Hallux Metatarsophalangeal Joint Research Articles

Minimally invasive Dorsal cheilectomy and Hallux metatarsophalangeal joint arthroscopy for the treatment of Hallux Rigidus

BackgroundMinimally invasive dorsal cheilectomy (MIDC) has become a popular alternative to an open approach for treating Hallux Rigidus (HR). To reduce some of the complications related to the MIDC approach, a first metatarsophalangeal (MTP) joint arthroscopy can be performed in addition to address the intra-articular pathology associated with Hallux Rigidus. This study aims to examine the effectiveness of MIDC with first MTP arthroscopy in patients with HR with a minimum 1-year follow-up. MethodsThis was a multicenter retrospective review for adult patients with Coughlin and Shurnass Grade 0–3 who were treated with MIDC and first MTP arthroscopy between 3/1/2020 and 8/1/2022, with at least one year of follow-up data. Demographic information, first MTP range of motion (ROM), visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOXFQ), and EQ-5D-5 L scores were collected. Continuous data was expressed as a mean and standard deviation, categorical data was expressed as a percentage. Wilcoxon Rank Sum test was used to compare continuous variables. All P < 0.05 was considered significant. ResultsA total of 31 patients were included in the study. Average follow-up time was 16.5 months (range: 12 to 26.2). There was 1 (3.2%) undersurface EHL tendon tear, 2 (6.5%) conversions to an MTP fusion, and 1 (3.2%) revision cheilectomy and capsular release for MTP joint contracture. There was a significant improvement in patient’s ROM in dorsiflexion (50 vs 89.6 degrees, P = 0.002), postoperative VAS pain scores (6.4 vs 2.1, P < 0.001), MOXFQ pain scores (58.1 vs 30.7, P = 0.001), MOXFQ Walking/Standing scores (56.6 vs 20.6, P = 0.001), MOXFQ Social Interaction scores (47.3 vs 19.36, P = 0.002), and MOXFQ Index scores (54.7 vs 22.4, P < 0.001). ConclusionWe found that MIDC with first MTP arthroscopy was effective at improving patient-reported outcomes at one year with low complication and revision rates. These results suggest that MIDC with first MTP arthroscopy is an effective treatment for early-stage HR. Level of EvidenceIV.

Association between Postoperative Medial: Middle Intercuneiform Joint Gapping and Recurrence Rates in Hallux Valgus

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Hallux valgus (HV) is a triplanar deformity of the first metatarsal, which may extend beyond the first ray. Compared with normal feet, previous studies have found that HV patients have an increase in hypermobility of the joints along the medial column and at the medial – middle (MM) intercuneiform joint. Despite increased instability at the MM intercuneiform joint, no study has investigated its clinical significance. The primary purpose of this study was to determine if postoperative widening of the MM intercuneiform joint was associated with recurrence in HV patients who undergo a first tarsometatarsal fusion (modified Lapidus procedure). A secondary purpose was to investigate whether other HV imaging parameters were associated with a widening of the MM intercuneiform joint. Methods: This study included 52 consecutive HV patients who underwent a modified Lapidus procedure and had preoperative and at least 5-month postoperative weightbearing CT (WBCT) scans. Preoperative and postoperative measurements of HV deformity, including the intermetatarsal angle and hallux valgus angle (HVA) on plain radiographs and triplanar pronation angle and sesamoid station from WBCTs, were performed as previously described. MM intercuneiform distance was measured on the coronal multiplanar reconstructed WBCT scans after reorienting the axial and sagittal planes such that the coronal cuts were orthogonal to the intercuneiform joint (Figure 1A). Recurrence of the HV deformity was defined as a postoperative HVA ≥ 20°. Paired t-tests were used to compare preoperative and postoperative imaging parameters, and Mann-Whitney U tests were used to compare measurements between patients with and without HV recurrence. Pearson correlation coefficients were used to explore associations between preoperative and postoperative measurements and the change in MM intercuneiform distance. Results: Nine of 52 patients (17.3%) had recurrence of their HV deformity. For the entire cohort, the mean preoperative and postoperative MM intercuneiform distances were 0.73 mm (standard deviation (SD) 0.3) and 1.08 mm (SD 0.5), respectively. In patients with and without HV recurrence, the mean widening at the MM intercuneiform joint was 0.69 mm (95% confidence interval (CI) 0.52-0.86) and 0.27 mm (95% CI 0.17-0.38, P&lt; 0.001), respectively. Patients with recurrence had significantly greater widening of the MM intercuneiform joint than patients without recurrence (P=0.001, Figure 1B and Table 1). While no preoperative imaging parameters were associated with a change in the MM intercuneiform distance, increasing postoperative sesamoid position (r=0.32, P=0.022) and HVA (r=0.28, P=0.046) were correlated with a greater change MM intercuneiform joint gapping. Conclusion: In patients undergoing a modified Lapidus procedure for correction of their HV deformity, postoperative widening of the MM intercuneiform joint was associated with recurrence of the HV deformity. As understanding of the HV deformity continues to evolve, our study suggests that there is a complex interplay between deformity at the hallux metatarsophalangeal (MP) joint, reduction of the metatarsosesamoid joint complex, and the instability at the tarsometatarsal and intercuneiform joints. This may guide surgical correction as surgeons may need to address both intercuneiform instability and correction at the hallux MP joint in order to decrease HV recurrence rates.

