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Hi Steve,
Thanks for that. What you have written about the two different presentations makes perfect sense. I suppose that variation makes decision making a bit more challenging. (Or maybe that comes with greater experience?)
Being the trainee in our team, I list the patients for whatever procedures the consultant frequently does (not what I want to see) and I think if I started listing for procedures he doesn't like to do, I'd find myself spending the next month's worth of theatre sessions doing heel pain clinics or something!
Having said that, as part of my training, I have to visit other centers and will hopefully get an opportunity to see what other surgeons here in the UK do and quiz them as to why. What are your favoured procedures for hallux limitus/rigidus?
I suppose at the end of the day, choice of procedure will inevitably reflect what you find gives most consistent results.
Lee:
cheers for the offer. I have my rotations timetabled for the next 18months and when I have my pod surgery sessions, I'll take you up on that.
Out of interest, do you favour Kessel Bonny and decompressive osteotomies as your joint preserving procedures? Have you had many instances of transfer pain following shortening of the 1st ray (I am assuming that you meant decompressive osteotomies when you mentioned met procedures?).
As for the title of the study, I did ask. Apparently the advisory board that reviewed the paper had suggested changing the title to rigidus rather than limitus.
Lee:
cheers for the offer. I have my rotations timetabled for the next 18months and when I have my pod surgery sessions, I'll take you up on that.
Out of interest, do you favour Kessel Bonny and decompressive osteotomies as your joint preserving procedures? Have you had many instances of transfer pain following shortening of the 1st ray (I am assuming that you meant decompressive osteotomies when you mentioned met procedures?).
As for the title of the study, I did ask. Apparently the advisory board that reviewed the paper had suggested changing the title to rigidus rather than limitus.
Cheers,
Ryan
Hello Ryan,
I'm sure we can sort something out - shouldn't be a problem. I generally favour Kessel Bonney's unless the 1st met's long or elevated, in which case it's a 1st met osteotomy. I've previously done procedures as Kevin has described for long 1st metatarsals with no elevatus (including the ?modified Youngswick? to decompress and plantarflex the metatarsal head) and I've had some great results with a plantarflexing (sagittal) scarf for those with elevatus.
In terms of rates of transfer metatarsalgia, so far (touch wood) the incidence has been minimal post op with the osteotomies - maybe I'm doing well with my pretty strict criteria for met vs phalanx osteotomy, or maybe I've been lucky (most likely). I try not to over-shorten the met and use intra-operative fluoroscopy for all the procedures. We'll see how the long term results go - I'll probably be less optimistic in a few years, but time will tell.
I don't actually see that much elevatus to be honest. In fact, I am yet to see a case where this has influenced the choice of procedure (excluding a number of cases where this has been as a result of previous hallux valgus surgery).
Having said that, I don't know if I am just missing it, not appreciating its importance it or a mixture of both!
I have always thought of metatarsus elevatus being as a result of the pathology due to platar soft tissue contracture or spasm as rather than as an aetiological factor. For that reason, it never really comes into my mind with surgical planning.
Would be interested to hear what you or others thought on this.
This thread has definitely made me think more about what I assumed I had a reasonable understanding of!! Thanks for the input.
I don't actually see that much elevatus to be honest. In fact, I am yet to see a case where this has influenced the choice of procedure (excluding a number of cases where this has been as a result of previous hallux valgus surgery).
Having said that, I don't know if I am just missing it, not appreciating its importance it or a mixture of both!
I have always thought of metatarsus elevatus being as a result of the pathology due to platar soft tissue contracture or spasm as rather than as an aetiological factor. For that reason, it never really comes into my mind with surgical planning.
Would be interested to hear what you or others thought on this.
This thread has definitely made me think more about what I assumed I had a reasonable understanding of!! Thanks for the input.
Cheers,
Ryan
No worries,
Hopefully, I haven't given the impression that I'm seeing loads of elevatus and doing loads of plantarflexing osteotomies? They're not all that common (I just seem to be getting a few through the door at the moment - like buses, etc...). You could be right about many cases of elevatus being contributed to by plantar soft tissue contracture.
Next time you have a patient with 1st MTPJ pain but fairly good motion NWB, load the first ray and see what you get. My prediction is that you will see more met/elevatus.
Lee:
It's good to hear that you are getting good results with the shortening osteotomies. I soured on the procedures when I was getting patients returning years later (or sooner) with continued and progressive arthritis. Perhaps I was expecting too much.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Next time you have a patient with 1st MTPJ pain but fairly good motion NWB, load the first ray and see what you get. My prediction is that you will see more met/elevatus.
Lee:
It's good to hear that you are getting good results with the shortening osteotomies. I soured on the procedures when I was getting patients returning years later (or sooner) with continued and progressive arthritis. Perhaps I was expecting too much.
