Hallux rigidus

ACFAS Clinical Consensus Statements: Hallux Rigidus

The following are clinical consensus statements (CCS) on the topic of hallux rigidus sponsored by the American College of Foot and Ankle Surgeons. A core panel synthesized the data and divided the topic in to twelve sections, each section contained a variable number of consensus statements, based upon complexity. Overall there were 24 consensus statements synthesized for this subject matter. The 24 statements were provided to the expert panel with all available evidence to come to a consensus utilizing all available evidence.

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.

The Role of the Flexor Hallucis Longus in the Treatment of the Painful Hallux Metatarsophalangeal Joint

BACKGROUND

Pain in the hallux metatarsophalangeal joint (MTPJ) is very common, yet the underlying etiology remains unknown. Previous clinical research and biomechanical research has implicated stenosing flexor hallucis longus (FHL) tendonitis as a possible cause. The hypothesis of this study was that treatment solely focusing on alleviating restricted FHL excursion would be beneficial in patients with hallux MTPJ pain.

METHODS

This is a retrospective study of those treated in the Foot & Ankle Division between January 2009, and December 2018, who were diagnosed with FHL tendonitis with associated pain in the hallux MTPJ. Demographics, comorbidities, examination findings, imaging results, pain scores, treatment instituted, and outcome was obtained from the electronic medical record. The primary outcome was the improvement in the pain score (visual analog scale [VAS]). The surgical patients were included if their procedure was solely related to the FHL (posteromedial ankle release ± os trigonum resection). The decision to have surgery was analyzed by univariate and multivariable statistics using demographics, comorbidities, and clinical findings as potential factors (P < .05).

RESULTS

In 75% (59 of 79 feet), nonoperative treatment of FHL stenosis resulted in a decrease in pain scores that the patients felt was satisfactory. The operative group that had an FHL release showed decreased pain in 90% (18 of 20 feet). Multivariable analysis identified the need for immobilization (OR 9.8, 95% CI 1.8-55.2, P = .009), participating in athletics (OR 8.7, 95% CI 1.8-42.2, P = .007), and higher initial VAS (OR 1.7, 95% CI 1.3-2.3, P < .001) as being associated with the decision for surgery.

CONCLUSION

Previous biomechanical studies have suggested that stenosing FHL synovitis can cause increased intraarticular loading in the hallux MTPJ. The current clinical study supports this hypothesis, demonstrating that treatment focused on relieving restricted FHL excursion can ameliorate pain in the hallux MTPJ in select cases.

Quantification of First Metatarsal Joint Surface Interactions in Hallux Rigidus Using Distance and Coverage Mapping: A Case-Control Study

BACKGROUND

Weightbearing cone-beam computed tomography (WBCT) has proven useful for analysis of structural changes of the foot and ankle when compared to conventional radiographs. WBCT allows for extraction of distance and coverage mapping metrics, which may provide novel insight into hallux rigidus (HR). This study retrospectively assessed HR joint space using distance and coverage mapping in a case-control study.

METHODS

WBCT images of the foot and ankle for 20 symptomatic HR and 20 control patients were obtained. Three-dimensional models were created and analyzed using a custom semiautomatic measurement algorithm. Distance and coverage mapping metrics for the first metatarsophalangeal and metatarsosesamoid joints were extracted from the models and compared between cohorts. Relationships between these metrics and visual analog scale (VAS) scores, a patient-reported outcome of pain, were assessed in HR patients.

RESULTS

Overall first metatarsophalangeal joint space narrowing was noted in HR patients when compared to controls by an average of 11.8% (P = .02). However, no significant changes in the overall coverage of the joint were noted. Decreased joint space width and increased surface-to-surface coverage were only and particularly observed at the plantar medial quadrant of the first metatarsal head in HR patients relative to controls. VAS score was significantly but weakly correlated with dorsolateral quadrant coverage (R2 = 0.26, P = .03).

CONCLUSION

Distance and coverage mapping serve as a complementary option to current techniques of quantifying HR changes. These metrics can expand the scope of future work investigating joint articulation changes in HR.

Effect of Prior Cheilectomy on Outcomes of First Metatarsophalangeal Joint Fusion

Cheilectomy, a joint-conserving procedure, is often a first-line choice for treating early stages of hallux rigidus. Recent evidence has revealed its efficacy in treating more advanced stages. However, when degeneration is profound, first metatarsophalangeal (MTP) fusion remains the most appropriate strategy. Nevertheless, it is common for surgeons to proceed initially with cheilectomy, reserving joint fusion for subsequent considerations if cheilectomy fails. This article will explore the relationship between the 2 procedures and evaluate the research surrounding the effect of prior cheilectomy on first MTP joint arthrodesis.

Moberg and Moberg-Akin ('Mo-Akin') Osteotomies for Hallux Rigidus

Hallux rigidus represents the arthritis affecting the first metatarsophalangeal joint. It often leads to limited dorsiflexion, affecting gait and causing pain. Moberg osteotomy involves a dorsal closing wedge osteotomy on the proximal phalanx performed for early stages of hallux rigidus. This osteotomy shifts the load to the plantar aspect and compensates for the limited dorsiflexion. Moberg osteotomy can be combined with Akin osteotomy to create a biplanar correction for hallux interphalangeus. The procedure has favorable outcomes and high patient satisfaction rates with low complications. Larger high-quality studies are required to draw further on its benefits.

Arthrodesis for Hallux Rigidus

First metatarsophalangeal (MTP) joint fusion, or arthrodesis, has been a cornerstone treatment for advanced joint degeneration since the 1950s, benefiting not only older patients but also younger individuals. The procedure boasts favorable long-term outcomes and a low rate of revision when fusion is successful. However, complications such as interphalangeal arthritis may occur, and nonunion or malunion can necessitate revision. While the first MTP fusion provides significant relief, its applicability varies, underscoring the need for careful patient selection.

High Preoperative Pain Score is a Predictor of Cheilectomy Failure in Hallux Rigidus

Hallux rigidus (HR) is a prevalent arthritic condition in the foot. Cheilectomy is a common joint-preserving procedure for HR, involving the removal of prominent osteophytes to relieve impingement of the 1st MTPJ. This study aims to identify factors associated with the failure of cheilectomy in the treatment of HR. A retrospective review of a prospectively collected database from 2007 to 2021 identified all cheilectomy cases. The minimum follow-up was 2 years. Preoperative demographic data, patient-reported outcome measures (PROMs) and foot radiographs were collected. PROMs were reassessed in postoperative reviews, and cases were categorized as successes or failures. Failure was defined by meeting at least one of the following criteria at the latest review: 1) Visual analog pain score (VAS) more than or equal to 4, 2) undergoing subsequent revision procedures, or 3) reporting poor or terrible satisfaction with the surgery. The analysis involved 66 patients, with 19 failure and 47 success cases. Both groups showed similar age, BMI, and gender profiles. Preoperative radiographic parameters were comparable between groups. However, preoperative VAS was significantly higher in the failure group: 7.16 vs 5.23 (p = .0029). Logistic regression confirmed preoperative VAS as a predictor of nonresponse (p = .023). Receiver Operating Characteristic analysis established an optimal cut-off VAS score of 7.0. Patients with a preoperative VAS score of more than 7 had an odds ratio of 5.11 (p = .0055) for failure. A higher preoperative VAS score is significantly associated with cheilectomy failure in HR treatment, suggesting a cutoff score of 7.0.

