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The objective of this retrospective study was to analyze the long-term clinical outcomes and patient satisfaction of operative care in patients with symptomatic hallux rigidus. Seventy-seven patients (94 feet) underwent cheilectomy, Keller resection arthroplasty, or arthrodesis between 1990 and 2000. All were invited to return for follow-up evaluation after a minimum of 2 years (mean, 7 years). The average patient age was 53 years (range, 22-77 years). Outcomes were assessed by questioning and examining the patients and by evaluating radiographs according to the Regnauld's classification system. Overall patient satisfaction was good; average visual analogue and American Orthopedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal scores were 1.8 and 81, respectively. Eighty-seven percent stated they would undergo the same procedure again. After cheilectomy, the average visual analogue score was 1.4 for grade I and 2.3 for grade II, and rating scale scores were 87 and 82, respectively. There were comparable results for the Keller resection arthroplasty where visual analogue scores were 0.4 and 1.6, respectively, while AOFAS scores were 94 and 83, respectively. Average visual analogue scores and AOFAS scores in grade III patients after a Keller procedure and an arthrodesis were 2.3; 87 and 2.0; and 73, respectively. In the arthrodesis group, 4 patients required revision because of complications. Cheilectomy is a good choice for patients with grade I and II hallux rigidus because it is a safe and simple joint-preserving procedure. For end-stage hallux rigidus without preexistent metatarsalgia, the Keller procedure was favored over arthrodesis of the first metatarsophalangeal joint.
Cheilectomy with phalangeal dorsiflexory osteotomy has been proposed for treatment of hallux rigidus because of its perceived safety and efficacy and because it does not prevent the ability to perform revision surgery. The author undertook a systematic review to identify material relating to the clinical outcomes after cheilectomy with phalangeal dorsiflexory osteotomy for hallux rigidus. Studies were considered only if they involved consecutively enrolled patients undergoing cheilectomy with phalangeal dorsiflexory osteotomy, evaluated patients at mean follow-up ≥ 12 months' duration, included some form of objective and subjective data analysis, and included details of complications requiring surgical intervention. Eleven studies involving a total of 374 procedures were identified that met the inclusion criteria. Pain was relieved or improved in 149/167 (89.2%) procedures, and 139/217 (77%) patients related being satisfied or very satisfied with their outcomes. A total of 18 (4.8%) procedures underwent surgical revision. Six studies involving 177 procedures specified the grade of hallux rigidus as follows: grade I, 10.2% (n = 18); grade II, 72.3% (n = 128); and grade III, 17.5% (n = 31). The results of this systematic review make clear the general improvement in objective and subjective data as well as the low incidence of revision surgery required after cheilectomy with phalangeal dorsiflexory osteotomy for hallux rigidus. Therefore, cheilectomy with phalangeal dorsiflexory osteotomy should be considered a first-line surgical treatment for hallux rigidus. However, there is still a need for methodologically sound prospective cohort studies that focus on the use of this procedure for specific grades of hallux rigidus and compare the subjective and objective outcomes as well as the need for surgical revision with other procedures.
Isolated cheilectomy has been proposed for treatment of hallux rigidus due to the perceived safety, efficacy, and ability to revise with repeat cheilectomy, implant or interpositional arthroplasty, or arthrodesis. A systematic review was undertaken to better understand the need for surgical revision after isolated cheilectomy for hallux rigidus. Studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing isolated cheilectomy or involved revision surgery of the first metatarsophalangeal joint after isolated cheilectomy, evaluated patients at mean follow-up >/= 12 months' duration, and included details of complications. Twenty-three studies, describing 706 cheilectomies, met the inclusion criteria, with 62 (8.8%) undergoing surgical revision in the form of arthrodesis (n = 23), no mention of revision procedure (n = 17), interpositional arthroplasty (n = 13), silicone implant arthroplasty (n = 4), Keller resection arthroplasty (n = 3), or repeat cheilectomy (n = 2). Twelve studies specified the grade of hallux rigidus as: 103 (19.9%) grade 1, 210 (40.6%) grade II, 189 (36.6%) grade III, and 15 (2.9%) grade IV. Six studies indicated the number of cheilectomies that required revision surgery as: 2 (20%) grade I, 8 (14.8%) grade II, 12 (9.1%) grade III, and 5 (55.6%) grade IV. These results make clear the low incidence of revision surgery after cheilectomy for hallux rigidus. Therefore, cheilectomy should be considered a first-line surgical treatment for hallux rigidus. There remains a need for methodologically sound prospective cohort studies that focus on the use of cheilectomy for specific grades of hallux rigidus.
