Metatarsophalangeal Joint Fusion Research Articles

Arthroscopically Assisted Reconstruction of Lateral Metatarsosesamoid Suspensory and Lateral Metatarsophalangeal Collateral Ligaments in the Management of Iatrogenic Hallux Varus Deformity

The medial and lateral metatarsosesamoid suspensory ligaments together with the sesamoid apparatus are the main contributors to the rotational stability of the first metatarsophalangeal joint (MTPJ). Rotational instability of first MTPJ is a major factor in the development of hallux valgus and varus deformities. As the great toe starts to rotate, the muscle pulls across the first MTPJ, causing it to become imbalanced and lead to progressive medial or lateral deviation of the great toe. The gold standard and most reliable option for hallux varus deformity is first MTPJ fusion. However, it results in stiffness and loss of joint function and is reserved for arthritic and stiff first MTPJ. Flexible iatrogenic hallux varus is corrected by optimally anatomic ligament reconstruction. The purpose of this Technical Note is to describe the details of arthroscopically assisted reconstruction of lateral metatarsosesamoid suspensory and lateral metatarsophalangeal collateral ligaments in management of iatrogenic hallux varus deformity. We reconstruct the lateral metatarsosesamoid suspensory ligament to restore the rotational stability of the first MTPJ in hallux varus deformity. This together with reconstruction of the lateral metatarsophalangeal collateral ligament anatomically corrects both the medial deviation and rotation deformity of the great toe.

First metatarsophalangeal joint implant arthroplasty reduces the first intermetatarsal angle similar to first metatarsophalangeal joint arthrodesis in short-term follow up

In the presence of hallux limitus/rigidus and an elevated 1–2 intermetatarsal angle (IMA), first metatarsophalangeal joint (MTPJ) arthrodesis (FUSION) is often chosen to simultaneously correct both issues; however, this procedure obliterates the first MTPJ function and can often shorten the first ray. Alternatively, the first MTPJ implant arthroplasty (IMPLANT) has the ability to preserve some motion at the joint and does not result in shortening. Despite its surgical utility in clinical restoration, there is a paucity of understanding surrounding the first MTPJ arthroplasty's effect on the IMA. To this end, we performed a retrospective cohort study comparing the changes in IMA in patients that received either a first MTPJ IMPLANT or first MTPJ FUSION at our institution between January 1, 2017 through December 31, 2021. Weightbearing AP films preoperatively and during the immediate (i.e., 4–8 weeks) postoperative period were used to evaluate changes in IMA. We identified 49 patients (20 IMPLANT, 29 FUSION). The IMA was reduced in patients that received FUSION (P < 0.0001) or IMPLANT (P < 0.0001). Surprisingly, we found that the amount of IMA reduction was similar in both groups. Therefore, we conclude that IMPLANT procedures reduce the IMA comparable to FUSION procedures during the immediate postoperative period. Moreover, the results of our work challenges the previous notions of adductor hallucis tendon involvement in IMA reduction in FUSION procedures.Level of Clinical Evidence: IV, retrospective case series

Minimally Invasive Fusion of the First Metatarsophalangeal Joint: A Technical Report

Hallux rigidus, a common arthritic condition of the forefoot, affects a significant portion of the population, with ~8% of the population developing it at some point in their lives. Failure of first-line nonoperative treatment options may necessitate surgical treatment in symptomatic patients. Traditional surgical approaches include cheilectomy for milder cases and open arthrodesis for severe cases. The minimally invasive surgery approach to first metatarsophalangeal joint fusion is a novel technique that utilizes small incisions and arthroscopy for joint fusion. Fusion rates of 93% to 97% and low complication rates were reported by several studies on this technique. The technique involves percutaneous portal development, joint preparation and debridement, joint reduction, and fixation using k-wires and compression screws. The proper positioning of the toe is crucial to ensure optimal functional outcomes. Indications for this technique include advanced arthritis, significant scar tissue, and patient concern for cosmetic outcomes. Contraindications include poor bone quality, revision fusion, significant bone loss, active infection, or vascular compromise. Preoperative planning involves a comprehensive physical examination and imaging to assess the extent of the arthritis and any associated deformities. Complications of the procedure may include nonunion, malunion, iatrogenic thermal burns, and asymmetrical joint preparation. Postoperative management includes weight-bearing restrictions, regular follow-up visits, and gradual progression to normal activities. Preliminary results demonstrate promising outcomes for minimally invasive surgery first metatarsophalangeal fusions.