Outcomes After Hallux Interphalangeal Joint Arthrodesis.

Hallux interphalangeal joint arthrodesis (HIPJA) is indicated for a variety of pathologies. Despite high nonunion rates, techniques remain unchanged. The aim of this study is to examine nonunion and complication rates and describe risk factors for treatment failure. A query of an institutional database was performed to identify all patients undergoing HIPJA procedure over a 10-year period. Records were reviewed to the procedure, evaluate patient factors, indications, and radiographic/clinical arthrodesis. Radiographic union was defined as 2 cortical continuations or bridging at the arthrodesis site, absence of hardware failure, and the absence of lytic gapping of the arthrodesis. Clinical fibrous union was defined as radiographic nonunion with painless toe range of motion and physical examination consistent with fusion across the interphalangeal joint. Two hundred twenty-seven primary HIPJA procedures were identified. Our cohort demonstrated a 25.5% nonunion rate (58/227) and 21.1% reoperation rate (48/227). Patients with diabetes were at higher risk for nonunion (P = .014), but no significant differences were identified based on smoking status or diagnosis of inflammatory arthritis. No difference was seen between implant groups: single screw, multiple screws, screw plus other fixation, nonscrew fixation. Patients with prior hallux metatarsophalangeal joint arthrodesis did not have a significantly higher nonunion rate than patients without prior first metatarsophalangeal joint arthrodesis. Patients diagnosed with radiographic nonunion were at higher risk for reoperation (P < .0001). Our cohort represents the largest single-center series of HIPJA procedures published to date. We found relatively high nonunion and reoperation rates with standard current techniques. Level III, retrospective case series.

Patient-Reported Outcome Measure for Cartiva® Synthetic Cartilage Replacement in Advanced Degenerative Disease of the Hallux Metatarsophalangeal Joint - A Single Surgeon Series

Cartiva® Synthetic Cartilage Implant (SCI) was introduced in our department in 2016 as an alternative treatment for advanced degenerative disease of the hallux metatarsophalangeal joint requiring fusion but would rather prefer to maintain joint movement.

Translation, Cultural Adaptation, and Validation of the American Orthopedic Foot and Ankle Society Scale in Patients With Hallux Valgus in Colombia

The American Orthopedic Foot and Ankle Society (AOFAS) scale for hallux metatarsophalangeal (MTP) and interphalangeal (IP) joints is used throughout the world for the clinical assessment of patients with hallux valgus, and it has 3 subscales: pain, function, and alignment. The objective of this prospective, observational study was to perform translation, cultural adaptation, and validation of this scale for Colombian Spanish. The Foot Function Index and Short Form-36 (SF-36) questionnaires were also used in the validation process. Patients who were 18 years or older, resided in the city of Bogota, were able to read and write in Spanish, and were within 4 years of corrective surgery for hallux valgus were included. A total of 79 patients were included in the study, 25 of whom were involved in the translation process and all of whom were involved in the validation process. Construct validity was demonstrated by significant positive Spearman's correlations between the AOFAS pain subscale and the AOFAS function subscale (rs=0.483), total AOFAS scale (rs=0.795), and SF-36 physical summary subscale (rs=0.364); and between the AOFAS function subscale and the total AOFAS scale (rs=0.894) and SF-36 physical summary subscale (rs=0.310). The test-retest process for reliability yielded intraclass correlation coefficients between the AOFAS pain, function, and alignment subscales that were all 0.70 or higher. The AOFAS scale for hallux MTP and IP joints was successfully translated and adapted into Colombian Spanish, and this version demonstrated construct validity and reliability, rendering it suitable for clinical use in Colombian patients with hallux valgus.