Steve
I can appreciate why Steve. I must say that I'm not one for over selling the procedure to the patients - I always give them advice on the fact that they will still have OA in the joint post surgery and that this may progress potentially leading to another surgery (usually after going through conservative care as needed). Patients keep telling me I'm a pessimist - I tell them I'm a realist!
Either way it's a difficult pathology to treat. Orthopods have no problem doing 3 or 4 knee scopes then a joint replacement then a joint replacement-replacement. Perhaps I just need an attitude adjustment rather than a different surgical procedure.
Steve,
The lead author is my surgical tutor. We perform the sesamoidectomy quite frequently.
If you have any specific questions, I'd happily do my best to try and answer them for you.
Regards,
Ryan
Hi Ryan, I may have a few questions for you!! I've downloaded the PDF that was kindly attached for a bit of bed time reading!! I'll be in touch.
Im currently looking at MPE / evidence based HR/HL treatment/surgery and ultimately a treatment pathway as a "nice project"
Compared with other surgical procedures for hallux rigidus, dorsal cheilectomy involves relatively less bone removal, maintains joint motion, and leaves the potential for further salvage surgery. The Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ) has a maximum score of 64 (worst foot health) and has been endorsed by the British Foot and Ankle Society to measure surgical outcome. We prospectively assessed patient-reported outcomes after dorsal cheilectomy for hallux rigidus using the MOXFQ. Patients were deemed suitable for dorsal cheilectomy if they had painful restriction of terminal dorsiflexion, with absence of pain in the mid-range of passive movement, and radiographic evidence of dorsal osteophytosis. Twenty-five patients with a mean age of 62 years (range, 39-80 years), including 17 (68%) women, underwent dorsal cheilectomy for hallux rigidus. The mean preoperative MOXFQ score was 33.0 (95% confidence interval = 27.4-38.6), and, at a mean of 17 months (range, 9-27 months) follow-up, the mean postoperative score was 9.6 (95% confidence interval = 6.0-13.2). Eighty-four percent of patients experienced clinically significantly improved walking domain, 68% in the social domain, and 59% in the pain domain of the MOXFQ. Four patients failed cheilectomy, including 3 who subsequently underwent arthrodesis for persistent pain and 1 who experienced no improvement in any domain of the MOXFQ. This prospective study provided further evidence of the success of dorsal cheilectomy as a treatment for hallux rigidus and demonstrated the potential usefulness of the MOXFQ in assessing surgical outcomes in foot surgery
Autogenous soft tissue interpositional arthroplasty has been proposed as an alternative to arthrodesis and other forms of arthroplasty for treatment of end-stage hallux rigidus because of the perceived safety and efficacy. The author undertook a systematic review of electronic databases and other relevant sources to identify material relating to the outcomes following autogenous soft tissue interpositional arthroplasty for end-stage hallux rigidus. Information from peer-reviewed journals, as well as from non-peer-reviewed publications, abstracts and posters, textbooks, and unpublished works, were also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing isolated autogenous soft tissue interpositional arthroplasty for the treatment of end-stage hallux rigidus, evaluated patients at mean follow-up of 12-months' duration or longer, included pre- and postoperative range of motion of the first metatarsal-phalangeal joint, determined pre- and postoperative outcomes using a scoring system, and documented any complications. Two studies involving a total of 28 autogenous soft tissue interpositional arthroplasties for end-stage hallux rigidus were identified that met the inclusion criteria. There were 12 men (52%) and 11 women (48%) with a mean age of 58.2 years followed for a mean of 21.6 months. Both studies used the AOFAS First Metatarsal-Phalangeal-Hallux Scoring System, which had a mean of 26.0 preoperatively rising to 89.4 postoperatively. First metatarsal-phalangeal joint dorsiflexion had a mean of 16.7 degrees preoperatively rising to 51.1 degrees postoperatively. Complications occurred in 4 (14.3%) feet and no feet required surgical revision. The results of this systematic review demonstrate improvement in patient outcomes and first metatarsal-phalangeal joint dorsiflexion, as well as few complications following autogenous soft tissue interpositional arthroplasty for end-stage hallux rigidus. However, there is still a need for methodologically sound prospective cohort studies that compare autogenous soft tissue interpositional arthroplasty with other forms of arthroplasty and arthrodesis for end-stage hallux rigidus.
Radiographic Outcomes Following Primary Arthrodesis of the First Metatarsophalangeal Joint in Hallux Abductovalgus Deformity.
