Results of metallic Hemi-Great Toe Implant for Grade III and early Grade IV hallux rigidus

[Biomechanics of the first metatarsophalangeal joint after replacement]

OBJECTIVE

Analysis of biomechanics of the first metatarsophalangeal joint after arthroplasty, interaction between bones and two implants of the first metatarsophalangeal joint using skeletal model of the foot.

MATERIAL AND METHODS

We developed anatomically adapted all-ceramic non-coupled endoprosthesis of proximal interphalangeal joint between 2016 and 2021. To create a model of the foot, we used diagnostic computed tomography whose images were applied in 3D sculpting system and computer-aided design system for final geometric modeling of the joint.

RESULTS

In dorsal flexion of the first metatarsophalangeal joint under 45° with the presence of implant, cortical bone tissue can withstand a load of up to 40 kg. Cortical bone tissue with implant can withstand a load of up to 305 kg without dorsal flexion. Strength of implant elements made of zirconium ceramics significantly exceeds strength of bone tissue within implant-bone tissue connection.

CONCLUSION

Postoperative axial load on the first metatarsophalangeal joint up to 35 kg with maximum dorsal flexion up to 45° is the most appropriate. Higher load and hyperextension over 45° may be followed by postoperative complications such as implant instability, dislocation and periprosthetic fracture.

Complications of Hallux Rigidus Surgery

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

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

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

Metallic hemiarthroplasty or arthrodesis of the first metatarsophalangeal joint as treatment for hallux rigidus: A systematic review and meta-analysis

BACKGROUND

Arthrodesis and metallic hemiarthroplasty are two surgical interventions for the treatment of end-stage osteoarthritis of the first metatarsophalangeal (MTP1) joint. This systematic review and meta-analysis aims to compare the two operations with regards to patient-reported outcomes, pain reduction, complications and revision rates.

METHODS

A systematic literature search identified all relevant studies. The methodological quality was assessed using two validated tools. Data of interest were derived and presented. For non-comparative studies, data was assessed for trends, while for comparative studies pooling statistics were performed.

RESULTS

A total of 33 studies were included for analysis. The majority of studies (>75%) reported an AOFAS-HMI score greater than 80 points after both metallic hemiarthroplasty and arthrodesis. The lowest VAS pain score was observed after arthrodesis (weighted mean difference -1.58, 95% confidence interval (CI) -2.16 to -1.00 P< 0.00001). Comparable numbers of complications (odds radio 1.48, 95% CI 0.81 to 2.73, P = 0.21, favoring: hemiarthroplasty) and revisions (odds ratio 1.16, 95% CI 0.62 to 2.15 P = 0.64, favoring: hemiarthroplasty) were observed after both interventions. The included non-comparative studies seem to confirm these findings of the comparative studies.

CONCLUSION

Metallic hemiarthroplasty and arthrodesis have excellent clinical outcomes and acceptable complication- and revision rates. Arthrodesis seems to be superior in pain reduction, while metallic hemiarthroplasty is a suitable alternative for patients performing activities that requires motion in the first metatarsophalangeal joint.

Dorsiflexory Phalangeal Osteotomy for Grade II Hallux Rigidus: Patient-Focused Outcomes at Eleven-Year Follow-Up

Dorsiflexory phalangeal osteotomy has been shown to be an effective treatment for mild to moderate hallux rigidus in short- to medium-term follow-up studies. It is speculated that the procedure alters the mechanical function of the joint and reduces the demand for hallux dorsiflexion by elevating the proximal phalanx into a more dorsiflexed position. However, it has been demonstrated that the first metatarsophalangeal (MTP) joint space and joint range of motion are reduced by the procedure, calling into question the long-term effectiveness of the operation. This study reviewed 27 dorsiflexory phalangeal osteotomy cases at an average of 11 years postoperatively. Twenty-one (77%) patients reported that they were completely satisfied with the results of their surgery; 4 (15%) patients reported that they were satisfied with reservations; and 2 (7%) patients reported that they were dissatisfied. The patients who were satisfied with reservations complained of interphalangeal (IP) joint pain or stiffness. One patient developed second MTP joint metatarsalgia after surgery, and in 1 patient first MTP joint pain returned at 24 months after surgery. One dissatisfied patient complained of second MTP joint metatarsalgia, and a second patient required revision excisional arthroplasty for continued joint pain. Ten patients (38%) reported stiffness of the first MTP joint, but only 2 patients reported any restriction of activity. Footwear restrictions were reported by 15 (58%) patients preoperatively and by 9 (35%) patients at final follow-up. Dorsiflexory phalangeal osteotomy maybe a reliable long-term treatment for grade II or moderate hallux rigidus and is a safe and effective alternative to first MTP joint fusion in joints where movement is still present and joint cartilage is viable.

