1st Metatarsophalangeal Research Articles

Return to activities in younger individuals (

Arthrodesis is a common procedure in the treatment of forefoot conditions affecting the first metatarsophalangeal (MTP) joint. Although this procedure has been shown to significantly improve individuals’ activities of daily living and effectively relieve pain, there is a lack of research specifically investigating younger patients below 60 yrs of age wishing to return to sports. Our aim is to evaluate their ability to return to sports after 1st MTP joint arthrodesis. A retrospective analysis of clinical records of 159 patient that had undergone first MTP arthrodesis performed by a single surgeon was undertaken to determine pre- and postoperative sf-FAOS and sporting activity scores. The Tobit constant censoring limit model was used to analyze change in sf-FAOS scores. After the application of inclusion and exclusion criteria, 58 patients (median age 54 years, range 30 – 59) were included in the final cohort with a mean follow up of 5.3 years (range 2.0 to 9.44, SD 2.10). There was a significant improvement in the mean pain score (p<0.001), as well as an improvement in the mean function score (p<0.001). The number of hours spent in sporting activities per week were significantly higher (p<0.001) post-surgery (5.29 hours, SD 5.0) in comparison to preoperative levels (4.26 hours, SD 3.1). There was no significant change in the intensity of sporting activities (p=0.176). First MTP joint arthrodesis remains a good treatment option for younger individuals wishing to achieve a satisfactory return to sports. Level of evidenceLevel 4

Design and development of a low-cost device to measure foot parameters in children with disability: A “footmeter”

AIM: To design and develop a low-cost device to measure foot parameters in children with disability. METHOD: Designing of the device was done using Solidworks software, after finalization of design, Phase 2 which involved the development of footmeter, materials used were, a rectangular wooden frame, an aluminum slider, goniometers, metal sheet with markings of 1 cm over an entire sheet in vertical as well as horizontal direction forming small grids. RESULT: An early version of “Footmeter” device was developed by assembling all the parts together. The Footmeter evaluates: foot length, width of forefoot, midfoot and hindfoot, height of Medial Longitudinal Arch(MLA) , abduction of 1st MetaTarso Phalangeal (MTP) and deviation for metatarsus adductus. CONCLUSION: The groundbreaking Footmeter device is meticulously designed for measuring foot parameters in children with disabilities. It offers an unparalleled blend of precision, efficiency, and simplicity. With its objective outcomes, minimal training requirements, decreased manual errors, and a streamlined assessment process, “Footmeter” device stands as the ultimate all-in-one tool for the meticulous measurement of foot parameters in children with disabilities.

Minimally Invasive Surgery vs Open Approach to First Metatarsophalangeal Joint Arthrodesis: A Comparison of Surgical Outcomes

Category: Midfoot/Forefoot; Other Introduction/Purpose: Minimally invasive surgery (MIS) is becoming increasingly popular among foot and ankle orthopaedic surgeons, as it has been shown to have limited complication rates and faster recovery times. Although there is robust data on MIS to treat hallux valgus, few studies have evaluated the role of MIS for 1st metatarsophalangeal (MTP) fusion to treat hallux rigidus - the most common arthritis of the foot. Hallux rigidus affects 2.5% of the U.S. population over age 50. Given this disease prevalence, it is important to characterize outcomes following MTP fusion procedures to optimize surgical approaches. In this retrospective cohort study, we aim to compare (1) patient-reported pain, (2) rate of successful fusion, and (3) rate of complications between groups who underwent open or MIS 1st MTP arthrodesis. Methods: This retrospective cohort study was conducted by evaluating clinical metrics, surgical outcomes, and radiographic data through chart review of 78 patients (25 male, 53 female), who underwent a 1st MTP fusion procedure at a large urban academic medical center from July 2015 through January 2023. 71 patients had a diagnosis of hallux rigidus, with other common diagnoses including hammertoe (24), hallux valgus (24), additional arthritides (11), and metatarsalgia (11). Two patients were excluded from our analysis due to lack of sufficient orthopaedic follow-up preventing evaluation of joint fusion. Pre- and post-operative pain scores were recorded on a 0-10 scale, though some notes documented subjective experience of pain (e.g., “minimal”). Complications were identified using post-operative clinic notes. The following radiographic data were included: hallux valgus angle, intermetatarsal angle, Coughlin classification, presence of arthritis, pre-operative sesamoid position, fusion construct materials, and success of fusion. Results: Of the 80 1st MTP fusion surgeries (two patients received both left and right foot operations), 51 were open and 29 were minimally invasive. There was no significant difference in the change in pre- to post-operative pain between the two groups (p=0.39). MIS patients had a higher successful fusion rate (100.0%) when compared to open surgery patients (94.1%), though this difference was insignificant (p=0.55). There was no significant difference in overall complication rates between MIS and open surgery groups (p=0.79). However, the MIS patients did not have any cases of deep infection or wound dehiscence and all (5/5) of their complications were related to hardware removal after fusion, whereas half of the complications (5/10) for the open surgery patients were related to infection and wounds. Conclusion: This retrospective analysis of 78 patients treated for hallux rigidus with 1st MTP fusion surgery showed no significant difference in rates of successful fusion and complications among patients who received an MIS procedure compared to an open surgery. There was no difference in patient-reported pain improvement between the two groups. Our main limitation is provider specialization, as only one surgeon in this study performed the MIS cases. Further studies should be done to obtain higher-level evidence to elucidate potential benefits of MIS over open surgery for 1st MTP arthrodesis.