Rotating Scarf osteotomy in treating hallux valgus combined with the first metatarsal rotation

To explore clinical effect of rotational Scarf osteotomy in treating hallux valgus (HV) with rotation of the first metatarsal bone. From January 2018 to October 2019, 35 patients (40 feet) with HV and rotation deformity of the first metatarsal were treated with rotational Scarf osteotomy, including 5 males and 30 females;aged from 25 to 76 years old with an average of (40.32±5.43) years old. Hallux valgus angle(HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), the first metatarsal length (FML) were observed and compared, American Orthopedic Foot and Ankle Society(AOFAS) of hallux metatarsophalangeal interphalangeal joint score and visual analogue scale (VAS) were used to evaluate functional evaluation. Thirty-five patients(40 feet) were followed up from 12 to 36 months with an average of (14.35±3.62) months. HVA, IMA and DMAA were corrected from (36.32±4.51) °, (14.21±3.22) ° and (28.35±4.32) ° before operation to (14.32±5.71) °, (5.83±3.97) ° and (7.32±2.14) ° after operation respectively (P<0.05). There was no satistical difference in FML before and after operation (P>0.05). AOFAS score and VAS improved from (57.00±4.31) and (6.00±1.21) before operation to (90.31±3.28) and (1.42±0.83) after operation, respectively, and had significant difference(P<0.05);according to AOFAS score, 23 feet got excellent results, 15 feet good and 2 feet fair. Rotational Scarf osteotomy with strong correction and high dimension could effectively correct HV combined with rotation deformity of the first metatarsal bone, improve function of the forefoot, and obtain good clinical results.

Evaluation of range of motion of hallux metatarsophalangeal and interphalangeal joints after periarticular osteotomies

Objective: Evaluate the impact of Chevron and extended Chevron techniques associated with Akin osteotomy on the range of motion (ROM) of hallux metatarsophalangeal joint (MPJ) and interphalangeal joint (IPJ) after three months and one year. Methods: Sixteen patients (17 feet) were evaluated for the ROM of hallux MPJ and IPJ pre-and postoperatively, the flexion-extension measurements were performed using a goniometer. Results: Comparing the pre-and postoperative measurements at three months and one year, the ROM decreased in MPJ extension and flexion, 9o and 5o, respectively, and IPJ flexion, 5o. The values presented statistical significance according to the analysis demonstrated (p&gt;0.05). However, the decrease in IPJ extension was not statistically significant (decrease of 0.8o and p&lt;0.05). Conclusions: Periarticular osteotomies of hallux MPJ had a significant decrease in the ROM after three months and one year. Level of Evidence II; Therapeutic Studies - Investigating the Results of Treatment; Prospective Comparative Study.

Traumatic Great Toe MCL Avulsion in Professional Athlete Treated Surgically with MCL Repair with Suture Tape Augmentation Allowing Rapid Return to Sport

Category: Sports; Midfoot/Forefoot; Trauma Introduction/Purpose: Acute medial collateral ligament (MCL) tears of the great toe metatarsophalangeal joint (MTPJ) are a rare occurrence. There is minimal literature existing regarding both operative and non-operative management of this pathology, also known as 'traumatic bunion' due to its low incidence. The closest analog is a traumatic ulnar collateral ligament (UCL) rupture in the hand (Skier's thumb). Suture anchor repair with an internal brace has proven to be an effective treatment for thumb UCL tears with rapid rehabilitation and early range of motion. This method has not yet been reported in literature for a weightbearing joint such as the hallux MTPJ. We present a case report for a professional surfer with traumatic great toe MCL avulsion with surgical technique allowing rapid return to sport. Methods: We present a case report of a novel technique for this rare traumatic MCL avulsion. Surgical management of the great toe MCL was performed utilizing a pre-loaded interference screw to fixate suture at the MCL origin with suture tape augmentation. A mid-axial medial approach was used with L-shaped capsular flap to expose the MCL. 3-0 braided suture was passed through the proximal avulsed MCL. A drill tunnel was prepared at the MCL origin, and the MCL was repaired to its anatomic origin with an interference screw technique for knotless technique. The interference screw was preloaded with suture tape. The suture tape from the interference screw was passed extra articular and the capsule was repaired. The sutuer tape was then inserted into the MCL insertion on the distal phalanx using a small interference screw and drill tunnel for a suture tape augmentation while the toe was held in neutral MTPJ position. Results: He was made weightbearing as tolerated in a CAM boot post-operatively. Immediate active great toe MTPJ motion was permitted. At 2 weeks post-op, sutures were removed, and he was allowed self-directed passive range of motion of the toe, with continued weightbearing as tolerated in the boot. All restrictions were lifted at 4 weeks for a return to play protocol and the patient resumed surfing immediately at that time. His last follow up appointment was at 3 months post-op, at which time he had resumed full activity, had no deformity recurrence, no pain, and his range of motion was symmetric to the contralateral foot. The patient was able to compete at full activity in a national tournament to continue the professional tour at 3 months post- operatively. Conclusion: This report demonstrates a novel surgical technique for the treatment of a rare traumatic MCL avulsion of the great toe (the 'traumatic bunion'). In this case of great toe MCL repair in a professional surfer, we utilized a knotless technique to repair the MCL to it's anatomic origin and also provide suture tape augmentation to allow rapid rehabilitation. This report demonstrates rapid return to sport, an excellent outcome, easy rehabilitation, and straightforward surgical technique. More research will be needed to demonstrate the success of this technique in a broader population.