Revision Surgery After Failed Index Synthetic Cartilage Implant Resurfacing for Hallux Rigidus: Single-Surgeon 5-Year Experience

BACKGROUND

While metatarsophalangeal joint (MTPJ) arthrodesis is regarded as the gold standard treatment option for end-stage hallux rigidus (HR), synthetic cartilage implant (SCI) resurfacing has gained popularity. This study aimed to identify the SCI resurfacing failure rate for a single surgeon, while also comparing clinical outcomes of patients who underwent SCI replacement or MTPJ arthrodesis after failed index SCI resurfacing.

METHODS

Health records were queried from 2016 to 2021 for patients with HR who were treated with SCI resurfacing by a single surgeon. Preoperative and postoperative range of motion, visual analog scale (VAS) pain scores, and hallux valgus angles were compared. A subgroup analysis was performed on patients who underwent revision with SCI replacement or MTPJ arthrodesis. SCI replacement included the use of bone graft, bone putty, or a custom 3D printed baseplate to prevent implant subsidence.

RESULTS

A total of 219 SCI resurfacing procedures were performed by a single surgeon, including 23 revisions. When analyzing index procedures, an 8.2% revision rate was determined. The revision cohort (n = 23) consisted of 19 female patients and presented with a mean body mass index of 29.5 ± 5 kg/m2, mean age of 52.8 ± 11 years, mean follow-up duration of 22.3 (range, 3-54) months, and mean time to a revision surgery of 12.1 ± 12 (range, 1-50) months. Specifically, 12 procedures resulted in an SCI replacement, while 11 procedures resulted in arthrodesis. While all patients experienced significant improvement in their VAS pain scores (P < .001), the arthrodesis cohort experienced a greater improvement than the SCI revision cohort (P = .04).

CONCLUSION

When analyzing SCI revision procedures, MTPJ arthrodesis reduced pain more significantly than SCI replacement.

LEVELS OF EVIDENCE

Level IV: Retrospective case series.

A prospective comparison of WALANT technique and general anesthesia in forefoot surgery

INTRODUCTION

Wide Awake Local Anesthesia No Tourniquet (WALANT) technique has been widely used in hand surgery, but there are few prospective data on its use in forefoot surgery.

HYPOTHESIS

The WALANT technique reduces pain compared to general anesthesia for bone surgery on the first ray of forefoot.

METHODS

This was a prospective, longitudinal, comparative, non-randomized cohort study in adult patients undergoing bone surgery on the first ray of forefoot. The primary objective was the level of pain (0-10 visual analogic scale) 4 h after the procedure with WALANT technique versus general anesthesia supplemented by ropivacaine infiltration.

RESULTS

A total 37 patients were analyzed in the WALANT group and 24 in the general anesthesia group (women, 90.2%; mean age, 51.3 years; hallux valgus, 85.2%; first metatarsal osteotomy, 80.3%). After generalized linear regression adjusted on a priori defined factors, there was no statistically difference for pain ≤3 at 4 h in WALANT vs. general anesthesia (odds-ratio 1.66; 95% CI, 0.17-20.49; p = 0.2548). At 24 h, pain level was also comparable in the two groups. Time spent in operating room was significantly shorter with WALANT (40.8 vs. 49.7 min; p = 0.0001). Mean length of stay in the recovery room was also significantly shorter with WALANT (4.4 vs. 75.6 min; p < 0.0001). Anxiety before/after surgery, uptake of analgesic/anti-inflammatory drugs and quality of life were comparable in the two anesthesia groups.

CONCLUSION

Postoperative pain with WALANT technique or general anesthesia was comparable. Time spent in the operating room and in recovery room was significantly shorter with WALANT technique.

LEVEL OF EVIDENCE

III; prospective non-randomized comparative study.

A Comparison of PROMIS Scores of Metatarsophalangeal Joint Arthrodesis and Polyvinyl Alcohol Hydrogel Implant Hemiarthroplasty for Hallux Rigidus

Background

The current literature shows similar clinical outcomes between first metatarsophalangeal (MTP) joint arthrodesis and synthetic cartilage implant (SCI) hemiarthroplasty in the treatment of hallux rigidus; however, prior studies have not reported validated patient-reported outcome measures (PROMs). To our knowledge, this is the first study to compare PROMs using 6 domains of the validated Patient-Reported Outcomes Measurement Information System (PROMIS) in patients treated for hallux rigidus with MTP joint arthrodesis and with SCI hemiarthroplasty. In addition, this novel study provides comparative data on the complication and revision rates for each procedure.

Methods

A single-center, retrospective registry search identified all patients with preoperative PROMIS scores who underwent MTP joint arthrodesis or SCI hemiarthroplasty for hallux rigidus between February 2016 and June 2021. The study aimed to determine if the 2 procedures showed statistically or clinically equivalent PROMIS scores in 6 domains: physical function, pain interference, pain intensity, global physical health, global mental health, and depression. A multivariable linear regression analysis was performed to compare adjusted 1-year postoperative PROMIS scores between the 2 cohorts. Complication and revision rates were also compared.

Results

The study included 82 patients who underwent SCI hemiarthroplasty and 101 who underwent MTP joint arthrodesis. Demographic data and preoperative hallux rigidus severity showed no significant differences between the cohorts. PROMIS scores were mostly comparable between the 2 groups, except for the pain intensity domain. The patients who underwent MTP joint arthrodesis exhibited significantly better pain relief at 1 and 2 years postoperatively, which was supported by adjusted postoperative PROMIS scores. At 2 years, the SCI group had worse pain intensity scores and lower global physical health scores. There were no differences between the cohorts in additional PROMIS scores or complication data.

Conclusions

While outcomes in most of the domains were similar, MTP joint arthrodesis was more effective at mitigating pain intensity compared with SCI hemiarthroplasty. This information can guide patient counseling and decision-making when considering surgical intervention for hallux rigidus.

Level of Evidence

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparing the Clinical Outcomes of Percutaneous Cheilectomy to Open Cheilectomy With Moberg Osteotomy for the Treatment of Hallux Rigidus

Background

Both an open cheilectomy with a Moberg osteotomy and percutaneous cheilectomy have been successfully used to treat hallux rigidus and preserve motion.However, there have been no studies that have compared these 2 procedures using validated patient-reported outcomes such as the Patient Reported Outcome Measurement Information System.

Methods

A retrospective review of hallux rigidus patients between January 2016 and July 2021 collected 48 percutaneous cheilectomy (PC) patients and 71 open cheilectomy with Moberg (OCM) patients. Preoperative and minimum 1-year postoperative PROMIS scores were collected.

Results

The OCM and PC cohorts did not have significant differences in their postoperative PROMIS scores. Both cohorts had modest but significant improvements postoperatively in the physical function, pain interference, and pain intensity domains. The OCM group had a larger degree of improvement in physical function, pain interference, and pain intensity (P = .015, .011, .001, respectively). No significant difference was identified in the reoperation rate.

Conclusion

Patients undergoing an OCM had worse preoperative PROMIS scores and a modestly greater change in patient-reported outcomes than patients undergoing a PC.

Level of Evidence

Level III, retrospective review.