Three-Dimensional Analysis of Windlass Mechanism Using Loading Computed Tomography in Patients With Hallux Rigidus and Healthy Volunteers

Category: Midfoot/Forefoot; Basic Sciences/Biologics Introduction/Purpose: The windlass mechanism (WM) increases the height of the medial longitudinal arch (MLA) of the foot by tensing the plantar aponeurosis during dorsiflexion of the metatarsophalangeal (MTP) joint. We speculated that this mechanism may be deeply involved in the pathogenesis of forefoot diseases such as hallux rigidus (HR). These conditions are three- dimensional (3D) deformities including rotational deformity, but the role of the WM has been evaluated only two-dimensionally by measuring the height of the navicular on lateral plain radiographs. The purpose of this study was to analyze in detail the WM of normal and HR feet in 3D. Methods: Participants were 14 patients with HR (17 feet) and 13 volunteers (21 feet). The volunteers had no history of foot disease or trauma, whereas the patients with HR had Coughlin and Shurnas classification I or II. Computed tomography (CT) of the foot with a load equivalent to the participant’s body weight was performed. Imaging was performed with the 1st MTP joint in the neutral position and dorsiflexed 30 degrees. 3D models were created using the software Mimics Research 17.0. Next, we used the iterative closest point (ICP) algorithm, which allows 3D objects to be superimposed without specifying anatomical feature points. Then, we performed 3D measurements of the (1) rotation of each bone in the MLA with respect to the tibia, (2) rotation of the distal bone in each joint of the MLA, and (3) changes in the height of the geometric center of the navicular. Results: At the calcaneus, navicular and medial cuneiform, the HR group showed less inversion, adduction than healthy group. (P &lt; 0.05) At the talonavicular joint, the navicular was 3.7° inversion, 2.9° adduction in the healthy group and 2.4°inversion, 1.3° adduction in the HR group. At the talocalcaneal joint, the calcaneus was 1.7° inversion, 1.5° adduction in the healthy group and 0.9°inversion, 0.6° adduction in the HR group. In the talonavicular and talocalcaneal joint, the HR group showed less inversion and adduction than control. (P &lt; 0.05) With dorsiflexion of the hallux, the height of the navicular increased by 2.1 mm in the healthy group and 1.3 mm in the HR group. There was a significant difference (P &lt; 0.05) between the two groups. Conclusion: In both groups, the calcaneus, navicular, and medial cuneiform bones moved not only in the sagittal plane but also in the frontal plane. But the movement of the talonavicular and talocalcaneal joints and the change in height of the navicular were significantly reduced compared with the healthy group. In other words, in the HR group, the motion of the midfoot and hindfoot was limited, suggesting that there may be a close relationship between WM dysfunction and midfoot and hindfoot motion. This study indicates that the dysfunction of the WM may have been a clue to the cause of HR.

Comparable Outcomes of Cartiva Implant, Cheilectomy, and Fusion for Hallux Rigidus of the 1st Metatarsophalangeal Joint: A Matched Cohort Study

Category: Midfoot/Forefoot; Other Introduction/Purpose: The primary goal of treating hallux rigidus of the 1st metatarsophalangeal (MTP) joint of the foot is to reduce pain. Treatment options include cheilectomy, interposition arthroplasty, and arthrodesis for more severe disease. Recently, the use of a synthetic cartilage implant (Cartiva, Stryker Inc., MI, USA) has been introduced with the advantage of motion preservation. While a Level 1 study has demonstrated similar outcomes of fusion and Cartiva, other comparative studies have shown less favorable results for the Cartiva implant. The purpose of this study was to evaluate minimum 2-year patient reported outcomes (PROs) of the Cartiva implant for the treatment of hallux rigidus in the 1st MTP joint in comparison to a matched cohort of patients treated with fusion or cheilectomy. Methods: Patients &gt;18 years old who underwent surgery for treatment of 1st MTP joint hallux rigidus with Cartiva implant, cheilectomy, or fusion performed by two surgeons (T.O.C. or C.T.H.) between January 2009 and January 2020 were identified. A 2:1 matched control cohort of patients who underwent cheilectomy or fusion was constructed using a nearest neighbor, greedy algorithm based on age, sex, prior surgery, and Coughlin osteoarthritis grade. Minimum 2-year follow-up was obtained with patients completing subjective questionnaires including Foot and Ankle Ability Measure (FAAM) with Activities of Daily Living (ADL) and Sport subscales, Short Form-12 (SF-12), Tegner activity scale, and patient satisfaction with surgical outcome. Demographics and patient-reported outcomes were compared between groups. Results: Follow-up was obtained for 22/27 (82%) Cartiva patients (mean age 54±19) at median 4.3 years and 41/49 (84%) control patients (mean age 58±11) at median 3.5 years. Prevalence of Coughlin grade was similar between Cartiva and control groups (6 vs 10 grade 1, 8 vs 15 grade 2, 2 vs 6 grade 4, 6 vs 10 grade 5; p=.93), respectively. There was no significant difference in median post-operative FAAM-ADL (96 vs 95, p=.53), FAAM-Sport (92 vs 89, p=.89), SF-12 PCS (56 vs 51, p=.054), SF-12 MCS (56.3 vs 57.5, p=.50), Tegner score (4 vs 3, p=.30), or patient satisfaction (9 vs 9, p=.91) between Cartiva and control cohorts, respectively. Revision surgery was required for 3 (14%) Cartiva patients and 4 (10%) control patients (p=.70). Conclusion: Patients treated with a Cartiva synthetic cartilage implant for 1st MTP joint hallux rigidus had similar patient-reported outcomes and revision rate compared to patients treated with cheilectomy or fusion for Coughlin grade 2-5 osteoarthritis.