Low-grade central osteosarcoma of the hallux with a 7-year undiagnosed course: Case report

Low-grade central osteosarcoma usually exhibits a long course with nonspecific symptoms, while the imaging and histological findings may be easily confused with a variety of benign fibroosseous lesions. A 15-year-old boy was referred for a painless swelling of the proximal phalanx associated with shortening of the right hallux. A benign cystic bone lesion complicated by a pathological fracture had been diagnosed on the radiographs at 8 and 10 years of age after sport injuries. He was referred for evaluation and treatment of the bone lesion. Magnetic resonance imaging and computed tomography were performed. A referral centre was contacted, since there was a strong evidence of malignancy. An open biopsy was suggested, which indicated bone malignancy. The patient was then referred to the specialized tumor centre. A new biopsy was performed there, since the previous sampling was considered insufficient or inadequate to secure a differentiation from fibrous dysplasia. It ensured the diagnosis of low-grade central osteosarcoma. Radical excision of the proximal phalanx and reconstruction of the defect with an iliac graft associated with arthrodesis of both the hallux metatarsophalangeal and interphalangeal joints was the treatment of choice. Disturbed wound healing necessitated hardware removal 4 months postoperatively. No further interventions were required in the follow-up. Clinical and radiographic evaluation at 12 years confirmed no evidence of local recurrence or distant metastasis. The patient was satisfied with the final outcome and reported unrestricted participation to physical activities and sports. • The rarity and the highly variable presentation of the foot and ankle malignancies may explain why they are often not considered in the differential diagnosis and the increased likelihood of delayed or incorrect diagnosis. • A low-grade central osteosarcoma localized in the proximal phalanx of the great toe of a 15-year-old boy is presented. The imaging appearance of the lesion was not correctly assessed to suggest a potentially malignant pathology and to require an early bone biopsy leading to a 7-year delayed diagnosis. • All available clinical and imaging features should be carefully considered in decision making, during the diagnostic steps in a patient with a potentially malignant bone tumor of the foot or ankle, to ensure that the diagnosis will not be delayed or missed and that proper treatment by a specialized tumor surgeon in a designated tumor centre will be offered.

Two Orthogonal Nitinol Staples and Combined Nitinol Staple-Screw Constructs for a First Metatarsophalangeal Joint Arthrodesis: A Biomechanical Cadaver Study.

End-stage hallux metatarsophalangeal (MTP) joint arthritis is commonly treated with arthrodesis using stainless steel or titanium implants. These implants provide static compression that is maximal at the time of implant insertion. Alternatively, nitinol staples are capable of dynamic compression. They have most frequently been used for midfoot arthrodesis procedures. However, their biomechanical performance during hallux MTP arthrodesis has not been described. 8 matched pairs of cadaveric feet (4 female, 4 male) were prepared for hallux MTP arthrodesis using cup and cone reamers. Cadaveric pairs were then instrumented with either (1) a transarticular lag screw and dorsal nitinol staple or (2) orthogonal nitinol staples placed dorsally and medially. Walking in a short leg cast for 6 weeks was simulated by applying 90-N forces at 3 Hz to the plantar proximal phalanx for up to 250 000 cycles. Failure was defined as catastrophic implant failure or plantar gapping beyond 7 mm. 15 of 16 specimens failed cyclic loading. All 8 specimens fixed with orthogonal staples failed at an average of 37 ± 81 cycles. 7 of 8 specimens fixed with a dorsal staple and crossed screw failed at 14 900 ± 39 000 cycles. Collectively, 5 specimens failed because of bone fracture (1 in orthogonal staples, 4 in staple-screw group) and 10 failed because of excessive gap formation (7 in orthogonal staples, 3 in staple-screw group). The number of cycles to failure was significantly lower (P = .0469) in the orthogonal staple constructs compared with the dorsal staple and crossed screw constructs. The tested constructs permit significant motion at the first MTP fusion surface during simulated protected weightbearing. Although multiple in vivo factors should be considered when extrapolating results from this cadaveric study, this motion may result in clinical failure with early postoperative weightbearing protocols. We report the first biomechanical evaluation of hallux MTP arthrodesis using modern nitinol staples in 2 separate constructs.

