Surgical treatment of advanced hallux rigidus by interpositional arthroplasty

Interposition Arthroplasty in the Treatment of End-Stage Hallux Rigidus: A Systematic Review

PURPOSE

Patients affected by moderate to severe hallux rigidus may opt for interposition arthroplasty to avoid the movement restrictions of arthrodesis and the complications related to prosthetic replacement. The propose of this article was to review the current literature about interposition arthroplasty to examine the overall outcomes and to evaluate the advantages and disadvantages of different types of technique, compared with more consolidated procedures.

METHODS

A literature PubMed search was performed. Studies reporting the results of interposition arthroplasty in moderate to severe hallux rigidus were included. The data were pooled and weighted for number of patients in every study.

RESULTS

The overall results for interposition arthroplasties are comparable to other alternatives for end-stage hallux rigidus, providing better plantar load distribution than arthrodesis and avoiding the drawbacks of prosthetic replacement. Among the various interposition arthroplasty techniques, the Modified Oblique Keller Capsular Interposition Arthroplasty technique preserves toe length and flexor hallucis brevis function, showing the highest satisfaction rate, with lowest metatarsalgia and revision rate.

CONCLUSION

Although long-term randomized controlled trials are lacking for interposition arthroplasty, it represents a valid alternative for the treatment of end-stage hallux rigidus also in the young active patient who wants to avoid a definitive intervention immediately.

LEVEL OF EVIDENCE

III (systematic review of level III-IV-V studies).

"In Situ" Joint Preparation Technique for First Metatarsophalangeal Arthrodesis: A Retrospective Comparative Review of 388 Cases

"Cup-shaped power reamers" and "flat cuts" (FC) are common joint preparation techniques in first metatarsophalangeal (MTP) joint arthrodesis. However, the third option of an "in situ" (IS) technique has rarely been studied. This study aims to compare the clinical, radiographic, and patient-reported outcomes (PROMs) of the IS technique for various MTP pathologies with other MTP joint preparation techniques. A single-center retrospective review was performed for patients who underwent primary MTP joint arthrodesis between 2015 and 2019. In total, 388 cases were included in the study. We found higher nonunion rates in the IS group (11.1% vs 4.6%, p = .016). However, the revision rates were similar between the groups (7.1% vs 6.5%, p = .809). Multivariate analysis revealed that diabetes mellitus was associated with significantly higher overall complication rates (p < .001). The FC technique was associated with transfer metatarsalgia (p = .015) and a more first ray shortening (p < .001). Visual analog scale, PROMIS-10 physical, and PROMIS-CAT physical scores significantly improved in IS and FC groups (p < .001, p = .002, p = .001, respectively). The improvement was comparable between the joint preparation techniques (p = .806). In conclusion, the IS joint preparation technique is simple and effective for first MTP joint arthrodesis. In our series, the IS technique had a higher radiographic nonunion rate that did not correlate with a higher revision rate, and otherwise similar complication profile to the FC technique while providing similar PROMs. The IS technique resulted in significantly less first ray shortening when compared to the FC technique.

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.

Metatarsophalangeal HAPY® spherical pyrocarbon implant: Technical note

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

Excision Arthroplasty With Interpositional Achilles Tendon Autograft: A Novel Approach to Talonavicular Joint Osteoarthritis Associated With Ankle Arthrodesis

Talonavicular joint arthritis is a great concern after ankle fusion. Although arthrodesis is the gold standard treatment for this complication, it could initiate a vicious cycle of further adjacent joint arthritis. An alternative that may delay or eliminate the need for arthrodesis is excision arthroplasty; however, there are only a few reports on its application on a talonavicular joint. We report 3 cases of excision arthroplasty with interpositional Achilles tendon autograft for the treatment of end-stage talonavicular osteoarthritis in low-demand elderly patients. In 1 patient, excision arthroplasty was performed after tibiotalocalcaneal arthrodesis, and in 2 patients, it was performed after tibiotalar arthrodesis, in which the subtalar joints were also damaged and fused simultaneously on performance of the interpositional arthroplasty of the talonavicular joint. In all cases, pain relief and functional activities of daily living improvement were achieved with this procedure. At a minimum follow-up of 1 year, no patient reported adjacent joint symptoms or flatfoot progression. These cases show that interpositional arthroplasty with Achilles tendon autograft is an effective treatment for end-stage talonavicular arthritis in patients with fused ankle and subtalar joints. This procedure was helpful in relieving pain and improving activities of daily living function in low-demand elderly patients with the preservation of movement of the talonavicular joint. Autograft was considered to be superior to other grafts with respect to availability, graft rejection, or allergy development. Fused subtalar joint resolved the concerning issues, such as flatfoot progression and muscular weakness of ankle plantar flexion, associated with this procedure.