Return to Alpine Sport and Physical Activity After First Metatarsophalangeal Joint Arthrodesis

Category: Midfoot/Forefoot; Sports Introduction/Purpose: First metatarsophalangeal (MTP) arthrodesis is an effective procedure to alleviate pain and correct deformity. The unique location of our academic center allows us to study an extremely active patient population with high rates of participation in impact sports and particularly alpine specific sports, including Nordic and alpine skiing, snowboarding, hiking, trail running and biking. There is limited literature regarding these specific activities with regards to a 1st MTP arthrodesis. The goal of the study is to better define the ability to return to physical activity, with a focus on alpine and mountain sports. This will help physicians counsel patients appropriately when discussing surgical options. Methods: Patients over 18 years old who underwent MTP arthrodesis with minimum 1 year follow up were identified using CPT code 27850. Patients undergoing concomitant forefoot and hindfoot procedures were excluded. Demographic data and complications were recorded by retrospective chart review. A custom sports questionnaire, PROMIS Physical Function (PF), PROMIS Pain Interference (PI), and Foot and Ankle Ability Measure (FAAM) scores were administered to patients. Postoperative radiographs were analyzed for time to union and fusion position. Results: 96 patients were eligible for analysis. Preliminarily, 34 have completed the follow-up survey. Most common activities were walking, hiking, alpine skiing, biking and running. Compared to preoperatively, patients rated 70.5% of activities as less difficult, 20.5% as the same, and 9.0% as more difficult. 74% of patients returned to their activities by 6 months and 62% of patients reached their maximum level of activity by 9 months postoperatively. Patients who participated in skiing/snowboarding were all able to ski the same level of terrain compared to before surgery, but nearly half (46%) of patients required boot modifications. 43% of patients were able to increase incline when hiking/trail running, and 48% of patients were able to increase their running/walking mileage. Average PROMIS PF was 51.9 (±6.20). Conclusion: Patients are able to participate in a variety of high impact and alpine related sports after 1st MTP arthrodesis. The majority of patients are able to function at similar or increased levels when returning to hiking, walking, skiing and snowboarding. Up to 25% of patients may not reach maximum level of activity until 1 year postoperatively. Additional investigation is required to identify potential risk factors for patients that may experience difficulty returning to activity. Continued survey participation is underway to strengthen these results. Patient counseling on activity participation following hallux MTP arthrodesis is important to optimize outcomes and patient satisfaction.

Converting 1st metatarsophalangeal joint fusion to interposition arthroplasty. Mid-term results of a case series

BackgroundFusion of the first metatarsophalangeal (MTP) joint has been considered as the gold standard for treatment of advanced hallux rigidus. The main disadvantage is the restriction of movement which may not be as favorable as anticipated by several patients. The purpose of this study was to report clinical and functional outcomes on patients who were treated with interposition arthroplasty after a 1st MTP joint fusion which had not fulfilled their expectations. MethodsBetween 2009 and 2014, 11 patients who were not satisfied by 1st MTP joint fusion for hallux rigidus, underwent a conversion to interposition arthroplasty. After removal of hardware, the fusion was taken down by removal of a bone block from the fused joint. A fascia lata graft was interposed. Intraoperative and postoperative complications, range of motion of the first MTP joint, length of first ray, and patients’ satisfaction were recorded as the primary outcomes. ResultsMean age was 34 years (range, 24–42 y). The mean ± SD AOFAS/H/MTP/IP score was 61 ± 5.5 preoperatively, 90.5 ± 4.5 at one year and 92 ± 4 at five years postoperatively (p < 0.001). The mean ± SD VAS-FA score was 91 ± 3.5 preoperatively, 94.5 ± 2.5 at one year and 95 ± 2.5 at five years postoperatively (p > 0.05). Mean ROM at the final follow-up was 58° ± 5° of dorsiflexion and 27° ± 4° of plantarflexion. No inter- or postoperative complications were encountered. The length of the hallux was decreased by a mean of 1.5 mm (range, 1–2.5 mm). All patients were satisfied with the overall outcome, walking ability and shoe-wear convenience and graded their condition as excellent (9 cases) or good (2 cases). ConclusionsConverting a 1st MTP joint fusion to interposition arthroplasty with a fascia lata allograft could be a safe alternative with promising results in selected cases especially in relatively young and athletic population. Level of evidenceLevel IV retrospective case series.

Effects of foot and ankle mobilisations combined with home stretches in people with diabetic peripheral neuropathy: a proof-of-concept RCT

IntroductionPeople with diabetic peripheral neuropathy (DPN) and limited joint mobility syndrome (LJMS) can experience increased forefoot peak plantar pressures (PPPs), a known risk factor for ulceration. The aim of this study was to investigate whether ankle and 1st metatarsophalangeal (MTP) joint mobilisations and home-based stretches in people with DPN improve joint range of motion (ROM) and reduce forefoot PPPs.Design and methodsSixty-one people with DPN (IWGDF risk 2), were randomly assigned to a 6-week programme of ankle and 1st MTP joint mobilisations (n = 31) and home-based stretches or standard care only (n = 30). At baseline (T0); 6-week post intervention (T1) and at 3 months follow-up (T2), a blinded assessor recorded dynamic ankle dorsiflexion range using 3D (Codamotion) motion analysis and the weight bearing lunge test, static 1st MTP joint dorsiflexion ROM, dynamic plantar pressure and balance.ResultsAt T1 and T2 there was no difference between both groups in ankle dorsiflexion in stance phase, plantar pressure and balance. Compared to the control group, the intervention group showed a statistically significant increase in static ankle dorsiflexion range (Left 1.52 cm and 2.9cms, Right 1.62 cm and 2.7 cm) at 6 (T1) and 18 weeks (T2) respectively p < 0.01). Between group differences were also seen in left hallux dorsiflexion (2.75°, p < 0.05) at T1 and in right hallux dorsiflexion ROM (4.9°, p < 0.01) at T2 follow up. Further, functional reach showed a significant increase in the intervention group (T1 = 3.13 cm p < 0.05 and T2 = 3.9 cm p < 0.01). Intervention adherence was high (80%).ConclusionsCombining ankle and 1st MTP joint mobilisations with home-based stretches in a 6-week programme in people with DPN is effective in increasing static measures of range. This intervention may be useful for improving ankle, hallux joint mobility and anteroposterior stability limits in people with diabetes and neuropathy but not for reducing PPP or foot ulcer risk.Trial registrationhttps://classic.clinicaltrials.gov/ct2/show/NCT03195855.