Results of Hallux Metatarsophalangeal Joint Arthrodesis with and without Calcaneus Autograft

Category:Bunion; Midfoot/Forefoot; OtherIntroduction/Purpose:Hallux rigidus is the most common degenerative arthropathy of the foot. Primary hallux metatarsophalangeal (MTP) joint arthrodesis is the most common surgical treatment for end-stage hallux rigidus and can also be utilized for correction of hallux valgus. Though satisfaction rates following hallux MTP joint arthrodesis are very favorable, nonunion rates have been reported as high as 12%. Many surgeons use orthobiologics and/or autograft to augment arthrodeses about the foot and ankle in an effort to increase union rates. The purpose of this study is to retrospectively compare union rates of hallux MTP joint arthrodesis with and without calcaneus autograft.Methods:A query of our institution’s administrative database was performed to identify patients who underwent a primary hallux MTP joint arthrodesis between February 2016 and February 2019. We compared patients who underwent arthrodesis with and without calcaneus autograft. Surgeon preference dictated use of autograft, as some in our group routinely use graft while others do not. Patients 18 years and older who underwent a primary hallux MTP arthrodesis were included. Patients were excluded if they had radiographic evidence of significant bone loss or if allograft or biologic therapies were used. Patient charts and final radiographs were reviewed. The primary outcome was successful union of the hallux MTP joint arthrodesis. Secondary outcomes included preoperative diagnosis, type of surgical fixation and surgical complications. Data was compared using a student T-test.Results:There were 336 feet included in the final analysis, and 140 underwent hallux MTP arthrodesis with calcaneus autograft. Mean follow-up time was 14.8 weeks. Among all patients, 89.9% had a successful union. There was no difference in union rates between those who underwent arthrodesis with calcaneus autograft (87.9%) compared to without autograft (91.4%; p = 0.302). Hallux valgus was the preoperative diagnosis in 52.7% of cases followed by hallux rigidus (39.9%). The most common fixation method was a lag screw with a dorsal plate (80.5%). Painful hardware was the next most common complication (8.6%), and smoking and diagnosis of diabetes demonstrated no effect on union rates. In the autograft group, there were no complications related to the calcaneus autograft donor site.Conclusion:As orthobiologics and local bone autograft gain popularity in foot and ankle surgery, it is important to report clinical outcomes and establish evidence-based guidelines for use. In this relatively large retrospective comparison, the use of calcaneal graft was noted to be safe (no complications from graft site). However, there was no difference in union rate when comparing hallux MTP arthrodesis with and without calcaneus autograft.

The Hallux Metatarsophalangeal Capsule: An Anatomic Study With Respect to Percutaneous Hallux Valgus Correction.

Minimally invasive surgery for the treatment of hallux valgus deformities has become increasingly popular. Knowledge of the location of the hallux metatarsophalangeal (MTP) proximal capsular origin on the metatarsal neck is essential for surgeons in planning and executing extracapsular corrective osteotomies. A cadaveric study was undertaken to further study this anatomic relationship. Ten nonpaired fresh-frozen frozen cadaveric specimens were used for this study. Careful dissection was performed, and the capsular origin of the hallux MTP joint was measured from the central portion of the metatarsal head in the medial, lateral, dorsal, plantarmedial, and plantarlateral dimensions. The ten specimens had a mean age of 77 years, with 5 female and 5 male. The mean distances from the central hallux metatarsal head to the MTP capsular origin were 15.2 mm dorsally, 8.4 mm medially, 9.6 mm laterally, 19.3 mm plantarmedially, and 21.0 mm plantarlaterally. The MTP capsular origin at the hallux metatarsal varies at different anatomic positions. Knowledge of this capsular anatomy is critical for orthopaedic surgeons when planning and performing minimally invasive distal metatarsal osteotomies for the correction of hallux valgus. Cadaveric Study.

Arthrodesis of Ipsilateral Hallux Metatarsophalangeal and Interphalangeal Joints.

Background:Arthrodesis of the ipsilateral hallux metatarsophalangeal (MTP) and interphalangeal (IP) joints may be required for severe arthritis or deformity at both joints. The purpose of this study was to review outcomes of ipsilateral first MTP and IP joint arthrodesis.Methods:Twenty feet were identified, for which the diagnosis was rheumatoid arthritis in 14, failed hallux valgus surgery in 5, and hallux rigidus in 1. The IP arthrodesis was performed first in 6 feet; MTP first in 8 feet; and both joints simultaneously in 6 feet. Median follow-up was 28 months (range 12-94). Medical records and radiographs were reviewed. American Orthopaedic Foot & Ankle Society (AOFAS) score and patient satisfaction were determined.Results:Although all of the MTP arthrodeses healed, 8 of 20 feet (40%) failed to heal at the IP arthrodesis. The rate of IP nonunion was 17% (1/6) with IP arthrodesis first, 50% (4/8) with MTP arthrodesis first, and 50% (3/6) with simultaneous arthrodesis. Four of 8 IP nonunions were symptomatic. Subsequent surgery was required in 11 feet (55%), including repair of IP nonunion in 3 feet, hardware removal in 4, revision MTP malunion in 2, wound debridement in 1, and soft tissue reconstruction in 1. Median hallux AOFAS score for the cohort increased from 25 to 68. Eighteen feet resulted in patients who were very satisfied or satisfied with minor reservations. Neither AOFAS score nor satisfaction trended toward association with IP union.Conclusion:Ipsilateral arthrodesis of the hallux MTP and IP joints was challenging because of high rates of reoperation and IP nonunion, the latter of which was likely related to increased mechanical stress on the IP joint with immobilization of the MTP joint. Despite the high IP nonunion rate, IP nonunion did not predict patient-reported outcome. Fibrous ankylosis was an acceptable clinical outcome in many cases.Level of Evidence:Level IV, case series.