Sung W, Kluesner AJ, Irrgang J, Burns P, Wukich DK. J Foot Ankle Surg. 2010 Jul 14. [Epub ahead of print]
Quote:
The purpose of this study was to evaluate the radiographic outcomes of primary metatarsophalangeal joint arthrodesis for hallux abductovalgus deformities. Between January 2004 and March 2009, 56 consecutive patients (58 feet) underwent primary arthrodesis of the metatarsophalangeal joint (MTPJ) for severe hallux abductovalgus deformity and or hallux rigidus. Results were assessed by primary radiographic outcome measurements (hallux valgus and first-second intermetatarsal angle). Overall, the mean hallux valgus (HA) angle improved significantly from 31.9 degrees to 13.4 degrees (P < .01). The mean first-second intermetatarsal (IM) angle correction was also signficantly reduced from 14.0 degrees to 9.7 degrees (P < .01). When separated by deformity group (mild, moderate, and severe), the mean hallux valgus and first-second intermetatarsal angles demonstrated statistically significant correction in all groups when comparing preoperative and postoperative values (P < .01). Primary arthrodesis provides predictable radiographic outcomes and effective correction for patients with differing severity of hallux abductovalgus deformity and arthritis of the first metatarsophalangeal joint. A separate proximal osteotomy for severe metatarsus primus varus correction may not be necessary because of the correction achieved at the metatarsophalangeal joint arthrodesis level. The results of this study demonstrate that as the severity of the preoperative deformity increases, the amount of postoperative radiographic (HA and IM angle measurement) correction after MTPJ arthrodesis will improve correspondingly
OBJECTIVES: We evaluated the outcomes of interposition arthroplasty performed for the treatment of hallux rigidus. METHODS: The study included 19 feet (4 left, 15 right) of 17 patients (14 females, 3 males; mean age 61+/-5 years; range 55 to 71 years) who were treated with interposition arthroplasty for hallux rigidus. According to the grading system of Coughlin and Shurnas, 18 feet were grade 3, one foot was grade 4. One-third of the base of the proximal phalanx was resected at surgery. Preoperative and postoperative radiographic assessments included the measurements of the joint space width of the first metatarsophalangeal (MTP) joint, hallux valgus angle, and intermetatarsal angle. Clinical evaluations were made using the AOFAS (American Orthopaedic Foot and Ankle Society) hallux metatarsophalangeal-interphalangeal scale. Postoperative satisfaction levels of the patients were questioned. The mean follow-up period was 21 months (range 9 to 32 months). RESULTS: According to the AOFAS scale, the results were excellent in seven feet (36.8%), good in nine feet (47.4%), and fair in three feet (15.8%), with excellent and good results accounting for 84.2%. The mean total AOFAS score increased by 24.6 points postoperatively (p<0.05). The mean range of motion of the first MTP joint improved significantly from preoperative 24.2+/-5.4 degrees (range 10 degrees to 30 degrees ) to postoperative 54.3+/-9.4 degrees (p<0.05). The mean joint space width of the first MTP joint was 1.0+/-0.3 mm (range 1 to 2 mm) preoperatively, it increased to 3.0+/-1.1 mm (range 1 to 5 mm) on final radiographs (p<0.05). The mean hallux valgus angle decreased from preoperative 13.8 degrees (range 9 degrees to 17 degrees ) to postoperative 10.2 degrees (range 4 degrees to 13 degrees ), and the mean intermetatarsal angle increased from preoperative 10.5 degrees (range 8 degrees to 14 degrees ) to postoperative 11.2 degrees (range 8 degrees to 15 degrees ). Patient satisfaction levels were very good in nine feet (47.4%), good in seven feet (36.8%), moderate in one foot (5.3%), and poor in two feet (10.5%). Complications included metatarsalgia aggravated by long walks (n=11, 57.9%), hypoesthesia of the big toe (n=3, 15.8%), and loss of ground contact of the big toe (n=15, 79%). The push-off power of the big toes was measured as 3/5 in five cases, 4/5 in 11 cases, and 5/5 in three cases. None of the patients developed infection or osteonecrosis postoperatively. CONCLUSION: Interposition arthroplasty is an appropriate surgical treatment method for hallux rigidus for elderly patients with low functional capacity.
Background Hallux rigidus is a common problem characterized by localized osteoarthritis and limited range of motion of the hallux. First metatarsophalangeal joint arthrodesis has been the accepted procedure for the treatment of late-stage disease. Despite the success of arthrodesis, some patients object to the notion of eliminating motion at the metatarsophalangeal joint. For this reason, motion-sparing procedures such as the modified oblique Keller capsular interpositional arthroplasty have been developed.
Methods We compared a cohort of ten patients (ten toes) who had undergone the modified Keller arthroplasty with a group of twelve patients (twelve toes) who had undergone a first metatarsophalangeal joint arthrodesis at an average of sixty-three and sixty-eight months, respectively. Clinical outcomes were evaluated, and range of motion, great toe dynamometer strength, plantar pressures, and radiographs were assessed.