Does a 1st Metatarsophalangeal Fusion in a Patient with Pes Planus Improve the Pes Planus Deformity? A Retrospective Case Series

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: A pes planus deformity is a pathology relating to the loss of normality of the complex interaction of the bones and joints of the foot resulting in a flattening of the medial longitudinal arch with or without abduction of the midfoot. The distal aspect of the medial longitudinal arch can be a feature of the deformity. The fusion of the 1st metatarsophalangeal joint (MTPJ) is a common operation. In patients with concomitant pes planus deformity, it is unknown if reducing and stabilising the distal aspect of the medial ray through a 1st MTPJ fusion can subsequently improve the pes planus deformity. We sought to analyse the pes planus deformity pre and post 1st MTPJ fusion with the null hypothesis that there was no difference. Methods: We identified patients who had undergone 1st MTPJ fusion using our electronic database from January 2011 to October 2021. To meet the inclusion criteria, cases required pre- and post-operative weightbearing plain radiographs, with a Meary's angle of &gt;4 degrees on pre-operative imaging. Routine pes planus measurements were undertaken by 2 independent observers. Pre- and post-operative measurements were tested for significant change using Wilcoxon Signed Rank Test or Paired T-Test depending on the normality testing of the data. Routine demographic data was also collected. Data was analysed using IBM SPSS v.27. Results: Following radiographic analysis, 25 feet fitted the inclusion criteria. The mean patient age was 63 years. There was no pre-operative correlation between Meary's angle and the hallux valgus angle (Kendall's tau p=.441). Pre-operatively, Meary's line broke at the talo-navicular and navicular-cuneiform joints in 12 cases each; the remaining case broke at the tarsal-metatarsal joint. A statistically significant improvement between the pre- and post-operative measurements was identified in Meary's angle, calcaneal pitch angle, talo-navicular coverage angle, intermetatarsal angle and talo-navicular angle (see table). Significant changes were also noted in the medial cuneiform height (mean increase of 2.74mm; p=.022). A post-operative Meary's angle of &lt;4°was only achieved in 4/25 (16%) of cases. Of the remaining 21 cases, the point at which Meary's line broke moved proximally one joint in 4 and distally one joint in 3 cases; it remained at the same joint in 14 cases. Conclusion: Our results suggest that 1st MTPJ fusion improves axial alignment of the foot as well as reducing Meary's angle by a statistically significant amount, although diagnostic criteria for pes planus remained in most cases.

First Metatarsophalangeal Arthrodesis Outcomes of Hallux Rigidus vs Hallux Valgus

Category: Midfoot/Forefoot; Other Introduction/Purpose: First metatarsophalangeal (MTP) joint arthrodesis is a commonly performed surgical procedure for patients with hallux rigidus (HR) or severe hallux valgus (HV). The purpose of this study was to compare patient outcomes of 1st MTP arthrodesis between HR and HV cohorts. We hypothesized that there would be no difference in patient-reported outcome measures (PROMs) or complication rates between groups. Methods: A retrospective review was conducted at a single academic medical center of patients who underwent 1st MTP arthrodesis with one of two fellowship-trained foot and ankle orthopaedic surgeons between 2009 and 2021. A total of 136 patients (148 feet: HR=75, HV=47, both=44) met the inclusion criteria of the three-month follow-up minimum. Data collection included PROMs (i.e., Visual Analogue Scale [VAS], 12-item Short Form Survey [SF-12], Foot and Ankle Outcome Score [FAOS], and Foot and Ankle Ability Measure [FAAM], Patient-Reported Outcomes Measurement Information System [PROMIS]), radiographic markers, and complication and reoperation rates. The VAS, SF-12, FAOS, and FAAM were collected preoperatively; the FAOS and FAAM were collected postoperatively; and all were collected via prospective phone interview. Forty-six patients (50 feet: HR=21, HV=15, both=14) completed the phone interview at an average of 3.04 (range, 0.58-10.01) years postoperatively. Mean clinical follow-up was 1.25 (range, 0.25-6.14) years. Results: The HR had a significantly smaller improvement in HVA (HR=-3.60, HV=-17.44, combined=-15.27; p&lt;.001), IMA (HR=- 0.16, HV=-2.80, combined=-2.55; p&lt;.001), and 1st-5th metatarsal width (HR=-0.98, HV=-4.59, combined=-4.60; p&lt;.001). There was a trend toward improved PROMs, although only significant for all groups with the VAS (p&lt;.001, p&lt;.001, p&lt;.001), FAOS Quality of Life (p&lt;.001, p=.030, p=.001), and FAAM Activities of Daily Living (p&lt;.001, p=.046, p=.002) and Total (p=.001, p=.024, p=.016) scores. The HV group significantly improved among the least PROMs. (Table 1) Complication (HR=28.07%, HV=38.30%, combined=36.36%; p=.499) and reoperation (HR=14.04%, HV=25.53%, combined=20.45%; p=.334) rates did not differ by group, although both were lowest for the HR group. Superficial infection (HR=12.28%, HV=17.02%, combined=9.09%; p=.521) and nonunion (HR=17.54%, HV=10.64%, combined=13.64%; p=.599) rates also did not differ. Conclusion: Indication for MTP arthrodesis does not appear to influence subjective outcomes of 1st MTP arthrodesis, as only one postoperative PROM differed between cohorts. All groups trended toward PROM improvements at 1-year and 3-years postoperative, although the HR group was the only group to continue improving from 1-year to 3-years postoperative. Thus, this study begins to provide insight into the role that specific forefoot pathology plays in 1st MTP arthrodesis outcomes, as we only found radiographic measures to be significantly different.