Valenti resection arthroplasty for hallux rigidus: A systematic review

BACKGROUND

Valente Valenti proposed in 1976 a "V" resection of the first metatarsophalangeal joint (MPT1) on the sagittal plane for advanced stages of hallux limitus/rigidus, preserving length of the first ray, flexor hallux brevis and sesamoid function. The available literature concerning correct indications, management and clinical outcomes of the Valenti procedure (VP) and its modifications in patients affected by hallux limitus/rigidus was systematically analyzed.

METHODS

Titles and abstracts of all selected articles were independently screened by two authors to assess their suitability to the research focus.

RESULTS

Selection produced 8 articles as full-text, for a total of 347 patients, with a mean follow-up of 6±7.1 (range 0.2-17.5) years. Most common complication was transient sesamoiditis in 21 (7.4%) patients. No substantial differences in clinical outcomes were found between the original and modified techniques.

CONCLUSIONS

VP appears to allow an early recovery with few complications, if compared to fusion, interposition arthroplasties or osteotomies. The wide joint resection does not prevent, if necessary, further procedures such as fusion or implants.

LEVEL OF EVIDENCE

Level I, systematic review.

Biomechanical consequences of first metatarsaophalangeal joint arthrodesis on flexor digitorum longus function: A cadaveric study

BACKGROUND

First metatarsophalangeal joint (MTPJ) arthrodesis is a common treatment modality for hallux rigidus with successful outcomes. However, the effect of arthrodesis on flexor digitorum longus (FDL) is poorly understood. The purpose of this study was to investigate this effect in a biomechanical model.

METHODS

Ten cadaveric trans-knee amputated specimens were studied. Lesser toe range of motion (ROM) and FDL excursion on simulated FDL contraction were measured in the following three scenarios: (1) before 1st MTPJ arthrodesis, (2) after 1st MTPJ arthrodesis, and (3) after the knot of Henry release.

RESULTS

1st MTPJ arthrodesis reduced both mean lesser toe ROM and FDL excursion. However, there was improvement in these parameters after the knot of Henry release.

CONCLUSIONS

FDL function was reduced following 1st MTPJ arthrodesis. This effect was contributed by soft tissue connections at the knot of Henry, where FDL crosses flexor hallucis longus (FHL). Therefore, with restriction of FHL movement after 1st MTPJ arthrodesis, FDL movement was also restricted.

CLINICAL RELEVANCE

This result improved our understanding of 1st MTPJ arthrodesis biomechanics and suggested potential benefits of the knot of Henry release in 1st MTPJ arthrodesis to improve FDL function, thereby decreasing the rate of metatarsalgia and other associated problems.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

Hemiarthroplasty Versus Total Joint Arthroplasty for Hallux Rigidus: A Systematic Review and Meta-analysis

BACKGROUND

When surgery is indicated for hallux rigidus, toe arthroplasty is an alternative procedure to arthrodesis for patients who wish to preserve toe range of motion. Our study investigated midterm outcomes of first metatarsophalangeal joint (MTPJ) arthroplasty in an effort to discern whether or not partial or total joint replacement confers benefit in these patients.

METHODS

A systematic review of MTPJ arthroplasty was performed for the years 2000 to 2017. A Forest plot was created comparing preoperative and postoperative American Orthopedic Foot and Ankle Score (AOFAS), Visual Analogue Scale (VAS), and range of motion (ROM) results for both hemitoe and total-toe arthroplasty. Statistical analysis was performed.