Adverse Events Involving Hallux Metatarsophalangeal Joint Implants: Comprehensive Analysis of US Food and Drug Administration Data from 2010 to 2018

Category:Midfoot/Forefoot; OtherIntroduction/Purpose:The prevalence of osteoarthritis of the hallux metatarsophalangeal joint (MTPJ) is estimated to affect 1 in 40 people over the age of 50. Surgical treatment options for MTPJ arthritis include joint preservation, joint resurfacing, and salvage arthrodesis. Arthroplasty of the great toe MTPJ has evolved over the past several decades. The aims of this study were to examine the MAUDE database to determine reported adverse events for hallux MTPJ arthroplasty.Methods:The US Food and Drug Administration’s (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was reviewed from 2010-2018 to determine reported adverse events for approved implants. We recorded and categorized the type of adverse event and excluded duplicate reports and those extracted from already published literature.Results:Among 64 unique hallux MTPJ implant adverse events, the most common modes of failure were component loosening (34%), component fracture (9.4%), inflammation (9.4%), infection (14.1%), and allergic reaction (7.8%). In regards to implant type, synthetic implants (Cartiva) had the highest percentage of adverse events (23.4%), followed by Arthrosurface ToeMotion (20.3%), Ascension MGT (12.5%), Arthrosurface HemiCAP (10.9%), Futura primus (9.4%), and Osteomed Reflexion (6.3%). The number of adverse events reported increased substantially after 2016.Conclusion:Our study of the MAUDE database demonstrated that component loosening and infection are the most common modes of adverse events for hallux MTPJ implants. Cartiva accounted for one-fourth of the implant-related adverse events during our study period, followed by ToeMotion and Ascension MGT implants. Given that the adverse events for hallux MTPJ implants are underreported, improved reporting mechanisms should be utilized to improve our understanding on long-term effects of various hallux MTPJ implants.

Results of Hallux Metatarsophalangeal Joint Arthrodesis with and without Calcaneus Autograft

Category:Bunion; OtherIntroduction/Purpose:Hallux rigidus is the most common degenerative arthropathy of the foot. Primary hallux metatarsophalangeal (MTP) joint arthrodesis is the most common surgical treatment for end-stage hallux rigidus and can also be utilized for correction of hallux valgus. Though satisfaction rates following hallux MTP joint arthrodesis are very favorable, nonunion rates have been reported as high as 12%. Several studies have investigated how pathology, fixation techniques and joint preparation affect hallux MTP arthrodesis union rates. Many surgeons use orthobiologics and/or autograft to augment arthrodeses about the foot and ankle in an effort to increase union rates. The purpose of this study is to retrospectively compare union rates of hallux MTP joint arthrodesis with and without calcaneus autograft.Methods:A query of our institution’s administrative database was performed to identify patients who underwent a primary hallux MTP joint arthrodesis between February 2016 and February 2017. We compared patients who underwent arthrodesis with and without calcaneus autograft. Surgeon preference dictated use of autograft, as some in our group routinely use graft while others do not. Patients 18 years and older who underwent a primary hallux MTP arthrodesis were included. Patients were excluded if they had radiographic evidence of significant bone loss or if allograft or biologic therapies were used. Patient charts and final radiographs were reviewed. The primary outcome was successful union of the hallux MTP joint arthrodesis. Secondary outcomes included preoperative diagnosis, type of surgical fixation and surgical complications. Data was compared using a student T-test.Results:There were 130 feet included in the final analysis, and 55 underwent hallux MTP arthrodesis with calcaneus autograft. Mean follow-up time was 14.8 weeks. Among all patients, 90.8% had a successful union. There was no difference in union rates between those who underwent arthrodesis with calcaneus autograft (90.9%) compared to without autograft (90.7%; p = 0.96). Hallux valgus was the preoperative diagnosis in 46.1% of cases followed by hallux rigidus (34.6%). The most common fixation method was a lag screw with a dorsal plate (83.8%). Overall, 19 patients (14.6%) had a complication requiring a reoperation with painful hardware (10 patients) being most common. In the autograft group, there were no complications related to the calcaneus autograft donor site.Conclusion:As orthobiologics and local bone autograft gain popularity in foot and ankle surgery, it is important to report clinical outcomes and establish evidence-based guidelines for use. In this relatively large retrospective comparison, the use of calcaneal graft was noted to be safe (no complications from graft site). However, there was no difference in union rate when comparing hallux MTP arthrodesis with and without calcaneus autograft.