Clinical comparative study on resection and non-resection of the fifth metatarsal to rheumatoid forefoot deformity

To explore clinical effect of the fifth metatarsal head excision and non-excision in rheumatoid arthritis (RA) forefoot deformity reconstruction. Retrospective analysis was performed on 50 patients (76 feet) with moderate to severe forefoot deformity caused by RA treated from May 2015 to January 2019. According to degeneration of the fifth metatarsophalangeal joint,the fifth metatarsal head was retained or excised by wind-like forefoot reconstruction,and divided into the fifth metatarsal head preservation group (preservation group) and the fifth metatarsal head resection group (resection group). Twenty-four female patients in preservation group,aged from 47 to 81 years old with an average of (60.37±8.60) years old;the course of disease ranged from 13 to 22 years with an average of (19.00±3.06) years;body mass index (BMI) ranged from 21 to 28 kg·m-2 with an average of (23.53±2.47) kg·m-2;six patients (6 feet) with moderate hallux valgus deformity and 18 patients (30 feet) with severe hallux valgus deformity;treated with the first metatarsophalangeal joint fusion combined with the second th the fourth metatarsophalangeal joint arthroplasty and the fifth metatarsophalangeal joint cleanup. Twenty-six female patients in resection group were female,aged from 30 to 80 years old with an average of (58.53±13.70) years old;the course of disease ranged from 8 to 25 years with an average of (17.94±3.92) years;BMI raged from 20 to 28 kg·m-2 with an average of (24.60±2.03) kg·m-2;4 patients (4 feet) with moderate bunion valgus deformity and 22 patients (36 feet) with severe bunion valgus deformity;treated by the first metatarsophalangeal joint fusion combined with the second th the fifth metatarsophalangeal joint resection of the metatarsophalangeal head. Operation time and postoperative complications between two groups were observed,hallux valgus angle (HVA),intermetatarsal angles between the first and the second metatarsals (IMAFS),intermetatarsal angles between the first and fifth metatarsals (IMAFF),Japanese Society for Surgery of Foot (JSSF) score before surgery and at the latest follow-up were compared. Fifty patients were followed-up from 14 to 46(25.30±8.83) months in resection group and 12 to 48 with an average of (24.30±11.12) months in preservation group,while no significant difference between two groups (P>0.05). There were no significant difference in operation time and postoperative complications between two groups (P>0.05). JSSF scores,HVA,IMAFS and IMAFF in fesection group were improved from (45.09±3.35) points,(38.90±13.67) °,(12.88±1.72) °,(32.50±2.99) ° before operation to (81.60±3.27) points,(15.40±0.90),(9.06±2.27) °,(22.20±1.98) ° at the latest follow-up (P<0.05);preservation group were improved from (47.09±3.96) points,(43.30±12.65) °,(13.99±3.13) °,(33.20±6.14) ° to (83.10±3.66) points,(15.20±1.54) °,(8.99±1.02) °,(24.70±1.88) °,respectively. There were no significant difference in JSSF score,HVA,IMAFS and IMAFF between two groups before operation and the latest follow-up (P>0.05). At the latest follow-up,there were statistically significant differences in pain and deformity in JSSF scores between two groups (P<0.05). Both rheumatoid anterior foot reconstruction and anterior foot reconstruction fifth metatarsophalangeal joint debridement showed significant improvement in clinical efficacy and imaging results. Compared with rheumatoid prefoot reconstruction,the fifth metatarsophalangeal joint reconstruction for the treatment of moderate and severe deformity of rheumatoid prefoot showed better improvement in pain,but worse improvement in deformity. For the moderate to severe deformity of the forefoot caused by rheumatoid disease,patients with mild to moderate degenerative deformity of the articular surface of the fifth metatarsal phalanges may be considered for use.