Outcomes following minimally invasive dorsal cheilectomy for hallux rigidus: A systematic review

BACKGROUND

Cheilectomy of the 1st metatarsophalangeal joint (MTPJ) is one of the most common procedures for the management of hallux rigidus. However, there is no consensus regarding outcomes following minimally invasive dorsal cheilectomy (MIDC) for the management of hallux rigidus.

AIM

To evaluate outcomes following MIDC for the management of hallux rigidus.

METHODS

During November 2023, the PubMed, EMBASE and Cochrane Library databases were systematically reviewed to identify clinical studies examining outcomes following MIDC for the management of hallux rigidus.

RESULTS

Six studies were included. In total, 348 patients (370 feet) underwent MIDC for hallux rigidus at a weighted mean follow-up of 37.9 ± 16.5 months. The distribution of patients by Coughlin and Shurna's classification was recorded in 4 studies as follows: I (58 patients, 27.1%), II (112 patients, 52.3%), III (44 patients, 20.6%). Three studies performed an additional 1st MTPJ arthroscopy and debridement following MIDC. Retained intra-articular bone debris was observed in 100% of patients in 1 study. The weighted mean American orthopedic foot and ankle society score improved from a preoperative score of 68.9 ± 3.2 to a postoperative score of 87.1. The complication rate was 8.4%, the most common of which was persistent joint pain and stiffness. Thirty-two failures (8.7%) were observed. Thirty-three secondary procedures (8.9%) were performed at a weighted mean time of 8.6 ± 3.2 months following the index procedure.

CONCLUSION

This systematic review demonstrated improvements in subjective clinical outcomes together with a moderate complication rate following MIDC for the management of hallux rigidus at short-term follow-up. A moderate re-operation rate at short-term follow-up was recorded. The marked heterogeneity between included studies and paucity of high quality comparative studies limits the generation of any robust conclusions.

Long-term outcomes of first metatarsophalangeal hemiarthroplasty for hallux rigidus

Hallux rigidus (HR) is arthritis of the first metatarsophalangeal joint.First metatarsophalangeal joint hemiarthroplasty surgery is one of the treatment options for end stage hallux rigidus.The aim of this study is to evaluate the long-term outcomes of hemiarthroplasty of the first MTPJ with a metallic implant in patients with end-stage HR. Patients who underwent hemiarthroplasty surgery with the diagnosis of HR were included in the study. Self-Administered Foot Evaluation Questionnaire (SAFE-Q) and Foot and Ankle Disability Index (FADI) scores were used in pre-operative and post-operative final follow-ups to evaluate the clinical status of the patients. Post-operative 1st metatarsophalangeal joint range of motion was measured and recorded separately for each patient. The intra-hospital and follow-up complications and revision surgeries of the patients were recorded. Thirty-five patients with a mean follow-up of 8.1 years were included in the study. There was a statistically significant positive change in both FADI and SAFE-Q scores compared to the pre-operative process(p = 0.0001). The average dorsiflexion angle at the final follow-up was 22.0 ± 8.2. Thus, it was determined that the 5-year and 8-year survival rates of patients in this study were 97.1% and 87.8%, respectively. In conclusion, the long-term results show that the use of hemiarthroplasty in the treatment of end-stage HR leads to high patient satisfaction, increased range of motion and a high survival rate.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

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.

Arthrodesis vs arthroplasty for moderate and severe Hallux rigidus: Systematic review

Hallux rigidus is the most frequent arthritis of the foot, due to multiple factors. Arthrodesis and interposition arthroplasty are treatments considered in advanced stages of the disease, when conservative treatment has failed. Although arthrodesis may be considered the technique recommended by multiple authors, for patients in whom joint mobility is to be preserved, arthroplasty could represent a reliable alternative. The purpose of this systematic review is to investigate and compare the clinical outcomes and complications of arthrodesis and interposition arthroplasty for moderate and severe stages of hallux rigidus.

METHODS

For this systematic review we searched COCHRANE, EMBASE, PUBMED databases. Twenty-six research papers were obtained, with a total of 1348 feet, which were included for qualitative analysis. The following groups were included: Cartiva hemiarthroplasty (286), double stem silicone arthroplasty (276), total metallic arthroplasty (394) and arthrodesis (392).

RESULTS

In the arthrodesis group, the AOFAS-HMI score was the most used, ranging from 36 to 45 in the preoperative period and from 79 to 89 in the postoperative period. The greatest improvement in the VAS PAIN score was from 86 to 4. The fusion rate was 98.6% of the total number of cases, the most frequent complication was pain due to material discomfort. In the total metallic arthroplasty group, the ROTO-GLIDE system reported an AOFAS score of 95 points, with low complication rates; but, with the TOEFIT-PLUS and BIOMED-MERCK systems, despite the good postoperative value, they report 37% and 15% revision due to aseptic loosening in the series with the longest follow-up, respectively. The Cartiva group showed a significative increase in FAAM ADL and FAAM SPORT from 59.4 to 90.4 and from 60.9 to 89.7, respectively; similarly, 20.5% implant removal and conversion to arthrodesis were reported. Finally, the double stem silicone arthroplasty group, in the series with the longest follow-up, it manages to improve the MOXFQ score from 78.1 to 11.0, with an average range of mobility of 22.3 degrees. Lysis was reported in 10% of cases.

CONCLUSIONS

Arthrodesis has proven to be the best option for the treatment of advanced hallux rigidus. Arthroplasty can be a valid option for patients who demand to maintain the range of mobility of the joint; however, it is important to inform about the complications that may arise in the short and medium term.

LEVEL OF CLINICAL EVIDENCE

II.

Identification and interpretation of gait analysis features and foot conditions by explainable AI

Clinical gait analysis is a crucial step for identifying foot disorders and planning surgery. Automating this process is essential for efficiently assessing the substantial amount of gait data. In this study, we explored the potential of state-of-the-art machine learning (ML) and explainable artificial intelligence (XAI) algorithms to automate all various steps involved in gait analysis for six specific foot conditions. To address the complexity of gait data, we manually created new features, followed by recursive feature elimination using Support Vector Machines (SVM) and Random Forests (RF) to eliminate low-variance features. SVM, RF, K-nearest Neighbor (KNN), and Logistic Regression (LREGR) were compared for classification, with a Majority Voting (MV) model combining trained models. KNN and MV achieved mean balanced accuracy, recall, precision, and F1 score of 0.87. All models were interpreted using Local Interpretable Model-agnostic Explanation (LIME) method and the five most relevant features were identified for each foot condition. High success scores indicate a strong relationship between selected features and foot conditions, potentially indicating clinical relevance. The proposed ML pipeline, adaptable for other foot conditions, showcases its potential in aiding experts in foot condition identification and planning surgeries.

Quality and Readability Analysis of Online Information on First Metatarsophalangeal Joint Fusion

Patients frequently turn to the internet to learn about their orthopedic procedures. This study evaluates the readability and quality of first metatarsophalangeal (MTP) joint fusion information found online. We evaluated websites based on classification, search term, readability, HON code, DISCERN score, Journal of the American Medical Association benchmark criteria, and an author-created MTP fusion index (MFI). The average readability of websites was 8.48 ± 1.99, above the recommended sixth- or eighth-grade reading level. Almost half of all websites (48.98%) provided "poor" information. Keywords had no significant impact on the readability or quality of information. Academic/governmental websites had the highest quality of information, with the highest DISCERN and second highest MFI. Most websites (52.04%) were commercial and were the easiest to read, but had the second lowest DISCERN and MFI scores. Our results suggest that inappropriate information on the MTP joint fusion procedure is abundant online. Academic/governmental websites have the highest quality of information, but may be difficult for patients to comprehend. Many websites do have readable and relevant information. We recommend that physicians create a list of websites with accurate, relevant information for patients to circumvent the misinformation they may find while navigating and reading online.