The Effect of Knee Flexion on Active and Passive Popliteal Venous Flow When Using Crutches or Knee Scooter While Immobilized

Category:Trauma; OtherIntroduction/Purpose:Knee flexion has been demonstrated to impede popliteal venous return with large effect size among patients lying supine for surgery. Passive popliteal flow impedance has also been suggested to occur with knee scooter usage due to knee flexion. This study compared the effect of knee flexion angles on popliteal venous return between upright, crutch and knee scooter positioning when immobilized. Further, the countervailing effect of standardized hallux musculovenous pump activation was observed.Methods:This was an IRB approved study of young, healthy volunteers. Popliteal venous diameter and flow metrics were assessed with venous ultrasonography and compared between straight leg, crutch, and knee scooter positioning while wearing a walking boot and nonweightbearing. Flow was assessed with muscles at rest and with hallux musculovenous pump activation via active oscillation between hallux metatarsophalangeal joint extension and flexion at one motion per second (0.5 Hz) as paced by a metronome. Observer consistency was assessed. Paired-sample Student’s t-test and the Wilcoxon signed rank tests were used to assess within-subject differences for diameter and venous flow parameters, respectively. Knee flexion and musculovenous pump activation effects sizes were calculated. A priori sample size indicated 24 subjects were needed to achieve 80% power to detect a significant ( p < 0.006 ) difference in medial flow for any of 8 comparisons, assuming large effect sizes.Results:16 of 24 (67%) subjects were female. Twelve limbs (50%) were right sided. The mean age was 21.9 years (SD 3.0 years) and the mean body mass index was 21.9 (SD 1.9). Observer consistencies were excellent (0.93 to 0.99). No significant differences in mean vessel diameter, time-averaged mean velocity, and total volume flow occurred. Corresponding knee flexion effect sizes were small (range -0.04 to -0.26). A significant decrease (-24%) in active median time-averaged peak velocity (TAPV) occurred between upright and crutch position (20.89 cm/s vs. 15.92 cm/s, p < 0.001) with a medium effect size (-0.51). Hallux musculovenous pump increased all flow parameters (all p< 0.001) and effect sizes were comparatively larger (>0.6) across all knee flexion positions.Conclusion:Compared to values reported for supine individuals, upright passive popliteal venous return was observed to be markedly diminished at all knee flexion angles. Knee flexion had minimal effect on diameter, a small effect in further diminishing TAMV and TVF and a medium effect on diminishing TAPV. Hallux musculovenous pump activiation had a large effect on increasing flow at all knee flexion angles. Patients may well be counseled to use toe motion to counter the negative effects of gravity, and to a lesser extent knee flexion, when using crutches and knee scooters while their ankle is immobilized.

Analysis of the effects of arthrodesis of the hallux metatarsophalangeal joint on gait cycle: results of a GAITRite® treadmill test.

Approximately 80% of patients are satisfied with the outcome of arthrodesis of the hallux metatarsophalangeal (MTP) joint. The hypothesis of this study was that MTP arthrodesis does not influence the walking cycle. The aim of this study was to evaluate the effect of MTP arthrodesis on gait cycle and to measure the functional outcome of MTP arthrodesis after a minimum of two year follow-up. This was an observational prospective cohort study performed at a single centre that included 26 patients (32ft) who underwent unilateral or bilateral MTP arthrodesis during the period 2004-2014. An X-ray assessment based on the American Orthopaedic Foot and Ankle Society score was performed pre-operatively and at the last follow-up (average follow-up duration 8.3years). The walking cycle was analysed at the final follow-up using a GAITRite® treadmill test. Twenty unilateral and six bilateral MTP arthrodeses were included in this study. The average age of the patients was 70years. No significant difference was found in the walking cycle between the operated and non-operated sides for unilaterally MTP arthrodesis. However, we observed a non-significant increase in the percentage of contact time after MTP arthrodesis (65% on the operated side vs. 63% on the non-operated side). We also observed a significant decrease in the average walking rate, and a decrease in walking speed, in cases of bilateral MTP arthrodesis compared with normal walking cycle data from a laboratory study. MTP joint arthrodesis does not appear to have any effect on the walking cycle, but reduced patient pain and increased the walking distance. The patients reported satisfaction with the surgical outcomes and would recommend it to a relative with the same pathology.