RESULTS

Mean postoperative AOFAS scores in patients undergoing hemiarthroplasty improved by 50.7 points (95% CI = 48.5, 52.8), whereas the mean AOFAS score improvement in total joint arthroplasty patients was 40.6 points (95% CI = 38.5, 42.8). VAS outcomes were comparable. Mean postoperative MTPJ ROM improved by 43.0° (95% CI = 39.3°, 46.6°) in hemitoe patients, which exceeded the mean ROM improvement of 32.5° (95% CI = 29.9°, 35.1°) found in total joint arthroplasty cases. A meta-analysis revealed no significant difference.

CONCLUSION

Hemisurface implants in MTPJ arthroplasty may improve postoperative AOFAS and ROM results to a greater extent than total-toe devices.

LEVEL OF EVIDENCE

Level IV: Systematic review.

Outcomes Following Interposition Arthroplasty of the First Metatarsophalangeal Joint for the Treatment of Hallux Rigidus: A Systematic Review

Background:

Interposition arthroplasty of the first MTP joint has recently experienced renewed interest as a treatment for hallux rigidus. The purpose of this study was to systematically review the rapidly expanding literature on PRO following interposition arthroplasty of the first MTP joint.

Methods:

PubMed Central, Embase, and the Cochrane Central Register for Controlled Trials (CENTRAL) were searched. Inclusion criteria included length of time to follow-up, number of patients, outcome measure, and use of allogeneic or autogenous soft tissue or a synthetic matrix as interposition.

Results:

20 studies were included in the review, comprising 498 patients and 539 feet with mean time to follow-up of 4.5 years. The most common substance used for interposition in the included studies was autogenous first MTPJ capsular tissue, a technique reported on in 12 (60.0%) of the included articles. In studies reporting preoperative and postoperative outcomes by way of a standardized outcome scoring system, mean group improvements exceed minimal clinically important differences in the majority of studies. Eighty-five percent of the studies included in this review were of Level IV quality evidence, and of this subset of studies, 70.6% were of a retrospective nature. Progression to further surgery was observed in 3.8% of toes. The most common complication reported was transfer metatarsalgia of 1 or more lesser toes, observed in up to 57.9% of patients in one study.

Conclusion:

Interposition arthroplasty appears to be a viable option for the treatment of moderate to severe hallux rigidus in patients looking to salvage motion through the first metatarsophalangeal joint. A wide array of autogenous, allogeneic, and synthetic implant materials have surfaced in recent years, but long-term follow-up and prospective, comparative study designs with low risk of bias are limited.

Level of Evidence:

Level IV, systematic review of Level III-IV studies

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

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

Long-Term Follow-up of Capsular Interposition Arthroplasty for Hallux Rigidus

BACKGROUND

Capsular interposition arthroplasty is a joint- and motion-sparing procedure that has been shown as an effective alternative to fusion. This study aimed to evaluate patient function and satisfaction after long-term follow-up.

METHODS

Sixty-four patients were treated with capsular interposition arthroplasty for hallux rigidus by the senior author performed between February 1998 and July 2011. Twenty-two patients could not be reached for follow-up and were thus excluded from the analysis. Therefore, 42 remaining patients were evaluated using the visual analog scale (VAS), Foot Function Index (FFI), Short Form 12 (SF-12), and patient satisfaction scores. The mean follow-up was 11.3 (range, 4-16) years.

RESULTS

The mean VAS for pain was 7.9 preoperatively and 1.8 postoperatively ( P = .003). The mean preoperative SF-12 physical score was 42.0 vs 64.2 postoperatively ( P = .02). The mean preoperative SF-12 mental score was 50.7, while the postoperative SF-12 mental score was 54.6 ( P = .01). The total FFI score also significantly improved, with a preoperative value of 98.3 and a postoperative mean score of 49.6 ( P = .001). The mean patient satisfaction score was 7.4 of 10. Overall, 39 of 42 patients (92.9%) stated they would have the surgery again. Four of the 42 patients (9.5%) required conversion to hallux metatarsophalangeal fusion at a mean of 6.1 years after the index procedure secondary to pain, but no other complications were reported.