A prospective clinical and biomechanical analysis of feet following first metatarsophalangeal joint arthrodesis for end stage hallux rigidus

BACKGROUND

Hallux Rigidus is the result of degeneration of the 1st metatarsophalangeal joint (1st MTPJ). In end-stage hallux rigidus, treatment is mainly surgical with arthrodesis being a favourable option. Although the biomechanical effects of arthrodesis have been examined, a detailed comparison of pre- and post-operative biomechanics has yet to be conducted.

RESEARCH QUESTION

Does 1st MTPJ arthrodesis positively affect foot kinematics and plantar pressure distribution?

METHODS

Twelve 1st MTPJ arthrodesis were performed in patients with a mean age of 53.5 ± 5.4 years and follow up time of 6.9 ± 1.0 months. Pre- and post-operative data were collected at a CMAS (Clinical Movement Analysis Society) accredited gait laboratory using a BTS motion capture system and pedobarographic pressure plates. Patient outcome measures were also assessed using the MOXFQ. Statistical analysis was conducted using a two-way repeated measures ANOVA.

RESULTS

Significant changes in stride length, cycle duration, cadence and velocity were identified following 1st MTPJ arthrodesis. A significant reduction in forefoot-hallux dorsiflexion at toe-off was identified for the operated foot from the pre-operative (20.23 ± 5.98°) to post-operative (7.56 ± 2.96°) assessment. Post-operative sagittal and transverse plane changes in the operated foot were also identified. Peak pressure and PTI results indicated significant lateralisation of load for the operated foot, but importantly this was not influenced following arthrodesis. Finally, there was a significant improvement in MOXFQ score.

SIGNIFICANCE

Following 1st MTPJ fusion there is an improvement in overall gait mechanics which accompanied by the improved MOXFQ score indicates a reduction in pain and improved confidence during gait. The lack of post-operative dorsiflexion at forefoot-hallux caused load to remain lateralised and compensatory mechanisms to occur at the more proximal joints within the foot. These results provide valuable information for clinicians and will enable more accurate counselling to be provided to patients with end-stage hallux rigidus.

A Patient-Reported Outcome-Based Comparison of Cheilectomy With and Without Proximal Phalangeal Dorsiflexion Osteotomy for Hallux Rigidus

INTRODUCTION

This study provides the first comparison of patient-reported outcomes between isolated cheilectomy (C) and cheilectomy with Moberg (CM) osteotomy for hallux rigidus.

METHODS

A single-center, retrospective registry search identified all patients with preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores who underwent cheilectomy, with and without concomitant proximal phalangeal dorsiflexion osteotomy, for hallux rigidus between January 2016 and December 2020. Because there were far fewer isolated cheilectomies (62), all C patients were compared with a commensurate number of consecutive CM cases (67) using preoperative, 1-year, and 2-year PROMIS scores for physical function, pain interference, pain intensity, global physical health, global mental health, and depression, as well as complication and revision data from a chart review. A multivariable linear regression analysis was performed to compare adjusted postoperative PROMIS scores between the 2 cohorts.

RESULTS

There were no differences between groups among the demographic and preoperative variables compared. The CM cohort reported worse pain interference scores preoperatively (P < .001) and at 1 year postoperatively (P = .01). However, the C cohort reported worse pain intensity scores preoperatively (P < .001) and at 1 year postoperatively (P < .001). Adjusted postoperative PROMIS score comparison demonstrated that the CM cohort had better 1-year postoperative pain intensity scores (P < .05). However, there were no differences between cohorts for additional PROMIS scores or complications data.

CONCLUSION

The addition of a Moberg osteotomy does not appear to significantly change short- to medium-term outcomes of cheilectomy for hallux rigidus treatment.

LEVELS OF EVIDENCE

Level III: Retrospective comparative study.

Return to Sport After First Metatarsophalangeal Arthrodesis: A Systematic Review

BACKGROUND

First metatarsophalangeal (MTP) arthrodesis is a common surgical intervention for addressing MTP pain and deformity. Despite great interest on the topic of return to sport (RTS) after first MTP arthrodesis in the literature, no systematic review exists on this topic. The purpose of this systematic review is to investigate RTS after first MTP arthrodesis.

METHODS

This study is a systematic review using PubMed, Web of Science, CINAHL, and MEDLINE from database inception until May 10, 2023. Search algorithm used was (MTPJ OR MTP OR "hallux rigidus" OR cheilectomy OR metatarsal OR metatarsophalangeal) AND (arthrodesis OR fusion) AND sport. Inclusion criteria were surgical intervention of first MTP arthrodesis and outcomes related to sport.

RESULTS

Ten articles were included out of 249 articles initially retrieved. Patients (n = 450) had a frequency weighted mean (FWM) age of 58.6 ± 5.1 years with a FWM follow-up time of 32.1 ± 18.9 months. A total of 153 patients (reported in 34.0% of patients) had a FWM postoperative Foot and Ankle Ability Measure Sport score of 70.4 ± 21.8 at final follow-up. For sporting activities reported by multiple studies (running, yoga, golf, hiking, tennis, elliptical, and biking), about 9.8% to 28.1% of patients (n = 69 reports) stated that sporting activity difficulty decreased, 67.2% to 87.5% of patients (n = 340 reports) stated that sporting activity remained the same, and 1.8% to 8.5% of patients (n = 23 reports) stated that sporting activity difficulty increased after first MTP arthrodesis depending on the sporting activity. One article reported RTS time of 11.7 ± 5.1 weeks after first MTP arthrodesis (n = 39).

CONCLUSION

RTS after first MTP arthrodesis is highly variable depending on patient and sport. Numerous different sporting activities have high rates of RTS after first MTP arthrodesis, with a majority of patients reporting similar or increased ability to perform sporting activities after surgery.

A Novel Plating System for First Metatarsophalangeal Joint Arthrodesis: A Retrospective Comparison of Hybrid and Traditional Locking Plate Constructs

BACKGROUND

Dorsal plate fixation is commonly used for first metatarsophalangeal joint (1st MTPJ) arthrodesis and plate design continues to evolve. A new staple compression plate (SCP) design attempts to utilize the continuous compression of a nitinol staple across the fusion site while simultaneously providing the stability of a dorsal locked plate. Herein, we compare the radiographic, clinical, and patient-reported outcomes of 1st MTPJ joint arthrodesis using 2 dorsal locking plate constructs including a novel SCP construct.

METHODS

Forty-four patients who underwent 1st MTPJ arthrodesis between 2016 and 2020 were retrospectively evaluated. There were 2 group cohorts. Group 1 cohort included 23 patients who received a CrossRoads Extremity SCP, and Group 2 cohort included 21 patients who received a Stryker dorsal locking precontoured titanium plate (LPP). All patients were evaluated with radiographs, Patient-Reported Outcomes Measures Information System (PROMIS) outcome scores, and Foot Function Index (FFI).

RESULTS

The complication and union rates did not vary between groups with a fusion rate of 95.7% in the SCP group and 90.5 % in the LPP group. Similarly, we found no significant differences in PROMIS or FFI scores between the SCP and LPP plates.