Long-Term Results of Hemiarthroplasty Compared With Arthrodesis for Osteoarthritis of the First Metatarsophalangeal Joint

If operative treatment is opted for grade 3 and 4 osteoarthritis of the first metatarsophalangeal joint, arthrodesis is considered the standard of care. However, if preservation of joint mobility is preferred, implant arthroplasty could be favored. Previous studies have suggested hemiarthroplasty might result in less pain, better function, and greater patient satisfaction compared with arthrodesis. However, these studies only evaluated short-term results (range 2.2 to 6.6 years). The aim of our study was to determine whether patients treated with hemiarthroplasty would show better postoperative outcomes compared with those treated with arthrodesis after ≥5 years after surgery. The American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal interphalangeal (AOFAS-HMI) scale score was used as the primary outcome measure. Secondary outcomes addressed satisfaction rates, patient procedure recommendation, and number of unplanned repeat surgical procedures. We also addressed the influence of the procedures on daily activities (work and sports), the influence of smoking on the postoperative results, and the costs for both procedures. A total of 47 primary arthrodeses and 31 hemiarthroplasties performed between January 2005 and December 2011 were evaluated. After a mean follow-up period of 8.3 (range 5 to 11.8) years, the mean AOFAS-HMI scale score after arthrodesis and hemiarthroplasty was 72.8 ± 14.5 and 89.7 ± 6.6, respectively (p = .001). The patients were significantly more pleased after hemiarthroplasty (p < .001), and this procedure was recommended more often (p < .001). The number of unplanned repeat surgical procedures did not differ between the 2 groups. Patients resumed sports activities significantly sooner after hemiarthroplasty (p = .002). The overall crude costs were similar for both procedures. Our results have shown more favorable postoperative outcomes for hemiarthroplasty compared with arthrodesis as operative treatment of osteoarthritis of the first metatarsophalangeal joint after a mean follow-up period of 8.3 years.

PRINCIPLES OF SURGICAL TREATMENT IN PATIENTS WITH OSTEOARTHRITIS OF THE FIRST METATARSOPHALANGEAL JOINT

At present, there is no general approach to choosing surgical tactics for hallux rigidus. Many surgical procedures are used to treat osteoarthritis (OA) of the first metatarsophalangeal joint (FMPJ), which are relevant at different stages of the disease. Nevertheless, this fact also suggests that all proposed methods have one or other disadvantages. At the same time, FMPJ arthrodesis that relieves pain and is functionally inferior to joint-sparing surgery remains the gold standard. However, due to the fact that not only persons over the age of 50 years, but also younger patients often suffer from FMPJ OA, the most non-damaging option of joint-sparing surgery is cheilectomy with chondroplasty of the FMPJ, which allows restoration of painless joint motions, thus sparing the anatomy of the foot. Chondroplasty using the authologous matrix-induced chondrogenesis (AMIC®) technique for knee, hip, and ankle cartilage defects is described. There are no reports on FMPJ chondroplasty with the AMIC method in either Russian or foreign literature.

A comparison between metatarsal head-resurfacing hemiarthroplasty and total metatarsophalangeal joint arthroplasty as surgical treatments for hallux rigidus: a retrospective study with short- to midterm follow-up

Purpose

We evaluated the short- to midterm outcomes of metatarsal head-resurfacing hemiarthroplasty and total metatarsophalangeal joint arthroplasty (total joint replacement [TJR]) as surgical treatments for advanced-stage hallux rigidus (HR).

Patients and methods

From 2012 to 2014, all data from patients who underwent surgery for the treatment of grades 2–3 HR were retrospectively reviewed, and 45 patients were included in this study. Of these patients, 26 underwent metatarsal head-resurfacing hemiarthroplasty (Group I) and 19 underwent TJR (Group II). All patients were clinically graded prior to surgery and at their final follow-up visits using the American Orthopedic Foot and Ankle Society’s (AOFAS) hallux metatarsophalangeal–interphalangeal scale, a visual analog scale (VAS), and the “first metatarsophalangeal joint range of motion” (MTPJ ROM) score.

Results

Metatarsal head resurfacing was performed on 26 patients. Two patients underwent bilateral procedures, yielding a total of 28 cases in Group I. TJR was performed on 19 patients in Group II. Of the 26 Group I patients, 12 (46.2%) were male and 14 (53.8%) were female, with a mean age of 56.3±4.5 years (range: 47–63 years); the mean follow-up duration was 29.9±5.2 months. Of the 19 Group II patients, eight (42.1%) were male and eleven (57.9%) were female, with a mean age of 57.1±5.8 years (range: 45–66 years); the mean follow-up duration was 27.1±7.5 months. Significant improvements were evident in the AOFAS scores, and the VAS scores decreased, in both groups. No significant difference was evident between groups I and II.