CONCLUSION

Capsular interposition arthroplasty was a safe and effective treatment for severe hallux rigidus. These longer term results demonstrate a high level of patient satisfaction.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Hallux rigidus: How do I approach it?

Hallux rigidus is a degenerative disease of the first metatarsalphalangeal (MTP) joint and affects 2.5% of people over age 50. Dorsal osteophytes and narrowed joint space leads to debilitating pain and limited range of motion. Altered gait mechanics often ensued as 119% of the body force transmit through the 1^st MTP joint during gait cycle. Precise etiology remains under debate with trauma being often cited in the literature. Hallux valgus interphalangeus, female gender, inflammatory and metabolic conditions have all been identified as associative factors. Clinical symptoms, physical exam and radiographic evidence are important in assessing and grading the disease. Non-operative managements including nonsteroidal antiinflammatory drugs, intra-articular injections, shoe modification, activity modification and physical therapy, should always be attempted for all hallux rigidus patients. The goal of surgery is to relieve pain, maintain stability of the first MTP joint, and improve function and quality of life. Operative treatments can be divided into joint-sparing vs joint-sacrificing. Cheilectomy and moberg osteotomy are examples of joint-sparing techniques that have demonstrated great success in early stages of hallux rigidus. Arthrodesis is a joint-sacrificing procedure that has been the gold standard for advanced hallux rigidus. Other newer procedures such as implant arthroplasty, interpositional arthroplasty and arthroscopy, have demonstrated promising early patient outcomes. However, future studies are still needed to validate its long-term efficacy and safety. The choice of procedure should be based on the condition of the joint, patient’s goal and expectations, and surgeon’s experience with the technique.

Outcomes of the Distal Metatarsal Dorsiflexion Osteotomy for Advanced Hallux Rigidus

BACKGROUND

Hallux rigidus can be treated using several different methods and the best treatment option depends on the severity of degenerative changes of the metatarsophalangeal (MTP) joint. However, the ideal operative option for advanced hallux rigidus remains debatable. This prospective study was performed to evaluate the intermediate-term clinical outcomes of distal metatarsal osteotomy used as a joint-preserving method for the treatment of advanced hallux rigidus.

METHODS

Forty-two cases (39 patients) were followed for more than 3 years after distal metatarsal dorsiflexion osteotomy for advanced hallux rigidus of grade III-IV. Clinical evaluations included the American Orthopaedic Foot & Ankle Society (AOFAS) scores, Foot and Ankle Ability Measure (FAAM) scores, and patient subjective satisfaction scores. Range of motion (ROM) of great toe, complications, reoperation rates, width of the MTP joint space, and times to union were evaluated.

RESULTS

Mean AOFAS hallux and mean FAAM scores significantly improved from 56.4 and 61.2 points preoperatively to 87.6 and 88.7 points at final follow-up, respectively ( P < .001). Grade III and IV groups had significantly different AOFAS and FAAM scores at final follow-up. Mean dorsiflexion of great toe significantly improved from 14.8° preoperatively to 35.5° at final follow-up ( P < .001). Mean patient satisfaction score at final follow-up was 92.8 points. There were 4 cases (9.5%) of subsequent fusion and 2 cases (4.8%) of transfer metatarsalgia.

CONCLUSIONS

Distal metatarsal dorsiflexion osteotomy using bio-compression screws appears to be an effective operative option for grade III advanced hallux rigidus with viable cartilage on >50% of the first metatarsal articular surface, as it restored joint motion, provided reliable pain relief, and did not require implant removal. However, based on the unsatisfactory clinical results and the high rate of reoperation observed, the authors cannot recommend this operative method for the treatment of end-stage (grade IV) hallux rigidus.

LEVEL OF EVIDENCE

Level IV, prospective case series.

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.