Results Clinical outcome differences existed between the groups, with the American Orthopaedic Foot and Ankle Society score being significantly higher for the arthroplasty group than for the arthrodesis group. The arthroplasty group had a mean of 54° of passive and 30° of active range of motion of the first metatarsophalangeal joint. The plantar pressure data revealed significantly higher pressures in the arthrodesis group under the great toe but not under the second metatarsal head.
Conclusions The modified oblique Keller capsular interpositional arthroplasty appears to be a motion-sparing procedure with clinical outcomes equivalent to those of arthrodesis, and it is associated with a more normal pattern of plantar pressures during walking.
What a surprise study conclusion!
The Keller patients has more ROM than the fusion patients.
I hope the Government didn't pay for this study (i.e. my tax money)
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
First Metatarsophalangeal Joint Interpositional Arthroplasty Using a Meniscus Allograft for the Treatment of Advanced Hallux Rigidus: Surgical Technique and Short-term Results.
Delacruz EL, Johnson AR, Clair BL. Foot Ankle Spec. 2011 Apr 13. [Epub ahead of print]
Quote:
Hallux rigidus is a progressive disorder of the first metatarsophalangeal (MTP) joint. The disorder is characterized by a loss of range of motion, degenerative changes, and pain within the joint. In later stages of the disease, the surgical procedure of choice is arthrodesis of the joint. Recently, salvage procedures of the first MTP joint using soft tissue interposition has gained popularity. In this retrospective review of 12 patients (13 total procedures) who had late-stage hallux rigidus, we evaluated the effectiveness of a newly proposed salvage procedure using a cadaver meniscus allograft for interposition. First MTP joint dorsiflexion improved from 15.77deg; (range, 5°-30°) preoperatively to 47.77° (range, 40°-57°; P < .0001). AOFAS (American Orthopaedic Foot and Ankle Society) scores improved from 52.54 points (range, 35-69 points) preoperatively to 90.01 points (range, 82-95 points; P < .0001), with all patients showing improvement. The mean length of follow-up for this study was 16.46 months (range, 5-26 months) with no complications being recorded. The results show that cadaver meniscus allograft interposition is a viable procedure for end-stage hallux rigidus. Level of evidence: therapeutic, level III: retrospective review.
Nonunion after Arthrodesis of the First Metatarsal-Phalangeal Joint: A Systematic Review.
Roukis TS. J Foot Ankle Surg. 2011 Aug 12
Quote:
Arthrodesis of the first metatarsal-phalangeal joint (MTPJ) has been proposed for treatment of first MTPJ pathology because of the perceived safety and efficacy. Nonunion of the arthrodesis site has been purported as a common complication. The author undertook a systematic review of the electronic databases and other relevant sources to identify material relating to the incidence of nonunion and other complications after arthrodesis of the first MTPJ. In an effort to procure the highest quality studies available, the studies were eligible for inclusion only if they involved patients undergoing arthrodesis of the first MTPJ using modern osteosynthesis techniques (1980 onward time restriction), included a minimum of 30 feet in the publication, and evaluated patients at a mean follow-up of ≥12 months' duration. The studies were also required to include details of any complications requiring surgical intervention, had not primarily involved only rheumatoid arthritis as an indication, and had not involved the use of a structural bone graft. A total of 37 studies involving a total of 2,818 first MTPJ arthrodesis procedures were identified that met the inclusion criteria. The weighted mean age of the patients was 59.3 years, the follow-up was 34.3 months, and the union time was 64.3 days. For those studies that specifically mentioned the indications for first MTPJ arthrodesis, 2,656 joints were included as follows: severe hallux valgus (47.2%), hallux rigidus (32%), rheumatoid arthritis (11.5%), and revision of failed surgery (9.3%). Osteosynthesis involved three main configurations: compression screws, dorsal plate and screws, or staples. The overall nonunion incidence was 5.4% (153 of 2,818), with symptomatic nonunion occurring in 32.7% (50 of 153) of all nonunions (1.8% total incidence; 50 of 2,818). The overall incidence of malunion was 6.1% (39 of 640), with dorsal malunion accounting for 87.1% (34 of 39). The overall incidence of hardware removal was 8.5% (69 of 817). The historical comment that nonunion occurs in approximately 10% of attempted first MTPJ arthrodesis procedures is inaccurate. The incidence of malunion and hardware removal is inappropriately high, and efforts to determine effective methods of decreasing their incidence should be undertaken. Additionally, there is still a need for methodologically sound prospective cohort studies focusing on the use of arthrodesis of the first MTPJ for purely severe hallux valgus and specific grades of hallux rigidus, as well as specific forms of osteosynthesis, because this has only been infrequently reported in small series.