CONCLUSION

Use of either dorsal locking plate construct for 1st MTPJ arthrodesis was associated with high union rates and comparable functional outcomes. As locked plate technology continues to evolve for 1st MTPJ arthrodesis, it is important that clinical outcomes are reported.

LEVELS OF EVIDENCE

Level IV.

Gait and dynamic pedobarographic analyses in hallux rigidus patients treated with Keller's arthroplasty, arthrodesis or cheilectomy 22 years after surgery

Background

Keller's arthroplasty, arthrodesis and cheilectomy are well-known surgical interventions for hallux rigidus. This study aimed to evaluate the effects of these surgical interventions on gait, plantar pressure distribution and clinical outcome in patients treated for hallux rigidus 22 years after surgery.

Methods

Spatio-temporal gait parameters and plantar pressure distribution, determined as pressure time integrals (PTIs) and peak pressures (PPs), were analyzed using a 7-foot tone analysis model. Patient-reported outcome was assessed using the Manchester-Oxford Foot Questionnaire (MOXFQ). Of the 73 patients (89 feet) from the original study, 27 patients (33 feet) and 13 healthy controls (26 feet) were available for evaluation 22 years after hallux rigidus surgery.

Results

Spatio-temporal gait parameters were comparable between all groups and were in line with healthy controls (P > 0.05). No differences (P > 0.05) in PTIs and PPs were found in the seven plantar zones between groups and as compared to healthy controls. MOXFQ scores in all domains (walking/standing, range 21.4-24.1; pain, range 16.5-22.2 and social interaction, range 23.8-35.4) were not clinically and statistically different (P > 0.05) between the three different surgical interventions.

Conclusion

These results suggest no long-term functional and biomechanical differences after these surgical interventions for hallux rigidus correction. The interventions seem to be appropriate treatment options for a selective group of patients with symptomatic hallux rigidus.

Treatment of hallux rigidus with percutaneous metatarsophalangeal arthrodesis: a case series with a minimum follow-up of 2 years

BACKGROUND

Percutaneous metatarsophalangeal arthrodesis is an option for the treatment of hallux rigidus in more advanced cases. The aim of this study was to investigate the clinical and radiographic results at least 2 years after percutaneous metatarsophalangeal arthrodesis in patients with hallux rigidus.

METHODS

This is a case series of consecutive patients undergoing percutaneous metatarsophalangeal arthrodesis in patients with hallux rigidus grades III and IV with a minimum of 24 months of clinical and radiographic follow-up. The primary outcome was clinical assessment using the Visual Analog Scale for Pain (VAS). Secondary outcomes included American Orthopedic Foot & Ankle Society (AOFAS) score, patient satisfaction, complications, and bone healing (radiographic analysis).

RESULTS

Between August 2017 and February 2020, 29 feet (24 patients) underwent percutaneous metatarsophalangeal arthrodesis. The mean follow-up was 38.4 (range 24-54) months. There was an improvement in the pain (VAS) from 7.8 to 0.6 (p < 0.001) and in the AOFAS score from 49.9 to 83.6 (p < 0.001). There was a rate of bone union of 82.8% and screw removal of 13.8%. All patients considered the result to be excellent or good.

CONCLUSION

The treatment of grade III and IV hallux rigidus with percutaneous metatarsophalangeal arthrodesis demonstrated high patient satisfaction and significantly improves in clinical outcomes but the nonunion rate was higher than reported outcomes for open 1st metatarsophalangeal joint arthrodesis.

LEVEL OF EVIDENCE

IV, case series.

Percutaneous arthroscopically assisted cheilectomy combined to percutaneous proximal phalanx osteotomy in hallux rigidus: Clinical and radiological outcomes in 30 feet at a 48-month follow-up

BACKGROUND

Hallux rigidus is a degenerative condition affecting the middle age population. It affects patients by limiting their first metatarsophalangeal range of motion (ROM) and also, their shoe wear. The objective of our work was to present an original operative technique which preserves the native joint and improves pain with minimal complications.

METHODS

We conducted a retrospective multicenter cohort study of 28 patients (30 feet) suffering from moderate hallux rigidus, operated between October 2010 and October 2017 with at least 48months of follow-up. Clinical and radiological assessments included pre- and postoperative ROM, the American Orthopedic Foot and Ankle Society (AOFAS) score and forefoot radiological evaluation. No patients were lost to follow-up.

RESULTS

The mean AOFAS score increased from 59 (range, 51 to 67) preoperatively to 84 (range, 80 to 88) at final follow-up. A total of 37 patients (97%) were satisfied. From a ROM point of view, this remained relatively unchanged between preoperative and postoperative values.

CONCLUSION

The percutaneous arthroscopically assisted cheilectomy combined with a percutaneous proximal phalanx osteotomy, significantly improves pain in hallux rigidus with index minus in patients with Coughlin stage I and II after a mean of 4-year follow-up.

LEVEL OF EVIDENCE

IV.

Clinical Outcomes After Joint-Preserving and Joint-Sacrificing Surgery for Hallux Rigidus

Introduction Hallux rigidus (HR) is a degenerative condition affecting the first metatarsal phalangeal joint, causing stiffness and pain. Surgery is indicated for those who have failed a trial of conservative management. The purpose of this paper is to evaluate the functional outcomes at short and medium term after surgery for HR. Methods All patients who underwent surgical treatment for HR between 2017 and 2022 at the time of this study were identified and invited to return for a follow-up evaluation. Outcomes were assessed by comparison of pre-operative and post-operative visual analogue scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) scores. Results A total of 26 patients were included in our study with a mean follow-up of 31 months. There was a mean improvement in VAS score by 5.6 (p-value < 0.0001) and 5.7 (p-value = 0.0012) in patients who underwent joint-preserving (JP) and joint-sacrificing (JS) surgery, respectively. Patients who underwent JP surgery had a mean increase of 28.1 points (p-value < 0.0001) in the AOFAS Hallux score, while patients who underwent JS surgery had a mean increase of 27.29 points (p-value = 0.0066). Conclusion Functional outcomes after surgical management for HR are good at short- and medium-term follow-up. Good outcomes are seen with both JP and JS procedures. JP procedures should be considered as a first-line surgical option for HR as it allows revision procedures if required.

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.

Factors Associated With Nonunion in Arthrodesis of the First Metatarsophalangeal Joint: A Multicenter Retrospective Cohort Study

BACKGROUND

Arthrodesis of the first metatarsophalangeal joint is the current treatment of choice for symptomatic advanced hallux rigidus and moderate-to-severe hallux valgus. There are different methods to perform arthrodesis, yet no consensus on the best approach. Therefore, this study aimed to determine the effects of preoperative and postoperative hallux valgus angle (HVA), joint preparation and fixation technique, and postoperative immobilization on the incidence of nonunion.

METHODS

A retrospective multicenter cohort study was performed that included 794 patients. Univariate and multiple logistic regression was conducted to determine associations between joint preparation, fixation techniques, postoperative immobilization, weightbearing, and pre- and postoperative HVA with nonunion.