Clinical Features of the Course of Musculoskeletal Infection after Local Administration of Glucocorticoids

Summary. In the treatment of patients with inflammatory and degenerative-dystrophic lesions of the joints, soft tissues and ligaments, local administration of drugs is often used in practice, usually (mainly) glucocorticoids.&#x0D; Objective: to determine the place and role of local administration of glucocorticoids in the occurrence and development of musculoskeletal infection.&#x0D; Materials and Methods. The peculiarities of the occurrence and development of infectious complications, their clinical manifestations, laboratory and anamnestic data after local administration of glucocorticoids in 56 patients aged 24 to 78 years were analyzed.&#x0D; Results. 44 patients had moderate and severe subcompensated comorbidities. Betamethasone was the most commonly used for injections (32 patients, 57.2%). Glucocorticoids were administered intra-articularly to 43 (76.8%) patients: knee joint (37.5%), shoulder (25.0%), ankle (7.1%), hip (3.6%), elbow and 1st metatarsophalangeal (1 case each). In other cases (bursitis, enthesitis, etc.), glucocorticoids were administered paraarticularly. It was a single injection only in 32%; the rest of patients were injected 2 – 20 times. In 96% of cases, monocultures were microbiologically isolated (S.aureus in 52%). At the time of hospitalization, the acute stage of the infectious process was detected in 22 (39.3%) patients, subacute in 16 (28.6%), and chronic active fistula phase in 18 (32.1%). All cases of clinically similar manifestations are systematized into groups of symptom complexes – clinical variants: 1) abscess and/or phlegmon of paraarticular soft tissues, necrotizing fasciitis; 2) septic bursitis; 3) septic arthritis (synovitis); 4) septic destructive arthritis; 5) osteomyelitis.&#x0D; Conclusions. We found no clinical differences depending on the drugs used. The most important reasons for the development of infectious complications are ignoring the principles of dosing, multiplicity and time intervals of administration, unreasonable repeated use, and the presence of serious subcompensated comorbidities, which should be considered as a relative contraindication and as a risk factor.

Clinical Profile of Filipino Patients with Young-onset Gout

Objectives. Recent studies show that patients with young-onset gout present with visible tophi or nephrolithiasis on diagnosis. In the Philippines, where gout is prevalent, there is no published work on this subset of patients. This study presents the clinical characteristics of a cohort of Filipino patients with gout whose symptoms started at 30 years of age or younger.&#x0D; Methods. The case records of all patients who fulfilled the 1977 American College of Rheumatology (ACR) criteria for gout seen in four adult rheumatology services were reviewed. We selected those whose age of onset of gout was at 30 years or younger. The demographic characteristics, medical history, laboratory parameters, and presenting manifestations were described.&#x0D; Results. Six hundred sixty-nine records of patients with gout were reviewed; 101 (15%) fulfilled the young-onset gout criteria. The mean age of onset was 25±4.40 years (range 14-30), and the mean disease duration before diagnosis was 12.64±11.91 years. All of the patients were male and most were married; 76% were alcoholic beverage drinkers and 38% were smokers. A family history of gout was noted in 47%. Most patients (66%) were already on nonsteroidal anti-inflammatory drugs (NSAIDs), 24% on colchicine, and 14% on urate-lowering therapy before consult at the rheumatology clinic. By history, at onset, the most common pattern of joint involvement was monoarthritis (95%), affecting the ankles (60%), knees (52%), and 1st metatarsophalangeal (MTP) joint (51%). However, on the first rheumatology clinic visit, 34% of arthritis was polyarticular, more than 68% had more than three arthritis attacks per year, and there were tophi in 35%. The mean duration before visible tophi formation was 2.81±6.75 years. Around 21% had nephrolithiasis or a history thereof. The mean serum uric acid (SUA) was 9.18 mg/dL and the mean serum creatinine was 1.5 mg/dL. Thirty-seven percent had estimated glomerular filtration rate (GFR) &lt;60 mL/min.&#x0D; Conclusion. Young-onset gout was present in 15% of our patients and gout was familial in 47%. There was a delay in diagnosis of as long as ten years in most of the patients. On presentation at the rheumatology clinic, more than 34% had polyarticular arthritis, 35% had tophi, and 37% had low estimated GFR. This emphasizes the importance of awareness and prompt diagnosis to ensure correct treatment and prevention of complications

Revision First Metatarsophalangeal Joint Fusion for Non-Union, Implant Failures, and Failed Hallux Valgus Correction: Does the Indication Matter?