A Multicenter Retrospective Review of Outcomes for Arthrodesis, Hemi-Metallic Joint Implant, and Resectional Arthroplasty in the Surgical Treatment of End-Stage Hallux Rigidus
Paul J. Kim, et al Journal of Foot and Ankle Surgery (in press)
Quote:
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.
Arthrodesis of the First Metatarsophalangeal Joint Comparison of Three Techniques Kalpesh Shah, MBBS, Angelica Augustine, Robert Carter and Angus McFadyen JAPMA January/February 2012 vol. 102 no. 1 13-17
Quote:
Background: There are cadaveric and biomechanical studies comparing different methods of fixation for achieving arthrodesis in hallux rigidus. However, there are no comparative clinical studies. We compared the clinical and radiologic outcomes of first metatarsophalangeal joint fusion using three different techniques: lag screw, lag screw and circlage wire, and Memory staples.
Methods: This was a retrospective study of 46 patients who underwent first metatarsophalangeal joint fusion. All of the operations were performed by experienced surgeons. Each patient had clinical and radiologic assessments postoperatively.
Results: The three groups were matching in terms of demographic features and comorbidity. Intraobserver and interobserver reliability for radiographic metatarsophalangeal joint fusion was excellent. The mean time to clinical and radiologic union in the Memory staples group was earlier (7.6 weeks) than that of the other two techniques (8.0 and 8.1 weeks). The Memory staples group also had the lowest incidence of nonunion (1 of 15 compared with 4 of 15 in the single lag screw fixation group and 3 of 16 in the lag screw and circlage wire fixation group) and no hardware-related problems.
Conclusions: Our experience corroborates the advantages of Memory staples as described in the literature, including good approximation of bone fragments, technically easy application with fewer steps than an AO-applied screw, and an adequate source of internal fixation to achieve metatarsophalangeal joint fusion. There is also a suggestion that the time to achieve fusion is shorter.
Nonunion Rate of First Metatarsal-Phalangeal Joint Arthrodesis for End-stage Hallux Rigidus with Crossed Titanium Flexible Intramedullary Nails and Dorsal Static Staple with Immediate Weight-bearing
Thomas S. Roukis, Tristan Meusnier, Marc Augoyard Journal of Foot and Ankle Surgery
Quote:
Myriad forms of fixation have been proposed for arthrodesis of the first metatarsal-phalangeal joint (MTPJ). Regardless of the fixation type, nonunion of the arthrodesis site has been purported to be a common complication. We performed a retrospective review of all patients undergoing arthrodesis of the first MTPJ for end-stage hallux rigidus with 2 crossed flexible titanium intramedullary nails and a dorsal static 10-mm titanium staple followed by immediate protected weight-bearing. The inclusion criteria were as follows: the exact internal fixation technique described was employed for end-stage hallux rigidus of the first MTPJ only; preoperative and at least 6 weeks of postoperative weight-bearing radiographs were available; weight-bearing was initiated on the operative foot immediately in a protective shoe; the patient was followed for at least 6 months postoperatively; any complication was documented; and bilateral surgery was not done in the same setting. A total of 42 female patients (51 feet) with a mean age ± SD of 69.4 ± 9.2 years met the inclusion criteria. Complications resulting from technical error during insertion of the crossed titanium flexible intramedullary nails occurred in 3 feet (5.9%), but none led to nonunion or revision surgery. One delayed union (2%) occurred but it ultimately united. The incidence of nonunion after arthrodesis of the first MTPJ consisting of 2 crossed flexible titanium intramedullary nails and a dorsal static 10-mm titanium staple for end-stage hallux rigidus in an exclusively female population was lower than the historic mean for most other fixation techniques. However, methodologically sound prospective cohort studies that focus on the use of isolated arthrodesis of the first MTPJ for end-stage hallux rigidus in both male and female patients are still needed, as are comparisons of the presented technique with other modern osteosynthesis techniques.
Hinged External Fixation Distraction for Treatment of First Metatarsophalangeal Joint Arthritis.
Abraham JS, Hassani H, Lamm BM. J Foot Ankle Surg. 2012 Jun 29
Quote:
Treatment for hallux rigidus varies from joint preservation to joint destructive procedures. The objective of the present study was to report an alternative method of treatment of hallux rigidus using hinged external fixation distraction of the first metatarsophalangeal joint and to present our surgical technique. Ten distractions were performed in 9 patients (9 female feet [90%] and 1 male foot [10%]). The mean age at surgery was 41.0 (range 20 to 64) years. All patients had stage II or III hallux rigidus on the Regnauld classification system for hallux rigidus. The patients were evaluated clinically and radiographically before and after the distraction treatment. The mean period of fixation was 16.40 (range 7 to 21) weeks. Six of the patients (60%) with distraction experienced pin tract infections that were treated with oral antibiotics. The reported mean preoperative categorical pain score in 7 patients (7 feet) was 8.2 (range 5 to 10), and the postoperative score was 0.83 (range 0 to 2; p = .001). Of the 6 patients (6 feet) who responded to the remaining portion of the survey, 4 (66.67%) were very satisfied with their results, and 2 (33.33%) were satisfied with their surgical result. None of the patients required additional surgical treatment during the mean 2.2 (range 1.2 to 3.3) years of follow-up. Hinged first metatarsophalangeal joint distraction with external fixation has been shown to be a viable treatment option for joint preservation for stage II and III hallux rigidus in the short term
Metatarsal head resurfacing hemiarthroplasty in the treatment of advanced stage hallux rigidus: outcomes in the short-term.