Ten-Year Minimum Follow-up Study of First Metatarsophalangeal Joint Fusion in Young vs Old Patients.

Painful degenerative joint disease (DJD) of the first metatarsophalangeal joint (MTP I), or hallux rigidus, mainly occurs in later stages of life. For end-stage hallux rigidus, MTP I arthrodesis is considered the gold standard. As young and active patients are affected considerably less frequently, it currently remains unclear, whether they benefit to the same extent. We hypothesized that MTP I arthrodesis in younger patients would lead to an inferior outcome with decreased rates of overall with lower rates of patient postoperative pain and function compared to an older cohort. All patients aged <50 years who underwent MTP I arthrodesis at our institution between 1995 and 2012 were included in this study. This group was then matched and compared with a group of patients aged >60 years. Minimum follow-up was 10 years. Outcome measures were Tegner activity score (TAS), a "Virtual Tegner activity score" (VTAS), the visual analog scale (VAS), and the Foot Function index (FFI). Sixty-one MTP I fusions (n = 28 young, n = 33 old) in 46 patients were included in our study at an average of 14 years after surgery. Younger patients experienced significantly more pain relief as reflected by changes in VAS and FFI Pain subscale scores. No difference in functional outcomes was found with change in the FFI function subscale or in the ability to have desired functional outcomes using the ratio of TAS to VTAS. Revision rate did not differ between the two groups apart from hardware removal, which was significantly more likely in the younger group. In patients below the age of 50 years with end-stage DJD of the first metatarsal joint, MTP I arthrodesis not only yielded highly satisfactory postoperative results at least equal outcome compared to an older cohort of patients aged >60 years at an average 14 years' follow-up. Based on these findings, we consider first metatarsal joint fusion even for young patients is a valid option to treat end-stage hallux rigidus. Level III, a case-control study.

Quality and Readability Analysis of Online Information on First Metatarsophalangeal Joint Fusion

Patients frequently turn to the internet to learn about their orthopedic procedures. This study evaluates the readability and quality of first metatarsophalangeal (MTP) joint fusion information found online. We evaluated websites based on classification, search term, readability, HON code, DISCERN score, Journal of the American Medical Association benchmark criteria, and an author-created MTP fusion index (MFI). The average readability of websites was 8.48 ± 1.99, above the recommended sixth- or eighth-grade reading level. Almost half of all websites (48.98%) provided “poor” information. Keywords had no significant impact on the readability or quality of information. Academic/governmental websites had the highest quality of information, with the highest DISCERN and second highest MFI. Most websites (52.04%) were commercial and were the easiest to read, but had the second lowest DISCERN and MFI scores. Our results suggest that inappropriate information on the MTP joint fusion procedure is abundant online. Academic/governmental websites have the highest quality of information, but may be difficult for patients to comprehend. Many websites do have readable and relevant information. We recommend that physicians create a list of websites with accurate, relevant information for patients to circumvent the misinformation they may find while navigating and reading online.

Salvage First Metatarsophalangeal Joint Fusion with a Three-Dimensional-Printed Implant for Osseous Defects: A Case Series.

In this study, we aimed to describe a case series of revision first metatarsophalangeal joint fusion with a three-dimensional (3-D)-printed implant for osseous deficits of the first metatarsophalangeal joint. Bone defects of the first ray are a common problem in foot and ankle surgery. Etiologies include nonunion, avascular necrosis, osteomyelitis, failed first metatarsophalangeal joint implant arthroplasty, and failed hemijoint resection arthroplasty. Treatment options include acute shortening, block allograft, block autograft, distraction osteogenesis, vascularized free fibula, Masquelet technique, and partial first-ray amputation. Three-dimensional printing provides an opportunity to improve outcomes, with less donor site morbidity and less extensive recovery time than an external fixation device. It has been used in other facets of foot and ankle surgery with encouraging results. Three patients (four feet) underwent revision first metatarsophalangeal joint fusion with a 3-D-printed implant. Reasons for revision included avascular necrosis after distal metatarsal osteotomy in one patient and bone deficit after failed first metatarsophalangeal joint implant in two patients. All patients had a minimum follow up of 12 months. Two patients had painful hardware and had to undergo revision due to implant design. At most recent follow up all patients were pain free with improved pain scores. In revisional first metatarsophalangeal joint surgery with osseous deficits, the goal is to restore length and alignment, which improves function of the medial column. Custom 3-D-printed implants for first metatarsophalangeal joint revision can provide an opportunity for improved outcomes and healing.