RESULTS

Nonunion incidence was 15.2%, with 11.1% symptomatic and revised. Joint preparation using hand instruments (OR 3.75, CI 1.90-7.42) and convex/concave reamers (OR 2.80, CI 1.52-5.16) were associated with greater odds of a nonunion compared to planar cuts. Joint fixation with crossed screws was associated with greater odds of nonunion (OR 2.00, CI 1.11-3.42), as was greater preoperative HVA (OR 1.02, CI 1.00-1.03). However, the latter effect disappeared after inclusion of postoperative HVA in the model, with a small association identified between residual postoperative HVA and nonunion (OR 1.04, CI 1.01-1.08). Similarly, we found an association between odds of nonunion and higher body weight (OR 1.02, CI 1.01-1.04) but not of body mass index.

CONCLUSION

Based on our results, first metatarsophalangeal joint arthrodesis with planar cuts and fixation with a plate and interfragmentary screw is associated with the lowest odds of resulting in a nonunion. Higher body weight and greater preoperative HVA were associated with slight increase in rates of nonunion. It is crucial to properly correct the hallux valgus deformity during surgery.

LEVEL OF EVIDENCE

Level III, retrospective case control study.

Assessment and Management of Atraumatic First Metatarsophalangeal Joint Pain

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

Morton’s Extension on Hallux Rigidus Pathology

Study design, case-control study: Background, Morton’s extension (ME) is a kind of orthotic that has been used as a conservative treatment of painful hallux rigidus (HR) osteoarthritis, but only their effects on first metatarsophalangeal joint (MPJ) mobility and position in healthy subjects have been studied, but not on its applied pulled tension forces neither in subjects with HR. Objectives: This study sought to understand how ME’s orthotics with three different thicknesses could influence the kinematic first MPJ by measuring hallux dorsiflexion using Jack’s test and a digital algometer with a rigid strip anchored to the iron hook’s extremity and comparing subjects with healthy first MPJ mobility to those with HR. We aimed to clarify whether tension values were different between healthy and HR subjects. Methods: Fifty-eight subjects were selected, of whom thirty were included in the case group according to HR criteria and twenty-eight were included in the control group. A digital algometer (FPX®® 25, Wagner Instruments®®, Greenwich, CT, USA) was used to assess the pulled tension values (kgf) of the first MPJ during Jack’s test. Results: The pulled tension values were highly reliable (ICC > 0.963). There were no statistically significant differences between the pulled tension values for the different ME conditions in the case (p = 0.969) or control (p = 0.718) groups. However, as it’s expected, there were statistically significant differences comparing all pulled tension values between case and control group subjects (p < 0.001). Conclusions: Different ME’s thicknesses had no influence on the pulled effort applied during the dorsiflexion Jack’s test between the healthy and HR groups; therefore, it can be prescribed without joint-care danger. In addition, it is proven that there is greater resistance to performing Jack’s test in the HR group than in the healthy group, regardless of ME’s orthotics. Furthermore, it is shown that the digital algometer device is a valid tool to detect the first MPJ restriction and is more reliable than other tests.

Radiographic Outcomes of Hallux Valgus Deformity Correction With Chevron and Scarf Osteotomies

There is no gold standard in the treatment of hallux valgus deformity. The purpose of our study was to compare various aspects of radiographic assessment following scarf and chevron osteotomies and try to determine which technique helps achieve a more pronounced intermetatarsal angle (IMA) and hallux valgus angle (HVA) correction and produces lower rates of complications, including adjacent-joint arthritis. This study included patients who underwent hallux valgus correction with the scarf (n = 32) or chevron (n = 181) method with a follow-up period of over 3 years. We evaluated the following parameters: HVA, IMA, duration of hospital stay, complications, development of adjacent-joint arthritis. The scarf technique helped achieve a mean HVA and IMA correction of 18.3° and 3.6°, respectively, and the chevron technique helped achieve a mean correction of 13.1° and 3.7°, respectively. The achieved deformity correction in terms of both the HVA and IMA was statistically significant in both patient groups. The loss of correction assessed with the HVA was statistically significant only in the chevron group. Neither group showed a statistically significant loss of IMA correction. The duration of hospital stay, reoperation rates, and fixation instability rates were comparable in the 2 groups. Neither of the evaluated methods caused a significant increase in total arthritis scores in the evaluated joints. Our study showed good outcomes of hallux valgus deformity correction in both evaluated groups; however, scarf osteotomy yielded somewhat better radiographic outcomes in HVA correction and no loss of HVA correction at 3.5 years of follow-up.

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

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

First Metatarsophalangeal Joint Pathology in the Athlete

Movement of the first metatarsophalangeal joint is an essential function of many sports. Because of the high demand on this relatively small joint, it is prone to the development of several notable pathologic derangements that can prevent full and pain-free athletic performance. A complete understanding of the joint anatomy and a careful physical examination and history collection is crucial to identifying an accurate diagnosis. Treatment should be pathology specific and should keep in mind the career expectations of the athlete.

Metatarsophalangeal Joint Reconstruction Using Talar Osteochondral Allograft following a Failed Dorsal Cheilectomy

Dorsal cheilectomy is often used as a first-line surgical treatment for hallux rigidus; however, revision surgery is needed in nearly 9% of cases. One option for revision surgery is interpositional arthroplasty, which is designed to preserve joint motion and is favorable in young, active populations. This case discusses a young female patient with persistent, painful hallux rigidus and a large osteochondral defect despite prior dorsal cheilectomy. We performed an interpositional arthroplasty of the first metatarsophalangeal joint using an osteochondral allograft from the talus. At three-year follow-up, she had greatly improved function and was able to run without pain. To our knowledge, this is the first documented use of an osteochondral allograft from the talus in conjunction with metatarsophalangeal joint interpositional arthroplasty for treatment of hallux rigidus and a severe osteochondral defect. This technique introduces osseous subchondral scaffolding as well as mature hyaline cartilage into an osteochondral lesion, thereby reestablishing proper joint architecture and congruent articulation and ultimately improving range of motion and reducing pain. We present this technique as an experimental treatment option for restoring both the integrity and function of the metatarsophalangeal joint following trauma, osteochondritis dissecans, or prior operative failure in patients who wish to delay metatarsophalangeal joint fusion.

Retrospective Comparison of Two Different Fixation Methods for First Metatarsophalangeal Joint Arthrodesis

Background and Purpose: Arthrosis of the first MTP joint is a common condition. Among the available arthrodesis methods, plate/screw and screw methods are the current treatment methods of choice. In this study, we investigate whether there is a difference between these two methods. Methods: Thirty-four toes of 32 patients with advanced arthrosis were included in the study. Eighteen toes were fixed with plates/screws and 16 with cross-screws. In the radiological evaluations, malunion and nonunion were examined. Clinical evaluation was made according to AOFAS-HMI scoring. Results: The mean age of the patients was 57.74 years and the mean follow-up period was 22.21 months. There was no statistically significant difference in clinical scores or union times between the two groups. As complications, superficial skin problems developed in 2 (5.9%) cases, deep infection in 3 (8.8%) cases, and nonunion in 3 (8.8%) cases. There was no statistically significant difference between the two groups in this regard. Conclusion: Plate/screw and cross-screw techniques give similar clinical and radiological results in cases of arthrodesis of the first MTP joint. The cross-screw technique, which can be performed more easily and has lower costs, should be the first choice.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Clinical and Radiologic Outcome of First Metatarsophalangeal Joint Arthrodesis Using a Human Allogeneic Cortical Bone Screw

Background:

Different fixation techniques are established for first metatarsophalangeal joint (MTPJ) arthrodesis, including compression screws, plates, Kirschner wires, metal- and bioabsorbable screws as well as staples. The purpose of this study was to investigate and present first clinical and radiologic results using a novel human, allogeneic cortical bone screw for arthrodesis of the first MTPJ.