Category:Midfoot/Forefoot; BunionIntroduction/Purpose:The most common indications for revision of 1st Metatarsophalangeal (MTP) joint surgery are symptomatic failures of prior fusion, failed hallux valgus correction, and failed MTP arthroplasty implants. The outcome of revision 1st MTP fusion has rarely been studied. The purpose of this study was to compare the clinical, radiographic, and patient-reported outcomes of revision MTP fusion for different indications.Methods:A retrospective chart review was performed for patients who underwent revision 1st MTP fusion between January 2015 and December 2019 in a single-center, by 4 fellowship-trained foot and ankle surgeons. The complication, revision, and non- union rates as well as VAS and PROMIS scores and pre-operative and post-operative radiographs were analyzed and compared between the different indication groups. Univariate and multivariate analysis and logistic regression models were used to obtain odds ratio of the explanatory variables for outcome measures.Results:A total of 79 cases of revision MTP fusion were included. Thirty-eight cases of hallux valgus corrections salvage, 22 failed MTP arthroplasty implants, 6 failed polyvinyl alcohol hydrogel implants, 13 prior MTP fusion non-unions. The mean follow-up time was 350 days (Median 226, SD 306). Seven cases (8.9%) required structural iliac-crest bone graft during the revision. Seven cases (8.9%) required allograft augmentation. The overall complication rate was 40.7%. Fifteen patients (18.5%) were classified as Clavien-Dindo grade 3, which represents a complication that may require a revision surgery (i.e. non-union, deep infection, loss of correction). Eventually, 7 cases (8.9%) underwent further revision surgery. The logistic regression model demonstrated that indication for revision was not significantly related to union rate (p=0.280). Visual-Analogue-Scale significantly improved at 6 weeks, 3 months, and at last follow-up in all indications for revision (p=0.001). PROMIS-10 Physical and PROMIS-10 Mental did not change significantly during follow-up (p=0.860, p=0.589).Conclusion:Treatment of 1st MTP joint surgery failures is a clinical challenge in orthopaedic surgery. In our study, revision of 1st MTP joint surgery with MTP fusion had higher non-union rates and higher overall complication rates compared to primary 1st MTP fusion. Nevertheless, revision rates remained comparable to primary 1st MTP fusion. Complication rates and patient- reported outcomes were similar between the different indications for revision groups. Visual-analogue-scale improved significantly during follow-up in all groups. Diabetes mellitus had a significant impact on non-union rates and overall complication rates.

Early Outcomes, Revisions, and Patient Satisfaction Following Synthetic Cartilage Implant for Hallux Rigidus

Category:Midfoot/Forefoot; OtherIntroduction/Purpose:Hallux rigidus is a common condition estimated to affect 1 in 40 adults older than 60 years old. Patients experience functional limitations secondary to progressive pain and stiffness of the 1st metatarsophalangeal (MTP) joint.Historically, 1st MTP arthrodesis has been considered the gold-standard treatment for end-stage hallux rigidus. In 2016, the US Food and Drug Administration (FDA) approved the use of a synthetic cartilage implant (SCI) for the treatment of hallux rigidus grades 2-4 with an aim to improve pain and preserve range of motion at the 1st MTP joint. Studies evaluating patient satisfaction and need for reoperation have varied considerably (4-20%). We aim to evaluate outcomes, complication rate, revision rate, and overall satisfaction for patients undergoing primary SCI for hallux rigidus.Methods:In a single-institution retrospective study, we evaluated patients undergoing primary SCI for hallux rigidus between August 2016 to May 2020 by three fellowship-trained foot and ankle surgeons. Preoperatively, patient demographics, age at the time of surgery, laterality, body mass index (BMI), hallux rigidus grade, hallux valgus angle, and first-second intermetatarsal angle were collected. Operative reports were reviewed for concomitant procedures and implant size. Postoperatively, we recorded all additional treatments for continued pain or stiffness and need for revision surgery or conversion to arthrodesis. Patients were surveyed via email or telephone by an author not previously involved in their care administering patient reported outcomes (PROs): PROMIS physical function (PF), and pain interference (PI) surveys, foot and ankle SANE score, and a satisfaction survey.Results:A total of 59 feet in 56 patients underwent a primary SCI procedure for hallux rigidus. Patients were classified as grade 2 (32%), 3 (59%), or 4 (2%). Nineteen (34%) patients underwent additional procedures, and 8 (14%) had a history of prior surgery to the MTP joint. Forty-five patients (80%) completed surveys at an average of 19.5-month follow-up. The majority (58%) considered surgery a success and 42% reported being unsatisfied or very unsatisfied. Mean (+-SD) post-operative foot and ankle SANE, PROMIS PF and PI scores were 57 (+-27), 48 (+-7) and 54 (+-9), respectively. The overall revision rate was 11% (6/56) with 3 patients undergoing conversion to arthrodesis. The majority of patients (61%) stated they would undergo the procedure again.Conclusion:Consistent with existing literature, we found that the majority of patients undergoing the procedure were satisfied and would undergo the procedure again. Further, post-operative PRO scores were favorable, even when factoring in patients who were less satisfied. While our revision rate (11%) is consistent with early studies of the implant, 42% reported being unsatisfied or very unsatisfied with their procedure. These findings emphasize the importance of preoperative patient counseling regarding post- operative limitations, risks, satisfaction, and revisions rates. Further investigation into factors that may predict successful outcomes is needed to inform surgical decision-making and appropriate patient selection for this procedure.