Which parameters predict correction of the intermetatarsal angle after first metatarsophalangeal fusion?

Fusion of the first metatarsophalangeal joint (MTPJ) is a commonly performed surgical procedure. Although the effect of first MTPJ fusion on reduction of Intermetatarsal angle (IMA) is well described, contributing factors remain unclear. The aim of this study was to identity predictive parameters for IMA reduction. Fifty-one patients (68 feet) who underwent a first MTPJ fusion and had an IMA greater than fourteen degrees were assessed retrospectively. The average age was 68 (31.4-79.3) years. Sixteen demographic and radiographic variables were evaluated using a multivariate regression analysis for association with change in IMA after surgery. The mean preoperative IMA was 16.11 (range, 14.0-22.5) degrees with a mean reduction of 4.95 (range, 0-17) degrees after surgery. Multivariate regression analysis revealed three significant independent predictors of the change in IMA. Increased preoperative IMA (β = .663, CI = .419, .908, P &lt;.001), increased preoperative translation at base of MT1 (β = .490, CI = 0.005, .974, P = 0.039), and less postoperative translation in the fusion (β= -0.693, CI= -1.054, -.331, P= 0.002) significantly increased the amount of IMA reduction. Pre-operative IMA and translation at the base of the first metatarsal were positive predictors for correction of IMA after first MTPJ fusion. Translation at the level of the MTP I fusion was a negative predictor for the amount of IMA correction. Based on these findings, we recommend minimizing the lateral translation of the proximal phalanx relative to the metatarsal head to optimize IMA correction after MTPJ fusion.

Foot &amp; Ankle

The August 2023 Foot &amp; Ankle Roundup360 looks at: Achilles tendon rupture: surgery or conservative treatment for the high-demand patient?; First ray amputation in diabetic patients; Survival of ankle arthroplasty in the UK; First metatarsophalangeal joint fusion and flat foot correction; Intra-articular corticosteroid injections with or without hyaluronic acid in the management of subtalar osteoarthritis; Factors associated with nonunion of post-traumatic subtalar arthrodesis; The Mayo Prosthetic Joint Infection Risk Score for total ankle arthroplasty.

Republication of "First Metatarsophalangeal Joint Arthrodesis: Functional Outcomes Using 2 Different Fixation Techniques. Is More Expensive Better?"

First metatarsophalangeal (MTP) joint arthrodesis can be fixed using either a dorsal plate or crossed screws. However, there is considerable difference in the cost of these implants, and it is not known if there is sufficient difference in outcome that might justify this cost difference. Our aim was to compare the functional results and patient satisfaction rates after first MTP joint arthrodesis in a group of patients using the same surgical technique except for the fixation devices. A prospective cohort of 27 patients who underwent first MTP joint fusion by the same surgeon using 2 crossed screws or a single screw with a dorsal plate was recruited over a 3-year period. Demographic information, patient satisfaction rates, complications, and union rates were evaluated. American Orthopaedic Foot & Ankle Society (AOFAS) and visual analog scale (VAS) scoring systems were used pre- and postoperatively to compare the functional outcomes. Thirty consecutive procedures (screws, n = 15; plate, n = 15) were performed. Age (55.8 ± 11.1 vs 63.3 ± 12.4 years for screws and plate respectively; P = .091) and female gender percentages (80% and 73%, P = .666) were similar between groups. The overall union rate was 93% with no differences between groups. AOFAS and VAS scores improved significantly postoperatively for each technique, and no differences were found between the two in the improvement in AOFAS (42.4 ± 8.0 vs 44.3 ± 8.2, screws and plate respectively; P = .520) and VAS scores (66.0 ± 5.4 vs 69.0 ± 6.9;P = .195). The implant cost for screws was $40 and for dorsal plate, $328. First MTP joint fusion using either screws or plate fixation results in an improvement in AOFAS and VAS scores. Functional improvement and patient satisfaction did not differ between the 2 techniques, despite a considerable difference in cost between the two methods of fixation. Level III, prospective comparative study.