Methods:

Arthrodesis of the first MTPJ was performed in 31 patients with hallux rigidus. Percentage union and time to union were the first outcomes; visual analog scale for pain, hallux valgus angle (HVA), intermetatarsal angle, and American Orthopaedic Foot & Ankle Society (AOFAS) hallux score were secondary outcomes.

Results:

Median time to union was 89 days, and union was observed in all patients. There were 4 complications (2 osteolysis margin, 1 cystic brightening, and 1 severe swelling at the first follow-up) all of that resolved at last follow-up. Pain significantly decreased from visual analog scale 8.0 to 0.2 points ( P < .0001). The HVA decreased from 30.4 to 10.2 degrees in the patient group with deformities. The total AOFAS score increased significantly from 48 to 87 ( P < .0001).

Conclusion:

Primary and revision arthrodesis of hallux rigidus with the human, allogeneic cortical bone screw reveals satisfying results similar to clinical and radiologic outcomes of other surgical techniques. Within 1 year, the human, allogeneic cortical bone screw is fully remodeled to host bone.

Level of Evidence:

Level IV, retrospective case series without control group.

The Surgical Treatment of Osteoarthritis

Osteoarthritis is a degenerative condition affecting the whole joint with the underlying bone, representing a major source of pain, disability, and socioeconomic cost worldwide. Age is considered the strongest risk factor, albeit abnormal biomechanics, morphology, congenital abnormality, deformity, malalignment, limb-length discrepancy, lifestyle, and injury may further increase the risk of the development and progression of osteoarthritis as well. Pain and loss of function are the main clinical features that lead to treatment. Although early manifestations of osteoarthritis are amenable to lifestyle modification, adequate pain management, and physical therapy, disease advancement frequently requires surgical treatment. The symptomatic progression of osteoarthritis with radiographical confirmation can be addressed either with arthroscopic interventions, (joint) preservation techniques, or bone fusion procedures, whereas (joint) replacement is preferentially reserved for severe and end-stage disease. The surgical treatment aims at alleviating pain and disability while restoring native biomechanics. Miscellaneous surgical techniques for addressing osteoarthritis exist. Advanced computer-integrated surgical concepts allow for patient personalization and optimization of surgical treatment. The scope of this article is to present an overview of the fundamentals of conventional surgical treatment options for osteoarthritis of the human skeleton, with emphasis on arthroscopy, preservation, arthrodesis, and replacement. Contemporary computer-assisted orthopaedic surgery concepts are further elucidated.

Keller's arthroplasty for hallux rigidus: A systematic review

BACKGROUND

Several surgical procedures have been described to treat hallux rigidus. Keller arthroplasty is a joint-sacrificing procedure proposed in 1904. Considering the current trends to mini-invasiveness and the debate about the technique's suitability, this review intends to state Keller arthroplasty results and the conditions where it could be still adopted in the treatment of hallux rigidus.

METHODS

Selected articles were reviewed to extract: population data, surgical indications, different surgical techniques, clinical and radiological outcomes, and complications.

RESULTS

Seventeen retrospective studies were selected, counting 508 patients. Mean age at surgery was 55 years. Patients were affected by moderate-severe hallux rigidus. Three modified Keller arthroplasty were identified. Good clinical and radiological outcomes were reported. Metatarsalgia was the most frequent complication (12%).

CONCLUSION

Despite for many authors KA seems a viable surgical treatment for middle aged and elderly patients affected by moderate-severe hallux rigidus, the available literature provides little evidence on the real efficacy and safety of the technique. A non-negligible percentage of complications may occur, and therefore is essential to set correct indications through an accurate patients' selection.

Interpositional Arthroplasty in the Treatment of Hallux Rigidus: A Systematic Review

Hallux rigidus is the most common arthritic condition of the foot. Interpositional arthroplasty (IPA) is indicated for advanced-stage hallux rigidus and attempts to maintain joint motion through insertion of a biologic spacer into the joint. However, the data evaluating the effectiveness of IPA are limited. The purpose of this study was to systematically review the outcomes of IPA in the treatment of hallux rigidus. MEDLINE, EMBASE, and Cochrane Library databases were systematically reviewed based on the preferred reporting items for systematic reviews and meta-analyses guidelines. Outcomes collected and analyzed included: American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal (HMI) score, visual analogue scale score, short-form 36 score, range of motion (ROM), radiographic parameters, and postoperative complications. The level and quality of clinical evidence were recorded and assessed. Sixteen studies with a total of 428 patients met inclusion/exclusion criteria. The mean AOFAS-HMI score improved from 51.6 ± 10.1 (range 35.0-64.2) preoperatively to 86.0 ± 7.7 (range 71.6-95.4) postoperatively (p ≤ .001) at weighted mean follow-up of 58.0 ± 34.5 (range 16.5-135.6) months. The preoperative weighted mean total ROM was 39.3° ± 9.6° (range 24.2-49.9) and the postoperative weighted mean total ROM was 61.5° ± 4.8° (range 54.0-66.5) (p ≤ .001). The complication rate was 21.5% with metatarsalgia as the most commonly reported complication. One study was level 3 and 15 studies were level 4 clinical evidence. This systematic review demonstrates improvement in functional and ROM outcomes following IPA procedure at mid-term follow-up. The procedure however has a moderate complication rate. In addition, there is a low level and quality of evidence in the current literature with inconsistent reporting of data.

Average 4-Year Outcomes of Distal Oblique First Metatarsal Osteotomy for Stage 1 to 3 Hallux Rigidus

BACKGROUND

Hallux rigidus is the second most frequent pathology of the first ray. Surgical options for degenerative metatarsophalangeal joint disease are either joint destructive or conservative procedures. The hypothesis was that oblique distal shortening osteotomy of the first metatarsal is an effective conservative technique for the management of stage 1 to 3 hallux rigidus.

METHODS

We conducted a retrospective cohort study of 87 feet with Coughlin and Shurnas's stage 1-3 hallux rigidus, operated between 2009 and 2019. The cohort consisted in 72 patients (87 feet) with an average age of 57±9 (30/79) years; 22 of 87 (25.3%) feet had the first metatarsal surgery performed in isolation; 65 of 87 (74.7%) had concomitant forefoot procedures, including 31 of 87 (35.6%) with Akin phalangeal osteotomies and 34 of 87 (39.1%) with Moberg phalangeal osteotomies.We evaluated the American Orthopaedic Foot & Ankle Society (AOFAS) Scale, subjective satisfaction, joint amplitudes, shortening rate, and occurrence of postoperative complications with a mean follow-up of 51 months (16/134).

RESULTS

The AOFAS score increased from 54.2±11.3 (25/70) preoperatively to 92.2±7.8 (62/100) postoperatively (P < .001). Patients reported excellent or good outcome in 95.4% of cases. The 40-point self-reported pain subscale score improved from 19.6 (± 10.0) to 37.4 (± 5.4), P < .001.The overall range of motion increased from 61±21 (20/110) degrees to 69±17 (35/120) degrees (P < .001). The mean first metatarsal shortening rate (SR^po) was 9.6%. Neither the Coughlin grade, the metatarsal index, or the SR^po influenced the AOFAS score. At 6-month follow-up, 15 patients had transfer metatarsalgia compared with 5 at last follow-up without requiring another surgical procedure. The risk was not significantly different according to Coughlin's stage, preoperative metatarsal index, or SR^po.