Erdil M, Bilsel K, Imren Y, Mutlu S, Güler O, Gürkan V, Elmadağ NM, Tuncay I. Acta Orthop Traumatol Turc. 2012;46(4):281-5.
Quote:
OBJECTIVE:
The aim of this study was to evaluate the short-term outcomes of metatarsal head metal resurfacing hemiarthroplasty in patients with advanced stage hallux rigidus.
METHODS:
The study included 14 feet (4 left, 10 right) of 12 patients (10 female, 2 male; mean age: 63±5; range: 55 to 71 years) who underwent metatarsal head metal resurfacing hemiarthroplasty (HemiCAP®) between 2007 and 2010. Additionally, capsular release and periarticular osteophyte debridement were performed. Staging was made according to Coughlin and Shurnas' clinical and radiological grading system. Hallux valgus and intermetatarsal angles were measured using pre and postoperative standing AP and lateral foot views. Clinical assessment was made with first metatarsophalangeal joint range of motion, the AOFAS (American Orthopaedic Foot and Ankle Society) hallux metatarsophalangeal-interphalangeal scale and satisfaction level.
RESULTS:
Mean follow up was 19.5 (range: 14 to 26) months. Two patients had bilateral involvement. According to Coughlin and Shurnas' clinical and radiological grading system, nine feet were Stage 3 and five feet were Stage 4. According to the AOFAS scale, results of eight feet (57.1%) were excellent, four feet (28.6%) were good and two feet (14.3%) were moderate. Mean total AOFAS score increased by 26.2 points postoperatively (p<0.05). Mean range of motion of the first metatarsophalangeal joint improved significantly from a preoperative 22.2±5.6 (range: 10 to 28) degrees to a postoperative 56.3±9.6 degrees (p<0.05). Mean hallux valgus angle decreased from a preoperative 14.3 (range: 9 to 17) degrees to a postoperative 11.1 (range: 4 to 13) degrees and the mean intermetatarsal angle increased from a preoperative 10.5 (range: 8 to 14) degrees to a postoperative 10.8 (range: 8 to 15) degrees. Patient satisfaction levels were very good in 10 feet (71.4%), good in 3 (21.4%), and moderate in one (7.2%). Complications included metatarsalgia aggravated by long walks in one patient and hypoesthesia of the great toe in three patients. Push-off power of the great toes was measured as 4/5 in three cases, and 5/5 in others.
Open cheilectomy is an established surgical treatment for hallux rigidus. Cheilectomy is now being performed using minimally invasive (MIS) techniques. In this prospective study we report the outcome of minimally invasive cheilectomy comparing the results with a matched group who had cheilectomy using standard open procedure
Methods Prospective study of 47 patients. 22 patients had MIS cheilectomy between March 2009 and September 2010. We compared the outcome with a matched group (25 patients) who had open cheilectomy. Functional outcome was assessed using the Manchester Oxford Foot and ankle questionnaire (MOXFQ). The MOXFQ is a validated questionnaire designed to be self-completed and used as an outcome measure for foot surgery. Patients' satisfaction and complications were recorded.
Results In the MIS group, the median follow up was 11 months (4–23). The median preoperative MOXFQ score was 34/64(23) and the median postoperative score was 19/64 (p = <0.02). In the open group the median follow up was 17 months (9–27). The median preoperative MOXFQ score was 35/64 and the median postoperative score was 7.5/64 (p = <0.0001). The metric score of the three domains of the MOXFQ showed statistical improvement in both groups. The improvement didn't reach statistical significance between the open and MIS groups. There were three failures in the open group (Fusion) compared to none in the MIS.
Discussion There was significant improvement in foot pain, function and social aspect in the MIS group comparable to the open group. In our analysis we didn't account for the learning curve involved in the MIS technique. The MIS procedure has the advantage of small incision and dissection and accordingly less swelling and quicker recovery.
Conclusion MIS cheilectomy is an effective alternative procedure with satisfactory functional outcome and high patient satisfaction.
Results are comparable to the standard open cheilectomy with a lower apparent failure rate.
OBJECTIVE:
Fusion of the first metatarsophalangeal joint and realignment of the great toe in patients with painful arthritis to achieve pain-free walking.
