Nonunion Rate of First Metatarsal-Phalangeal Joint Arthrodesis with Crossed Titanium Flexible Intramedullary Nails and a Dorsal Static Staple with Immediate Weightbearing

Abstract

Myriad forms of fixation have been proposed for arthrodesis of the first metatarsal-phalangeal joint (MTPJ). Regardless of fixation type, nonunion of the arthrodesis site has been purported as a common complication. We performed a retrospective review of all patients undergoing arthrodesis of the first MTPJ with crossed flexible titanium intramedullary nails and a dorsal static staple followed by immediate protected weight bearing. The subjects were included if they had undergone the exact internal fixation technique described; surgery had been performed only by 1 of us; and they had not undergone bilateral surgery in the same setting. Also, the indication for surgery was required to be pathology of the first MTPJ other than rheumatoid arthritis. Weight bearing preoperative radiographs and weight bearing radiographs at least 6 weeks postoperatively were required. Also, the patients had to have initiated weight bearing on the operative foot immediately postoperatively in a protective shoe. Finally, documentation of any complications was required. A total of 83 patients (95 feet) met the inclusion criteria and were included. Of the 83 patients, 77 (92.7%) were female and 6 (7.3%) were male. Their mean age ± standard deviation was 69.7 ± 16.7 years. Of the 95 feet, 55 (57.9%) were right and 40 (42.1%) were left feet. The indications included 61 (64.2%) with severe hallux valgus deformity, 24 (25.3%) with hallux rigidus, and 10 (9.5%) with failed first MTPJ surgery. Complications related to technical error during insertion of the crossed titanium flexible intramedullary nails occurred in 16 feet (16.8%) but none led to nonunion or revision surgery. A total of 3 asymptomatic nonunions (3.2%) occurred, all in female patients with severe hallux valgus that did not require revision surgery. The incidence of nonunion after arthrodesis of the first MTPJ consisting of crossed flexible titanium intramedullary nails and a dorsal static staple for predominantly severe hallux valgus and hallux rigidus was lower than the historic mean for most other fixation techniques. However, methodologically sound prospective cohort studies are still needed that focus on the use of isolated arthrodesis of the first MTPJ for purely severe hallux valgus or hallux rigidus and a comparison of the technique we have presented with other modern osteosynthesis techniques.