Does Total Joint Replacement or Arthrodesis of the First Metatarsophalangeal Joint Yield Better Functional Results? A Systematic Review of the Literature.
Brewster M. J Foot Ankle Surg. 2010 Sep 11. [Epub ahead of print]
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As first metatarsophalangeal joint arthrodesis is generally considered to be a successful procedure for the treatment of hallux rigidus, many surgeons question the usefulness of total joint replacement. In an effort to elucidate the clinical evidence, we undertook a systematic review of the literature comparing the functional outcomes of arthrodesis and joint replacement in first metatarsophalangeal surgery. Using multiple search engines and medical subject headings, 10 articles were eligible for inclusion: 5 featured arthrodesis and 5 featured total joint replacement. The American Orthopaedic Foot and Ankle Society-Hallux metatarsophalangeal-interphalangeal score was used in all articles. The mean age at operation was 53 years for joint replacement patients and 55 for those undergoing joint arthrodesis. Most patients in all studies were female. There was a significant increase from pre- to postoperative scores in both procedures. The median postoperative score for joint replacement was 83/100 (range 74-95) and 82/100 (range 78-89) for arthrodesis. The median revision rate in joint replacements was 7% (range 0%-10%) and 0% (range 0%-12%) for arthrodesis. This systematic review reveals that arthrodesis achieves better functional outcomes than total joint replacement. The operative techniques and prostheses for joint replacements are however still in an early stage of development and advances still need to be achieved to produce a more successful and anatomical prosthesis that could be functionally superior to an arthrodesis.
Retrospective study of the first metatarsophalangeal joint arthrodesist : about 39 cases.
Mestiri M, Bouabdellah M, Zarrouk A, Kammoun S, Baccari S, Kooli M, Zlitni M. Tunis Med. 2010 Oct;88(10):725-30.
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Background : The first metatarsophalangeal joint arthrodesis is a fusion with optimal alignment of the first metatarsal and first phalanx wich conferring indolence, strength and stability Aim: The goal of this study was to evaluate the place of arthrodesis of the first metatarso-phalangeal joint in surgery of the fore foot .
Methods: This work is based on analysis of records of 35 patients between 1995 and 2006. 39 first metatarsophalangeal joint arthrodesis were practice (3 were bilateral). They had a follow up of from three to ten years. All patients were called for a complete exploration radiographic and clinical evaluation according to the criteria of KITAOKA. The average age of patients was 54 years.
Results: They were 28 women and 7 men. The indications were hallux rigidus in 51% cases and rheumatoid arthritis in 41% cases. The procedure used mostly a stable fixation with a compressive screw. The dorsal flexion recommended is between 20 and 30 °. Ankylosis of the ankle or the inter-phalangeal joint was an againstindication for the first metatarsophalangeal joint arthrodesis. The study found a patient subjective satisfaction rate of 92 per cent, there was no pain for 89 per cent of cases. It was noted 4 non-fusion cases paradoxically with satisfactory functional result. There was no pain of inter-phalangeal joint in all cases when X-rays showed arthritis in 4 cases.
Conclusion: The first metatarsophalangeal joint arthrodesis, provided we respect a few simple principles, restores painless and satisfying function of foot.
Long term follow up of hallux rigidus surgery
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