INDICATIONS:
Hallux rigidus grade 3/4, hallux valgus et rigidus, claw toe deformity of the great toe, salvage after endoprosthesis or cheilectomy, avascular necrosis of the first metatarsal head arthritis of the first metatarsophalangeal joint.
CONTRAINDICATIONS:
Infection, painful arthritis of the interphanageal joint (relative contraindication), and severe osteoporosis (relative contraindication).
SURGICAL TECHNIQUE:
Dorsal approach to the first metatarsophalangeal joint. Removal of all osteophytes and circumferential capsular release. Debridement of the sesamoids. Cartilage resection (flat cuts or "cup and cone" reaming) and multiple drilling of the subchondral layer. In case of osseous defects, interposition of a corticocancellous bone graft. Trial reduction and assessment of the toe alignment. Fixation with two screws, one lag screw and dorsal plating, or dorsal plating only. Wound closure in layers.
POSTOPERATIVE MANAGEMENT:
Full weight bearing in a postoperative shoe or partial weight bearing in a short cast for 4-6 weeks. If the X-ray reveals sufficient bone healing, patients are allowed to wear sneakers with a stiff sole for 3-6 months. Sport activities with impact loading are limited for at least 3 months. Final X-ray control after 6 months.
RESULTS:
A total of 70 feet with a fusion of the first metatarsophalangeal joint were followed up after 28 months. Postoperative complications (7.3%): 5 wound slough, 1 infection, and 6 painful delayed union. Modified AOFAS forefoot score (max. 85 points) was 43 (32-58) points preoperatively and 82 (71-85) points postoperatively. Great toe alignment was perfect in 57 feet. Nine toes showed a valgus (> 20°) and 4 toes a varus malalignment. Fifty-four attained full ground contact. Eight patients reached the ground by flexion of the interphalangeal joint and 8 patients presented with dorsiflexion of the great toe. X-ray showed consolidation of the arthrodesis in 64 feet (91.4%), while 8 feet (4 with interposition of a bone graft) revealed signs of incomplete healing. These patients were advised to have an annual clinical and radiological reassessment performed.
Locked versus nonlocked plate fixation for first metatarsophalangeal arthrodesis: a biomechanical investigation.
Hunt KJ, Barr CR, Lindsey DP, Chou LB. Foot Ankle Int. 2012 Nov;33(11):984-90.
Quote:
BACKGROUND:
First metatarsophalangeal (MTP) arthrodesis using dorsal plate fixation is a common procedure for painful conditions of the great toe. Locked plates have become increasingly common for arthrodesis procedures in the foot, including the hallux MTP joint. The biomechanical advantages and disadvantages of these plates are currently unknown. The purpose of this study was to compare locked and nonlocked plates used for first MTP fusion for strength and stiffness.
MATERIALS AND METHODS:
The first ray of nine matched pairs of fresh-frozen cadaveric feet underwent dissection, preparation with cup-and-cone reamers, and fixation of the MTP joint with a compression screw and either a nonlocked or locked stainless steel dorsal plate. Each specimen was loaded in a cantilever fashion to 90 N at a rate of 3 Hz for a total of 250,000 cycles. The amount of plantar MTP gap was recorded using a calibrated extensometer. Load-to-failure testing was performed for all specimens that endured the entire cyclical loading. Stiffness was calculated from the final load-to-failure test.
RESULTS:
The locked plate group demonstrated significantly less plantar gapping during fatigue endurance testing from cycle 10,000 through 250,000 (p < .05). Mean stiffness was significantly greater in the locked plate group compared with the nonlocked plate group (p = .02). There was no significant difference in load to failure between the two groups (p = .27).
CONCLUSION:
Compared with nonlocked plates, locked hallux MTP arthrodesis plates exhibited significantly less plantar gapping after 10,000 cycles of fatigue endurance testing and significantly greater stiffness in load-to-failure testing.
CLINICAL RELEVANCE:
As the use of locked plate technology is becoming increasingly common for applications in the foot, a thorough understanding of the biomechanical characteristics of these implants may help optimize their indications and clinical use.
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.
Treatment of Advanced Stages of Hallux Rigidus with Cheilectomy and Phalangeal Osteotomy
Martin Joseph O’Malley, MD; Harpreet S. Basran, MD; Yang Gu, BS; Stephanie Sayres, BS; Jonathan T. Deland, MD
J Bone Joint Surg Am, 2013 Apr 3;95(7):606-610. doi: 10.2106/JBJS.K.00904.
Quote:
Background:
Surgical treatment of hallux rigidus has usually consisted of cheilectomy for mild to moderate disease and arthrodesis for more advanced disease. The reported failure rate for cheilectomy alone in patients with advanced disease is approximately 37.5%. We reported our results with the combination of cheilectomy and extension osteotomy at the proximal phalanx for the treatment of advanced hallux rigidus.