Porous Titanium Wedges in Revision First Metatarsophalangeal Arthrodesis

Category:Midfoot/Forefoot; OtherIntroduction/Purpose:First metatarsophalangeal (MTP) arthrodesis is a common procedure for hallux MTP pathology. In the setting of prior procedures with resultant bone loss, porous titanium wedges provide an alternative to allograft or autograft. The purpose of this study was to report clinical and radiographic outcomes achieved with titanium wedges used in 1st MTP arthrodesis in a revision setting.Methods:A retrospective analysis was performed in 10 patients (mean age 65.8) with prior 1st MTP procedures who underwent 1st MTP arthrodesis with use of porous titanium wedges from February 2014 to March 2020. Outcomes were assessed using both clinical (Visual Analogue Scale, Foot and Ankle Ability Measure, Mental Health Continuum Short Form, 36-Item Short Form Survey, need for revision) and radiographic parameters. Patients were followed from a minimum of 6 months up to 6 years (mean 31.4 months).Results:Average Foot and Ankle Ability Measure (FAAM) score was 91.1 +/- 14.7 (75.1 +/- 5.3 FAAM Activities of Daily Living; 17.9 +/- 9.9 FAAM Sports). Average pain visual analogue scale was 1.9 +/- 1.7. Average Mental Health Continuum-short form score was 34.2 +/- 8.5. Postoperative computed tomography (CT) imaging demonstrated lack of osseous integration in two of six CT scans obtained. Four patients underwent subsequent revision procedures, 3 for hardware prominence and 1 for failure of fusion.Conclusion:To our knowledge, these data represent the first reported clinical and radiographic outcomes in patients undergoing revision 1st MTP arthrodesis with use of porous titanium wedges. Further research should focus on comparative data with other commonly performed operative techniques.

Radiographic Characterization of Midfoot and Transverse Tarsal Joint Osteoarthritis

Category:Ankle Arthritis; Midfoot/ForefootIntroduction/Purpose:Midfoot osteoarthritis affects over 16% of adults over the age of 50, interfering with activities of daily living and leisure. Non-operative management includes anti-inflammatory, carbon fiber shank/custom orthotics, and cortico-steroid injections. To improve accuracy, these injections are often done under fluoroscopic guidance. Operative intervention with midfoot fusions is sometimes performed, though non-union rates and continued pain after surgery can be challenging. Sometimes, there can be difficulty in determining exactly which midfoot joints are most arthritic/symptomatic based on radiographs. This study aims to quantify how well surgeons are able to diagnose midfoot and transverse tarsal joint arthritis on standing radiographs versus advanced imaging.Methods:We reviewed the records of 113 patients (144 feet) with midfoot arthritis, who were treated from 2015 to 2019 at an academic medical center by a single fellowship trained foot and ankle surgeon. The mean age was 63.0 years, the average BMI was 31.5, and 7 patients eventually underwent surgery. Each patient underwent both plain radiographs, according to a standardized protocol, and either a CT or MRI scan. Radiographs and advanced images were graded separately for the presence of joint space narrowing, subchondral cysts, and other signs of arthritis in the following joints: 1st tarsometatarsal (TMT), 2nd TMT, 3rd TMT, 4th TMT, 5th TMT, naviculocuneiforms (NC), talonavicular (TN), calcaneocuboid (CC), subtalar (ST), and 1st metatarsophalangeal (MTP). The sensitivity, specificity, precision, negative predictive value, and overall accuracy of radiographs compared to CT scans was calculated for each joint. Statistical significance was assessed using a paired t-test.Results:The most common joints affected by arthritis were the 2nd TMT (radiograph=75.7%, CT=79.9%) and 3rd TMT (radiograph=65.5%, CT=70.4%). Advanced imaging showed a significantly higher rate of arthritis in the 1st TMT (P<0.01), 4th TMT (P<0.01), and 5th TMT (P<0.01), as compared to radiograph. Only 16.9% of patients' radiographs had a direct correlation with the results of their CT scan. A CT scan showed one or two additional affected joints by 19.7% and 13.0 %, respectively; and rarely showed one or two less joints affected by arthritis (8.1% and 3.2%, respectively). We found radiographic sensitivity and specificity to be highly variable (1st TMT=61.3% & 92.3%, 3rd TMT=79.5% & 69.3%).Conclusion:Radiographs vary drastically in their sensitivities and specificities in diagnosing arthritic joints in the midfoot and transverse tarsal joints. When treating midfoot osteoarthritis surgically, we recommend obtaining advanced imaging preoperatively, rather than relying on plain radiographs alone to determine which joints may need to be managed surgically.

“In-Situ” Joint Preparation Technique for First Metatarsophalangeal Joint Arthrodesis: A Retrospective Comparative Study with “Flat-Cuts” Technique

Category:Midfoot/Forefoot; BunionIntroduction/Purpose:The most common joint preparation techniques mentioned in literature for 1st metatarsophalangeal (MTP) joint arthrodesis are 'cup and cone' and 'flat-cuts'. A third option of an 'in-situ' technique, has rarely been studied. This study compares the clinical, radiographic, and patients-reported outcomes of 'in-situ' joint preparation with a traditional 1st MTP joint preparation technique.Methods:The 'in-situ' technique utilizes the same dorsal surgical incision as traditional techniques. Cartilage and osteophyte removal are carried out using standard techniques without the use of specific reamers or a sagittal saw. The arthrodesis is performed in-situ with the similar freedom of joint positioning as the cup and cone technique, and traditional fixation constructs are applied. In this study, A retrospective chart review was performed for patients who underwent 1st MTP joint arthrodesis between January 2015 and December 2019. The complication, revision and non-union rates were examined in a multivariable logistic regression model. Patient reported outcome were analyzed in a repeated measures general linear model. Analysis of variance and Receiver Operating Characteristic were used to assess radiographic measurements.Results:Total of 388 1st MTP joint arthrodesis cases were included. Overall, 262 'Flat-Cuts' and 126 'In-Situ' cases were analyzed. Mean follow-up time was 292 days (median 174, SD 305). Joint-preparation technique did not have statistically significant impact on union rates (p=0.311) or revision rates (p=0.898). Diabetes-Mellitus was the most powerful predictor of non-union (p<0.001, OR 6.558, 95% CI: 2.534-16.969) and revision (p=0.02, OR 3.662, 95% CI: 1.230-10.905). The rate of transfer- metatarsalgia was significantly higher in 'flat-cuts' (p=0.015, OR 6.808, 95% CI: 1.460-31.744). Visual-Analogue-Scale and PROMIS- CAT-Physical significantly improved at 6-weeks, 3-months, and at last follow-up in both techniques (p<0.001, p=0.001), and the improvement was comparable between the techniques (p=0.078, p=0.100).'In-situ' technique resulted in significantly less mean 1st- ray shortening (3.05mm vs 7.64mm, p<0.001). In a Receiver-Operating-Characteristic analysis of transfer metatarsalgia and 1st ray shortening, the optimal diagnostic cut-off was 6.87 mm (LR 1.67, AUC 0.652, p=0.005, 95% CI: 0.56-0.74).Conclusion:'In-situ' joint preparation technique is a simple, safe, and cost-effective technique for 1st MTP joint arthrodesis. In our series, 'in-situ' technique had a similar or better complication profile than the 'flat-cuts', while providing similar patient- reported outcomes. 'In-situ' technique resulted in significantly less 1st ray shortening, which was a predictor of transfer metatarsalgia.

