus.

METHODS

In this prospective, randomized non-inferiority study, patients from 12 centers in Canada and the United Kingdom were randomized (2:1) to a synthetic cartilage implant or first metatarsophalangeal (MTP) joint arthrodesis. VAS pain scale, validated outcome measures (Foot and Ankle Ability Measure [FAAM] sport scale), great toe active dorsiflexion motion, secondary procedures, radiographic assessment, and safety parameters were evaluated. Analysis was performed using intent-to-treat (ITT) and modified ITT (mITT) methodology. The primary endpoint for the study consisted of a single composite endpoint using the 3 primary study outcomes (pain, function, and safety). The individual subject's outcome was considered a success if all of the following criteria were met: (1) improvement (decrease) from baseline in VAS pain of ≥30% at 12 months; (2) maintenance of function from baseline in FAAM sports subscore at 12 months; and (3) absence of major safety events at 2 years. The proportion of successes in each group was determined and 1-sided 95% confidence interval for the difference between treatment groups was calculated. Noninferiority of the implant to arthrodesis was considered statistically significant if the 1-sided 95% lower confidence interval was greater than the equivalence limit (<15%). A total of 236 patients were initially enrolled; 17 patients withdrew prior to randomization, 17 patients withdrew after randomization, and 22 were nonrandomized training patients, leaving 152 implant and 50 arthrodesis patients. Standard demographics and baseline outcomes were similar for both groups.

RESULTS

VAS pain scores decreased significantly in both the implant and arthrodesis groups from baseline at 12 and 24 months. Similarly, the FAAM sports and activity of daily living subscores improved significantly at 12 and 24 months in both groups. First MTP active dorsiflexion motion improvement was 6.2 degrees (27.3%) after implant placement and was maintained at 24 months. Subsequent secondary surgeries occurred in 17 (11.2%) implant patients (17 procedures) and 6 (12.0%) arthrodesis patients (7 procedures). Fourteen (9.2%) implants were removed and converted to arthrodesis, and 6 (12.0%) arthrodesis patients (7 procedures [14%]) had isolated screws or plate and screw removal. There were no cases of implant fragmentation, wear, or bone loss. When analyzing the ITT and mITT population for the primary composite outcome of VAS pain, function (FAAM sports), and safety, there was statistical equivalence between the implant and arthrodesis groups.

CONCLUSION

A prospective, randomized (2:1), controlled, noninferiority clinical trial was performed to compare the safety and efficacy of a small synthetic cartilage bone implant to first MTP arthrodesis in patients with advanced-stage hallux rigidus. This study showed equivalent pain relief and functional outcomes. The synthetic implant was an excellent alternative to arthrodesis in patients who wished to maintain first MTP motion. The percentage of secondary surgical procedures was similar between groups. Less than 10% of the implant group required revision to arthrodesis at 2 years.

LEVEL OF EVIDENCE

Level I, prospective randomized study.

Dual plating with bone block arthrodesis of the first metatarsophalangeal joint: A clinical retrospective review

BACKGROUND

First metatarsal phalangeal joint (MTP) arthrodesis is challenging in the setting of bone loss. The purpose of this study was to describe the results of interpositional grafting and arthrodesis of the first MTP joint using two plates in a 90/90 configuration.

MATERIALS AND METHODS

Eleven patients had an MTP arthrodesis with 90-90 plating with an interpositional allograft. We analyzed the fusion rate, restoration of first ray length, patient satisfaction, and complication rates.

RESULTS

The overall union rate was 90.9%, with an average restoration of 11 ± 4.5mm in length to the first ray. The average time to fusion was 10.7 ± 1 weeks. The mean preoperative AOFAS score improved significantly. The complication rate was 18.2% and included one superficial wound infection and one non-union who underwent a successful fusion after revision.

CONCLUSION

Arthrodesis of the first MTP joint with two 90/90 plates and restoration of length using an interpositional graft has excellent patient satisfaction and functional outcomes.

Radiographic Outcomes Following Lateral Column Lengthening With a Porous Titanium Wedge

BACKGROUND

Lateral column lengthening (LCL) is commonly utilized in treating stage II posterior tibialis tendon dysfunction. This study aimed to analyze the outcomes of LCL with porous titanium wedges compared to historic controls of iliac crest autograft and allograft. We hypothesized that the use of a porous titanium wedge would have radiographic improvement and union rates similar to those with the use of autograft and allograft in LCL.

METHODS

Between May 2009 and May 2014, 28 feet in 26 patients were treated with LCL using a porous titanium wedge. Of the 26 patients, 9 were males (34.6%). The average age for males was 43 years (range, 17.9-58.7), 48.7 years (range, 21-72.3) for females. Mean follow-up was 14.6 months. Radiographs were examined for correction of the flatfoot deformity and forefoot abduction. All complications were noted.

RESULTS

Radiographically, the patients had a significant deformity correction in the anteroposterior talo-first metatarsal angle, talonavicular coverage angle, lateral talo-first metatarsal angle, and calcaneal pitch. All but 1 patient (96%) had bony incorporation of the porous titanium wedge. The average preoperative visual analog scale pain score was 5; all patients but 3 (12%) had improvements in their pain score, with a mean change of 3.4.

CONCLUSION

LCL with porous titanium had low nonunion rates, improved radiographic correction, and pain relief.

LEVEL OF EVIDENCE

Level IV, case series.

First Metatarsophalangeal Joint Arthrodesis Technique With Interposition Allograft Bone Block

BACKGROUND

We present a technique of first metatarsophalangeal joint arthrodesis utilizing an interposition allograft bone block with a bipolar reaming technique that creates congruent fusion surfaces on both ends of the graft-host bone interface. In addition, we examined the union rates, fusion position, patient satisfaction, and functional outcome of this technique.

METHODS

Fifteen patients underwent first metatarsophalangeal joint arthrodesis with an interposition allograft bone block between September 2004 and October 2013. Charts and radiographs were reviewed. Six measures were compared on preoperative and postoperative radiographs. Clinical outcomes were measured using a telephone questionnaire, pre- and postoperative visual analog scale pain scale, and Foot and Ankle Ability Measure. Average follow-up was 46 weeks (range, 19 to 97).

RESULTS

Thirteen of 15 (87%) patients achieved bony union at an average of 21 weeks. One patient underwent revision arthrodesis for their nonunion. Symptomatic hardware was removed in 3 cases. Improvement was noted in visual analog scale pain scores (6 to 2) and functional scores as measured by the Foot and Ankle Ability Measure. There were no postoperative wound complications or infections. Average length of the first ray on anteroposterior radiograph increased from 10.7 to 11.3 cm and from 10.0 to 10.7 cm on the lateral radiograph. Thirteen of 14 patients were very satisfied or satisfied. One patient expressed dissatisfaction with the procedure. One patient was not available for clinical follow-up.

CONCLUSION

First metatarsophalangeal joint allograft bone block arthrodesis using the bipolar reaming technique achieved high bony union rates and satisfactory radiographic and clinical outcomes. This procedure was an effective salvage option for managing bone loss on 1 or both sides of the joint.

LEVEL OF EVIDENCE

Level IV, retrospective case series.