Conclusion

After failure of conservative treatment in patients with moderate-to-severe HR, both MTPJ hemiarthroplasty and TJR were associated with effective recovery of toe function and MTPJ ROM, as well as good short- to midterm functional outcomes.

Techniques in Hemiarthroplasty of the First Metatarsophalangeal Joint

Surgical intervention for hallux rigidus could be necessitated when conservative attempts fail to alleviate pain and dysfunction. Controversy exists as to which procedure is ideal and will provide lasting relief of hallux rigidus pain. Many arguments have been made for and against hemi-implant arthroplasty. We advocate the use of a low-profile hemimetallic endoprosthesis (Metasurg(®)) and present our technique of using a reamer to sculpt the articular surface of the metatarsal head when necessary. We further advocate for minimal resection of the phalangeal base when using a low-profile device to maintain the soft tissue periarticular intrinsics. We present a 2- to 3-position reamer decompression of the metatarsal and discuss the benefits of maintaining range of motion at the first metatarsophalangeal joint.

Proximal Phalanx Hemiarthroplasty for the Treatment of Advanced Hallux Rigidus

Multiple treatment options exist for the management of late-stage hallux rigidus. The goals of treatment are pain reduction and restoration of function. Arthrodesis remains the treatment of choice, but recent advances support the use of first metatarsophalangeal hemiarthroplasty as a viable and successful option in properly selected patients in whom preservation of motion and function are desirable.

The metatarsosesamoid joint: an in vitro 3D quantitative assessment

BACKGROUND

The anatomy of the first metatarsophalangeal (MTP) joint, particularly the metatarsosesamoid articulation, remains poorly understood. Our goal was to quantitatively define the excursion of the sesamoids.

METHODS

Seven cadavers were dissected to assess the articulating surfaces throughout a normal range of motion. The dissections were digitally reconstructed in various positions using a MicroScribe.

RESULT

For first MTP joint, excursion averaged 14.7mm for the tibial sesamoid in the sagittal plane and 7.5mm for the fibular sesamoid. The sesamoids also moved medially to laterally when the joint was dorsiflexed. For the maximally dorsiflexed joint, excursion averaged 2.8mm for the tibial sesamoid and 3.5mm for the fibular sesamoid.

CONCLUSION

Hallucal sesamoids appear to have differential tracking: the tibial sesamoid has greater longitudinal excursion; the fibular sesamoid has greater lateral excursion. The anatomical data will interest those involved with the design of an effective hallux arthroplasty.

End-stage osteoarthritis of the great toe/hallux rigidus: a review of the alternatives to arthrodesis: implant versus osteotomies and arthroplasty techniques

Hallux rigidus is defined as end-staged arthrosis of the first metatarsophalangeal joint. Although the literature supports arthrodesis as being the gold standard for the treatment of end-staged hallux rigidus, there are several other treatments available that can either prolong the life of the remaining joint or artificially mimic the original biomechanics by replacing a portion of or the entire joint with the added advantage of preserving joint mobility. There are several new and emerging joint preservative techniques that may delay or prevent the need for a joint-destructive procedure, such as arthrodesis or arthroplasty.

Evidence-based analysis of the efficacy for operative treatment of hallux rigidus

BACKGROUND

The aim of this article is to provide an evidence-based literature review and assessment of the quality of literature regarding operative interventions for hallux rigidus.

METHODS

A comprehensive evidence-based literature review of the PubMed database was conducted on June 24, 2011, identifying 586 articles, of which 135 were relevant in assessing the efficacy of common operative interventions for hallux rigidus. The 135 studies were then assigned a level of evidence (I-V) to denote quality. They were then reviewed to provide a grade of recommendation (A-C, I) in support of or against the operative intervention in treatment of hallux rigidus.

RESULTS

Based on the results of this evidence-based review, there is fair evidence (grade B) in support of arthrodesis for treatment of hallux rigidus. There is poor evidence (grade C) in support of cheilectomy, osteotomy, implant arthroplasty, resection arthroplasty, and interpositional arthroplasty for treatment of hallux rigidus. There is insufficient evidence (grade I) for cheilectomy with osteotomy for treatment of hallux rigidus.

CONCLUSION

There are no consistent findings in comparative studies that are properly powered with validated and appropriate outcome measures to allow any definitive conclusions on which procedure is best. However, the grade B recommendation assigned to arthrodesis may make it the logical leading candidate for future high-quality randomized controlled trials. Clearly, further studies-ideally, high-quality Level I randomized controlled trials with validated outcome measures-are needed to allow stronger recommendations to be made.

LEVEL OF EVIDENCE

Level III, systematic review.