Coronal Plane Deformity and Total Ankle Replacement: When to Stage with Cement Spacer Ankle Arthroplasty for Deformity Correction

Category:Ankle ArthritisIntroduction/Purpose:Degenerative ankle joint disease is a debilitating condition that causes significant pain, adversely affects function and quality of life. Though primary arthritis of the ankle can occur without deformity, frequently soft tissue imbalances or joint deformities complicate the clinical picture. Often, additional procedures are required to balance the foot and ankle during the index total ankle replacement procedure. When large deformities exist a staged approach to first, align the ankle joint to neutral as stage one and then implantation of the TAR as stage two can be deployed. This paper will further popularize the cement spacer staged TAR technique in correction of coronal deformities, share a clinical algorithm on approach, and depict a case series demonstrating its application.Methods:A case series was performed of 7 patients and 8 ankles, who underwent staged primary TAR utilizing a cement spacer to assist with deformity correction, between the years 2016-2019.Results:Patients' mean age 58.5 yrs., preoperative varus coronal plane deformity mean 19.1 degrees, preoperative valgus coronal plane mean 10.25 degrees. Mean time from stage 1 till 2 was 163.5, +-140.2 days. Stage 1 soft tissue procedures: Chrisman-Snook procedure with synthetic ligament graft, Brostrum-Gould with synthetic graft, Brostrum-Gould without graft, FDL transfer, and isolated medial release/peel. Osteotomies performed during stage one: Dwyer, MDCO, Cotton, and MDCO with medial malleolus osteotomy. Fusions performed during stage one consisted: Subtalar joint, talonavicular joint (TNJ), and STJ with 1st Metatarsophalangeal joint (MTPJ). Seven ankles were replaced with Cadence Total Ankle System (Integra), and one with INBONE II (Wright Medical Technology). Average follow-up time for included patients was 290.75 days (9.7 months). One revision was performed following index TAR procedure.Conclusion:This paper describes a cement wedge spacer staged total ankle arthroplasty technique for correction and stabilization of deforming forces at the ankle joint. While not all ankle deformities necessitate a staged approach, the complexity of the malalignment and the extent of tissue disruption needed to achieve a neutral ankle should be considered when correcting a given deformity with a staged or non-staged approach.

Intraosseous device for arthrodesis in foot and ankle surgery: Review of the literature and biomechanical properties.

BACKGROUNDArthrodesis is the surgical fusion of a diseased joint for the purposes of obtaining pain relief and stability. There have been numerous fixation devices described in literature for foot and ankle arthrodesis, each with their own benefits and drawbacks. AIMTo review the use of intraosseous devices in foot and ankle surgery. METHODSThere were 9 papers included in the review (6 clinical and 3 experimental studies) all evaluating arthrodesis in the foot and ankle using the IOFIX device (Extremity Medical™, Parsippany, NJ, United States). Outcome scores, union rates, as well as complications were analysed. RESULTSIOFIX appears to be safe and effective in achieving arthrodesis of the 1st metatarsophalangeal, and talonavicular joints with early rehabilitation. In comparison to plate/screw constructs there were fewer soft tissue complications and issues of metalwork prominence. Cadaveric and biomechanical studies on the use of intramedullary fixation for fusion of the tarsometatarsal and ankle joint showed decreased load to failure, cycles to failure and stiffness in comparison to traditional fusion methods using plates and screws, however IOFIX devices produced higher compressive forces at the joint. CONCLUSIONWe describe the reasons for which this biomechanical behavior of the intraosseous fixation may be favorable, until prospective and comparative studies with larger sample size and longer follow-up confirm the effectiveness and limitations of the method.

Arthrodesis of the first metatarsophalangeal joint: The "when and how".

Arthrodesis of the first metatarsophalangeal (MTP) joint has been established as the “gold standard” for the treatment of several first ray disorders, due to its perceived efficacy and the consistently reported good results in the literature. Arthrodesis is a commonly performed procedure for the treatment of end stage arthritis, rheumatoid arthritis with severe deformity, selected cases of severe hallux valgus (with or without signs of degenerative joint disease), as well as a salvage procedure after failed previous operation of the first ray. The goals of a successful 1st MTP arthrodesis are pain alleviation and deformity correction in order to restore a comfortable gait pattern and to improve shoe wear. Several techniques have been reported with several proposals regarding the preparation of the articular surfaces and the method of definitive fixation. As with any given surgical procedure, various complications may occur after arthrodesis of the 1st MTP joint, namely delayed union, nonunion, malunion, irritating hardware, etc.