Nonoperative Management of Hallux Limitus Using a Novel Forefoot Orthosis

Hallux limitus is among the most common arthritides of the foot and ankle, with increasing incidence in the aging population. Despite its prevalence and disease burden, treatment of the condition remains poorly understood. Many patients will fail initial conservative management, whereas controversy exists surrounding indications for and outcomes of surgery. The present study sought to examine the impact of a novel forefoot orthosis on foot function, pain, and plantar pressure distributions in patients with symptomatic hallux limitus. Nineteen adult patients completed a questionnaire consisting of the 23-item Foot Function Index and a 10-point visual analogue scale measuring pain. Standing pedobarographic maps were generated using a foot scanning system. Participants were instructed to wear the orthosis in athletic shoes for 4 weeks. Eighteen participants (94.7%) experienced improvements in foot function and pain, with 12 (63.2%) reporting complete resolution of pain at the end of the 4-week trial. Mean Foot Function Index scores improved significantly from 43.0% at baseline to 11.0% with the orthosis (p < .001). Similarly, mean visual analogue scale pain scores decreased significantly from 4.87 to 1.18 (p < .001). Pedobarographic analysis while wearing the orthosis demonstrated increased ability of participants to bear weight on the arthritic hallux metatarsophalangeal joint and restoration of physiologic stance. Compared to existing products, the device was well tolerated and did not require footwear modifications or impede normal gait. Overall, the orthosis offers an appealing solution to patients dissatisfied with existing treatment options as well as those who may be averse to or ineligible for surgery.

Adverse events involving hallux metatarsophalangeal joint implants: Analysis of the United States Food and Drug Administration data from 2010 to 2018

BackgroundThe prevalence of osteoarthritis of the hallux metatarsophalangeal joint (MTPJ) is 1 in 40 people over the age of 50. Surgical treatment options for MTPJ arthritis include joint preservation, joint resurfacing, and arthrodesis. Hallux MTPJ implants have evolved over the past several decades, but are associated with various complications. The aim of this study was to examine the MAUDE database to determine reported adverse events for hallux MTPJ implants. Materials and methodsThe US Food and Drug Administration’s (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was reviewed from 2010 to 2018 to review voluntary reported adverse event reports for approved implants within the United States. We recorded the type of adverse event and excluded duplicate reports and those extracted from already published literature. ResultsAmong 64 reported hallux MTPJ implant adverse events, the most common modes of adverse events were component loosening (34%), infection (14.1%), component fracture (9.4%), inflammation (9.4%), and allergic reaction (7.8%). Regarding implant type, Cartiva SCI had the highest percentage of adverse events (23.4%), followed by Arthrosurface ToeMotion (20.3%), Ascension MGT (12.5%), Arthrosurface HemiCAP® (10.9%), Futura primus (9.4%), and Osteomed Reflexion (6.3%). There was an increase in reported adverse events after 2016. The MAUDE database does not report the total incidence of implant insertion. ConclusionOur study of the MAUDE database demonstrated that component loosening and infection are the most common modes of adverse events for hallux MTPJ implants. Cartiva accounted for one-fourth of the implant-related adverse events during our study period, followed by ToeMotion, and Ascension MGT implants. Continued reporting of adverse events will improve our understanding on short and long-term complications of various hallux MTPJ implants. Level of evidenceLevel IV; Case Series from Large Database Analysis; Treatment Study.

Outcomes of bilateral simultaneous hallux MTPJ fusion

BackgroundArthrodesis of the first metatarsophalangeal joint (MTPJ) is a frequently performed surgical procedure. Many patients have bilateral hallux MTPJ pathology requiring bilateral arthrodesis. There are concerns that bilateral simultaneous hallux surgery, under one anaesthetic, results in the patient being severely incapacitated in the early post-operative period. We hypothesize that bilateral simultaneous hallux MTPJ fusions does not compromise outcomes or the patients’ post-operative comfort and rehabilitation and is cost and time effective. MethodsIn this retrospective study, 16 patients who underwent bilateral simultaneous first MTPJ arthrodesis were compared to 16 patients who had unilateral MTPJ arthrodesis with regards to outcome, tolerance, cost and time effectiveness. Outcome measures were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux score and the Self-Reported Foot and Ankle questionnaire (SEFAS). ResultsThere was a significant improvement in the AOFAS scores post surgery in the bilateral group and according to the SEFAS grading, 14 patients (87.5%) had good or excellent outcome scores with 13 (81.25%) of these patients having excellent scores. This was comparable to the outcome scores in the unilateral group. Two patients developed non-unions bilaterally compared to one in the unilateral group. There is also a notable general cost saving and less time off work when bilateral fusions are done at the same setting. ConclusionBilateral simultaneous hallux MTPJ arthrodesis is an effective, convenient and cost effective option for patients requiring MTPJ fusions for bilateral hallux pathology. Level of evidenceLevel 4