Methods:
Between 2000 and 2007, eighty-one patients with advanced hallux rigidus (classified as Hattrup and Johnson Grade III) underwent a unilateral cheilectomy and great toe proximal phalangeal extension osteotomy. Outcome assessment was determined by comparison of preoperative and postoperative American Orthopaedic Foot & Ankle Society scores, radiographs, first metatarsophalangeal joint motion, and patient satisfaction. Sixty-four of the eighty-one patients had complete clinical and radiographic examinations at a minimum duration of follow-up of two years.
Results:
The mean duration of follow-up was 4.3 years. The mean dorsiflexion of the first metatarsophalangeal joint improved significantly (p < 0.05), by 27.0°, from 32.7° preoperatively to 59.7° postoperatively. The average American Orthopaedic Foot & Ankle Society scores improved significantly (p < 0.05) from 67.2 points preoperatively to 88.7 points postoperatively. Radiographs of the interphalangeal joint made postoperatively showed no evidence of development of interphalangeal joint arthritis. Of the eighty-one patients, sixty-nine (85.2%) were satisfied with the results of treatment and four (4.9%) subsequently underwent arthrodesis to treat persistent symptoms at the first metatarsophalangeal joint.
Conclusions:
To our knowledge, this study is the first to support the use of a combination of cheilectomy and extension osteotomy of the great toe proximal phalanx as an alternative to first metatarsophalangeal joint arthrodesis to manage patients with advanced hallux rigidus.
Intermediate-Term Results Following First Metatarsal Cheilectomy.
Bussewitz BW, Dyment MM, Hyer CF. Foot Ankle Spec. 2013 Apr 19.
Quote:
Hallux rigidus is a term describing degenerative joint disease (DJD) to the first metatarsal phalangeal joint (MTPJ). It is the most common DJD encountered in the foot and is the second most common pathology of the great toe behind hallux valgus. The goal of a cheilectomy is to relieve pain and increase MTPJ motion. Critical evaluation of the cheilectomy must include longevity of desired results. The primary goal of this study was to determine how long a cheilectomy can be expected to last before an arthrodesis or joint destructive procedure is performed, if ever. We examined 189 cheilectomies with a mean radiographic follow-up of 235 days and mean chart review follow-up of 1184 days (3.2 years). Analysis showed 5 repeat cheilectomies, 1 interpositional arthroplasty, and only 2 arthrodeses subsequently performed. This retrospective study provides intermediate term evidence that cheilectomy is an appropriate procedure for stages 1, 2, and 3 first MTPJ DJD with reliable, lasting results
I'm betting that a longer follow up than 3 years would drastically change the results.
Also: the age of the patient at the time of surgery is a critical criteria for prognosis.
My take: This paper is of no value to surgeons deciding how to treat Hallux rigidus.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Comparison of Arthrodesis, Resurfacing Hemiarthroplasty, and Total Joint Replacement in the Treatment of Advanced Hallux Rigidus.
Erdil M, Elmadağ NM, Polat G, Tunçer N, Bilsel K, Uçan V, Erkoçak OF, Sen C. J Foot Ankle Surg. 2013 May 6. pii: S1067-2516(13)00115-4
Quote:
The purpose of the present study was to compare the functional results of arthrodesis, resurfacing hemiarthroplasty, and total joint replacement in hallux rigidus. The data from patients treated from 2006 to 2010 for advanced stage hallux rigidus were retrospectively reviewed. A total of 38 patients who had at least 2 years (range 24 to 66 months, mean 31.1) of follow-up were included in the present study. Of the 38 patients, 12 were included in the total joint replacement group (group A), 14 in the resurfacing hemiarthroplasty group (group B), and 12 in the arthrodesis group (group C). At the last follow-up visit, the functional outcomes were evaluated using the American Orthopaedic Foot and Ankle Society-Hallux Metatarsophalangeal Interphalangeal (AOFAS-HMI) scale, visual analog scale (VAS), and metatarsophalangeal range of motion. Significant improvements were seen in the AOFAS-HMI score, with a decrease in the VAS score in all 3 groups. According to the AOFAS-HMI score, no significant difference was found between groups A and B. However, in group C, the AOFAS-HMI scores were significantly lower than in the other groups owing to the lack of motion. According to the final VAS scores, no significant difference was found between groups A and B; however, the VAS score had decreased significantly more in group C than in the other groups. No major complications occurred in any of the 3 groups. After 2 years of follow-up, all the groups had good functional outcomes. Although arthrodesis is still the most reliable procedure, implant arthroplasty is also a good alternative for advanced stage hallux rigidus.
Re: Surgery for hallux rigidus
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