Medial Femoral Condyle Free Flap for Persistent Osseous Nonunion of the First Metatarsophalangeal Joint: A Preliminary Report of a New Surgical Indication for the Medial Femoral Condyle Free Flap.

Recalcitrant or persistent nonunions of the metatarsophalangeal (MTP) joint occur following failed MTP surgery for MTP fusion, failed MTP prosthesis, for hallux rigidus or due to infection and erosion. A deficient soft tissue envelope and compromised vascular supply of tissues in this region compound further attempts to salvage the great toe and preserve function. The medial femoral condyle (MFC) free flap provides vascularized corticocancellous bone and periosteum and has been successfully used for a variety of complex hindfoot and ankle pathologies. We present an additional indication with a small cohort study demonstrating its use in persistent nonunions of the first MTP joint. A retrospective review was completed of all MFC flaps used for revision of failed first MTP joint fusion from January 2019 to November 2022. Demographic information, comorbidities, as well as clinical and radiologic follow-up was obtained from the patient charts. Three patients were included with MTP nonunion and an average of 7.5 (range, 5-11) failed prior surgeries. Mean age at index surgery was 50 (range, 46-57) years. An osseous union was achieved in all patients after 82 (range, 75-88) days. Hardware removal was possible after 81 (range, 55-98) days. Mean follow-up was 17 (range, 5-31) months. We note a 100% flap success rate without returns to the operating room. The lengths of the bone flaps were 2 to 4 cm, the volumes were 8 to 12 cm3. Fixation was performed with 1 intramedullary K-wire. The recipient vessel in all patients was the dorsalis pedis artery or a tributary thereof. All arterial anastomoses were performed under the operating microscope. The MFC free flap is a reasonable option for salvage of complex recalcitrant or persistent nonunions of the first MTP joint. More prospective long-term studies with functional outcomes are necessary to confirm these findings. Level IV, retrospective case series.

Cross Screw Fixation for First Metatarsophalangeal Joint Arthrodesis: A Technical Guide

Background: First metatarsophalangeal joint (MPJ) arthritis, treatments, and fixation methods have been well described in the literature. Indications for the fusion of the first MPJ include hallux rigidus, severe hallux valgus, failed bunionectomy, failed joint arthroplasty, rheumatoid arthritis, and neuromuscular disorders. Crossing screw fixation has been found to be a stable construct that provides reliable outcomes with high patient satisfaction, specifically for those patients with hallux rigidus and minimal hallux valgus deformity. Crossing screw fixation has also been found to be reliable and more cost-effective than other fixation techniques. However, this method may pose some challenges to novice surgeons and those at academic training institutions. Objective: The objective of this technical guide is to propose a reproducible technique to first MPJ fusion with 2 crossing, cannulated screws. This technique is designed to increase the reliability and speed of the crossing screw technique. Conclusion: Overall, using this technique with cross screw fixation, we have found decreased operative times, better reproducibility of results, efficiency with use in training with resident learners, and reduced hardware costs. Levels of Evidence: Level V, expert opinion

Association of Fusion of the First Metatarsophalangeal Joint and Pes Planus Deformity Correction.