CONCLUSION

Oblique distal osteotomy of the first metatarsal for stage 1-3 hallux rigidus, often in combination with other first ray procedures, performed well during our follow-up time period, with a high subjective satisfaction rate and few complications.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Needle Arthroscopy Cheilectomy for Hallux Rigidus in the Office Setting

Hallux rigidus is a progressive degenerative process of the first metatarsophalangeal joint characterized by altered joint mechanics and formation of dorsal osteophytes. Cheilectomy is the preferred operative intervention at early stages. Technologic advances, patient preference, and cost considerations combine to stimulate the development of minimally invasive and in-office interventions. This Technical Note highlights our technique for needle arthroscopy cheilectomy for hallux rigidus, which can be used either in the operating room or in the wide-awake office setting.

Hallux rigidus: current concepts review and treatment algorithm with special focus on interposition arthroplasty

BACKGROUND AND AIM OF THE WORK

Hallux rigidus represents a surgical challenge, with a multitude of possible surgical options, but with no ideal procedures.  The propose of this paper was to review the actual knowledge on the operative techniques, paying particular attention to the evolution of interposition arthroplasties, as an alternative to arthrodesis and prosthesis in the advanced stages of the disease.

METHODS

A comprehensive literature PubMed search was performed, and the actual literature regarding hallux rigidus was overviewed. The operative and nonoperative options for HR were described. Studies on interposition arthroplasty were classified by publication year, summarizing the operative technique, results and complications.

RESULTS

Among the various techniques for interposition arthroplasty, the Modified Oblique Keller Interposition Arthtoplasty (MOKCIA) showed the lower complication rate. It does not sacrifice the insertion of the flexor halluces brevis, maintaining the stability, length and strength of the big toe.

CONCLUSIONS

Although long-term randomized controlled trials are lacking for interposition arthroplasties, the reported results are comparable to the other alternatives for the treatment of end-stage hallux rigidus, making this technique a valid alternative also in the young active patient, without precluding other end-stage procedures in case of failure. Based on the current knowledge, a treatment algorithm was developed, according to the Coughlin classification.

A systematic review of total arthroplasty and arthrodesis for end-stage hallux rigidus: A biomechanical perspective

BACKGROUND

Both arthrodesis and total arthroplasty are acceptable surgical options for end stage hallux rigidus without significant angular deformity. Total arthroplasty preserves first metatarsophalangeal joint (MTPJ) motion, which may help restore a more physiological gait pattern.

RESEARCH QUESTION

Is there a difference in the findings of gait studies after 1st MTPJ total arthroplasty or arthrodesis for end-stage hallux rigidus?

METHODS

PRISMA guidelines were followed to conduct a systematic review of literature for studies reporting gait analysis after the above procedures. Predetermined criteria were used to select papers and evaluated the findings of kinematic (spatial-temporal and dynamic motion), kinetic and foot pressure (pedobarographic) studies.

RESULTS

12 titles were short-listed for synthesis. There was 1 randomized controlled trial comparing the two procedures. Among the remaining cohort studies, 5 reported on total arthroplasty and 6 on arthrodesis of the 1st MTPJ. Due to significant heterogeneity, a narrative synthesis was undertaken. No studies in the arthroplasty group reported spatial-temporal or kinetic parameters. Only 2 papers, 1 in each group, recorded motion within the foot. One of them showed preserved dynamic motion at the 1st MTPJ after total arthroplasty. Pedobarographic studies had discordant findings in studies within both groups regarding restoration of weight bearing through the medial forefoot and the pulp of the great toe during gait.

CONCLUSION

Currently available studies are heterogenous and report inconsistent findings, which do not convincingly answer our research question. Prospective comparative studies with a large sample size, using standardized methodology in accredited laboratories with detailed reporting of kinetic, kinematic and pedobarographic components of gait analysis are required in order to draw concrete conclusions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV, case series.

Prevalence of and risk factors for hallux rigidus: a cross-sectional study in Japan

Background

Hallux rigidus (HR) is a common osteoarthritis of the first metatarsophalangeal joint. However, the epidemiology and risk factors of this pathology have yet to be clarified.

Methods

We have been conducting cohort studies among individuals over 50 years old every 2 years since 1997. This study analyzed data from the 7th to 10th checkups in 2009, 2011, 2013, and 2015. We investigated the prevalence of HR and its risk factors in a total of 604 individuals (mean age, 67.1 ± 6.4 years; 208 men, 396 women). Radiographic HR was defined as Hattrup and Johnson classification grade 1 or higher. Knee osteoarthritis (KOA) was scored according to the Kellgren-Lawrence grading system. Radiographic KOA was defined as grade 2 or higher. Cases with a hallux valgus (HV) angle of 20° or higher were defined as showing HV. Statistical analyses were performed using the Kruskal-Wallis test, Fisher’s exact test, logistic regression modeling, and the Cochran-Armitage trend test. All p-values presented are two-sided and values of p < .05 were considered statistically significant.

Results

The prevalence of HR was 26.7% (161/604). Rates of grade 0, 1, 2, and 3 HR according to the Hattrup and Johnson classification were 73.3% (443/604), 16.4% (99/604), 8.0% (48/604), and 2.3% (14/604), respectively. Overall ratio of symptomatic HR was 8.1%. Univariate analysis revealed KOA, gout attack (GA), and HV as significantly associated with HR. The same factors were confirmed as independent risk factors for HR in multivariate analysis. All parameters were significantly associated with HR. Odds ratios of KOA, HV, and GA for HR were 1.73, 3.98, and 3.86, respectively. The presence or absence of KOA was significantly associated with severity of HR.

Conclusions

This study revealed that the prevalence of HR in the elderly (≥50 years) was 26.7%. KOA, HV, and GA were independent risk factors for HR. KOA was associated with severity of HR.

Avascular necrosis of the first metatarsal head in a young female adult: A case report and review of literature

BACKGROUND

This case study describes an atypical presentation of avascular necrosis (AVN) of the first metatarsal head, which is largely unfounded in the literature.

CASE SUMMARY

A healthy 24-year-old female initially presented with pain at the first metatarsophalangeal joint (MTPJ) and was diagnosed with AVN by physical examination and magnetic resonance imaging. The patient demonstrated atypically poor progress in recovery, despite being in otherwise good health and being of young age, with no history of corticosteroid or alcohol use. The patient also did not have any history or clinical features of autoimmune disease or vasculitis, such as systemic lupus erythematosus. The patient was managed with conservative treatment for 18 mo, which allowed for gradual return of full range of motion of the first MTPJ and subsiding pain, permitting the patient to return to high-intensity sports training and full weight-bearing. Throughout her recovery, many differential diagnoses were ruled out through specific investigations leading to further reinforcement of the diagnosis of AVN of the 1^st metatarsal head.

CONCLUSION

Atypical AVN may occur with no predisposing risk factors. Treatment is mainly conservative, with unclear guidelines in literature on management.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

PROTOCOL VERSION

21 June 2021 V.2.0.

TRIAL REGISTRATION NUMBER

NCT04590313.