Autogenous capsular interpositional arthroplasty surgery for painful hallux rigidus: assessing changes in range of motion and postoperative foot health

The autogenous capsular interpositional arthroplasty procedure can be a motion-sparing alternative to arthrodesis for the treatment of recalcitrant hallux rigidus deformity. Previous studies have reported positive results; however, many had small samples or lacked comparable preoperative measures. The present study used a prospective cohort study to assess the benefit of this technique for increasing range of motion, and comparative data to assess the reduction of pain and improvements in perceived foot health status for a consecutively drawn sample of patients. Thirty-four patients (44 feet) reviewed using a long-arm goniometer at a mean of 3.75 years after surgery experienced a significant increase in dorsiflexion (preoperative mean 11.09° ± 10.13°; postoperative mean 26.64° ± 10.07°; p < .001); plantar flexion remained unchanged. Additionally, 15 of 17 patients for whom the hallux abductus angle was initially greater than the normal range was within the normal range postoperatively. The postoperative patient perceptions of foot pain were significantly better than those from a comparable sample of patients presenting for a surgical opinion (t[69] = 6.80), just as were the perceptions of foot function, foot health, and footwear comfort (p < .001 for all). The postoperative perceptions of foot pain were comparable with the postoperative results from a range of previously published studies. These results have shown, with improvements in range of motion and reduction in pain, that autogenous capsular interpositional arthroplasty is a useful, motion-sparing technique in the treatment of painful hallux rigidus and should be considered for classification as a clinical practice guideline.

Metatarsal head resurfacing for advanced hallux rigidus

BACKGROUND

Advanced stages of first metatarsophalangeal (MTP) arthritis have traditionally been treated with various arthroplasties or arthrodesis. Studies suggest the outcomes of arthrodesis are superior to those of metallic joint replacement; however, complications and suboptimal outcomes in active patients still remain with arthrodesis of the first MTP joint. This study reports results of patients with advanced MTP arthritis who underwent metallic resurfacing of the metatarsal side of the MTP joint.

METHODS

From 2005 to 2006, 26 patients (30 implants) with stage II or III hallux rigidus underwent resurfacing with the HemiCAP® implant and consented to participate in a study comparing pre- and postoperative radiographs, range of motion (ROM), American Orthopedic Foot and Ankle Society, and Short Form 36 Health Survey (SF-36) scores. Average age of these patients was 51 years. Patients were assessed at a mean of 27 months with outcome measures and contacted at 60 months to assess current symptoms and satisfaction.

RESULTS

Assessment at 27 months demonstrated statistically significant improvements in ROM, AOFAS, and SF-36 scores (P < .05) when compared to baseline. Mean preoperative AOFAS scores improved from 51.5 to 94.1. Mean active ROM improved from 19.7 to 47.9 degrees. Mean passive ROM improved from 28.0 to 66.3 degrees. Mean RAND SF-36 physical component score improved significantly from 66.7 to 90.6. Average time for return to work was 7 days. At 60 months, all patients reported excellent satisfaction with their current state and would repeat the procedure. Implant survivorship was 87% at 5 years. Of the 30 implants, 4 were revised at 3 years.

CONCLUSION

The results at 5 years were very promising. Preservation of joint motion, alleviation of pain, and functional improvement data were very encouraging. Because minimal joint resection was performed, conversion to arthrodesis or other salvage procedures would be relatively simple if further intervention became necessary.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Interposition ankle arthroplasty using Achilles tendon allograft ("the AAA procedure"): a case report

Surgical treatment options for end-stage osteoarthritis of the ankle joint typically consist of debridement, distraction arthroplasty, osteochondral allograft transfer system, arthrodesis, or total ankle arthroplasty. Interposition arthroplasty is an additional surgical treatment that may delay or eliminate the need for ankle arthrodesis. We report the use of a free Achilles tendon allograft as interposition arthroplasty for treatment of end-stage ankle osteoarthritis, the Achilles Ankle Arthroplasty or "AAA" procedure. The clinical presentation and course of treatment are described, as well as the surgical technique. This case showed that interposition arthroplasty with tendon allograft is an effective treatment for end-stage ankle arthritis.