Surgical management of hallux rigidus

Hallux rigidus is the most common degenerative joint pathology of the foot. Untreated, it may result in notable limitations in gait, activity level, and daily function. Positive outcomes can be achieved with nonsurgical management; surgery is recommended for the sufficiently symptomatic patient for whom nonsurgical measures are unsuccessful. Surgery is selected based on grade of involvement. Early to mid-stage hallux rigidus is best managed with cheilectomy or cheilectomy and proximal phalanx osteotomy. Arthrodesis and arthroplasty are reserved for late-stage hallux rigidus.

Long-term results following Keller resection arthroplasty for hallux rigidus

BACKGROUND

We assessed the long-term results following Keller resection arthroplasty for the treatment of hallux rigidus. We then compared them with alternative surgical methods like cheilectomy, arthrodesis and joint replacement.

METHODS

Eighty-seven cases of Keller resection arthroplasty for hallux rigidus were reviewed with mean followup of 23 years. Their mean age at time of surgery was 50 years. Analysis included personal clinical evaluation with the AOFAS Hallux Score, quality-of-life assessment using the SF-36, radiographic assessment, pedobarographic evaluation and analysis of the patients' charts to detect any postoperative complications.

RESULTS

At the time of followup only five (5%) feet had undergone revision surgery. For all other cases we calculated a mean AOFAS score of 83 points. Sixty-nine of 73 unrevised patients (94%) would opt for this operation again under the same circumstances. SF-36 parameters showed age related normal values. Pedobarographic assessment revealed only moderate weightbearing alterations. Our long-term results compare favorably with published results following arthrodesis, cheilectomy or joint replacement for the treatment of painful hallux rigidus. Clinical results and subjective assessments were very good and complication rates were low compared to competing methods.

CONCLUSION

Keller resection arthroplasty remains a valuable surgical option for the treatment of advanced stages of hallux rigidus with high patient satisfaction, moderate weightbearing alterations and comparable low complication rate in our experience.

A multicenter retrospective review of outcomes for arthrodesis, hemi-metallic joint implant, and resectional arthroplasty in the surgical treatment of end-stage hallux rigidus

This is a retrospective, multicenter study examining the long-term results for the treatment of end-stage hallux rigidus using 3 different surgical procedures. A total of 158 subjects (105 females and 53 males) were included in the present study. They had undergone 1 of the following surgical procedures: arthrodesis, hemi-implant, or resectional arthroplasty. The long-term results for the subjective assessment of pain, function, and alignment, as well as objective radiographic and physical findings, were examined. The median interval to postoperative follow-up for the 3 procedure groups was 159 weeks. No statistically significant difference was found in age or the number of subjects included in the 3 treatment groups (p = .11 and p = .16, respectively). The body mass index was significantly different statistically among the 3 treatment groups, with the hemi-implant group representing a smaller body mass index compared with the other procedures (p = .007). No statistically significant difference was found in the subjective outcomes among the 3 treatment groups using the American College of Foot and Ankle Surgeons' First Metatarsophalangeal Joint and First Ray Scoring Scale (patient questionnaire) or the modified Hallux Metatarsophalangeal-Interphalangeal Scale of the American Orthopedic Foot and Ankle Society (p = .64 and p = .14, respectively). Furthermore, the correlation coefficient between the 2 subjective scoring scales was 0.78, statistically significant and reflecting a moderate to high correlation (p < .001). The results of the radiographic and clinical evaluation revealed that metatarsalgia was the most common finding for the arthrodesis group (9.8%), bony overgrowth into the joint for the hemi-implant group (28.3%), and floating hallux for the resectional arthroplasty group (30.9%). The results of our study suggest that all 3 surgical procedures are viable options for the treatment of end-stage hallux rigidus.

Surgical treatment of advanced hallux rigidus by interpositional arthroplasty

BACKGROUND

While arthrodesis is the gold-standard for end-stage hallux rigidus, it leads to loss of mobility. The purpose of this paper was to report our clinical results with modified interpositional arthroplasty for the treatment of advanced (Grade III and IV of Coughlin and Shurnas) hallux rigidus.

MATERIAL AND METHODS

Twenty-five feet with Grade III and IV hallux rigidus underwent cheilectomy, minimal proximal phalanx resection (modified Keller) and interposition of the dorsal capsule and EHB.

RESULTS

At a minimum followup of 15 months, the mean postoperative hallux AOFAS score was 93.6 points with a pain subscore of 36.4 (maximum, 40 points) and functional subscore of 42.5 (maximum, 45 points). Subjectively, patients were completely satisfied with the surgical outcome in 75% of the cases.

CONCLUSION

The modified interpositional arthroplasty was a feasible surgical option to address advanced hallux rigidus in middle aged patients.