There has been scant investigation on the relationship between the distal aspect of the medial longitudinal arch and pes planus deformity. The aim of this study was to investigate whether the reduction and stabilization of the distal aspect of the medial longitudinal arch through fusion of the first metatarsophalangeal joint (MTPJ) can subsequently improve pes planus deformity parameters. This could be useful in both further understanding the role of the distal medial longitudinal arch in patients with pes planus and planning operative intervention in patients with multifactorial medial longitudinal arch problems. A retrospective cohort study was undertaken between January 2011 and October 2021, including patients undergoing first MTPJ fusion with a pes planus deformity on weightbearing preoperative radiographs. These were compared to postoperative images, and multiple pes planus measurements were taken for comparison. A total of 511 operations were identified for further analysis, with 48 feet meeting the inclusion criteria. There was a statistically significant reduction identified between the pre- and postoperative measurements of Meary angle (3.75 degrees, 95% CI 2.9-6.47 degrees) and talonavicular coverage angle (1.48 degrees, 95% CI 1.09-3.44 degrees). There was a statistically significant increase between the pre- and postoperative measurements of calcaneal pitch angle (2.32 degrees, 95% CI 0.24-4.41 degrees) and medial cuneiform height (1.25 mm, 95% CI 0.6-1.92 mm). Reduced intermetatarsal angle was significantly associated with an increase in first MTPJ angle postfusion. Many of the measurements made were found "almost perfectly" reproducible by the Landis and Koch description. Our results demonstrate that fusion of the first MTPJ is associated with improvement of medial longitudinal arch parameters of a pes planus deformity but not to levels considered to be clinically normal. Therefore, the distal aspect of the medial longitudinal arch could, to some degree, be a feature in the pes planus deformity etiology. Level III, retrospective case control study.

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.

The first metatarsophalangeal joint fusion combined with lateral toe rotation Weil osteotomy for hallux valgus with severe metatarsal adduction

To explore clinical effect of the first metatarsophalangeal joint fusion combined with lateral toe rotation Weil osteotomy in treating hallux valgus with severe metatarsal adduction. From March 2017 to August 2021, 37 patients ( 69 feet ) with severe plantar adductor hallux valgus were treated with the first metatarsophalangeal joint fusion combined with rotational Weil osteotomy were retrospectively analyzed, including 8 males(11 feet) and 29 females (58 feet), aged from 67 to 83 years old with an average of (70.03±2.87) years old;3 cases on the left side, 2 cases on the right side and 32 cases on both sides. Visual analogue scale(VAS) was used to evaluate degree of pain relief before operation, 6 weeks after operation and at the final follow-up. American Orthopaedic Foot and Ankle Surgery (AOFAS) forefoot score was used to evaluate function of the affected foot before operation and final follow-up. Hallux valgus angle(HVA) and intermetatarsal angle(IMA) were measured before operation and at the final follow-up. Thirty-seven patients(69 feet) were followed up from 12 to 48 months with an average of(22.8±0.6) months. Bone healing was achieved at the first metatarsophalangeal joint from 7 to 10 weeks with an average of (8.00±1.21) weeks after operation, without delay and nonunion. HVA was increased from (44.30±2.84)° before operation to (15.20±2.13) °at the final follow-up, and had statistical difference(t=65.781, P<0.05);while no difference in IMA before and after operation(P>0.05). VAS was decreased from (6.73±1.48) points to (2.78±0.71) points at 6 months after operation(t=3.279, P<0.05), and had difference compared with the latest follow-up(1.16±1.12)(t=4.859, P<0.05). AOFAS forefoot score increased from (52.14±5.78) preoperatively to (86.70±4.86) at the fonal follow-up, and 25 feet got excellent results, 40 feet good and 4 feet fair. The first metatarsophalangeal joint fusion combined with lateral toe rotation Weil osteotomy in treating severe plantar adduction hallux valgus could significantly relieve pain and appearance of forefoot, stabilize the first sequence, and significantly improve walking function.

Impact of BMI on Outcomes after First Metatarsophalangeal Joint Arthrodesis

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: First metatarsophalangeal joint (MTPJ) arthrodesis is a commonly performed procedure for patients with various disorders of the first ray including hallux rigidus, severe hallux valgus, failed 1st MTPJ replacement, and failed hallux valgus correction. Outcomes are generally favorable and similar outcomes have been shown in the young and elderly. It is well documented that medical comorbidities have deleterious effects on outcomes in foot and ankle surgery. Obesity - in particular - has been broadly studied among the foot and ankle literature and has been associated with increased complications. Presently, there is a paucity of studies examining obesity's effect on outcomes of 1st MTPJ arthrodesis. This study's purpose was to evaluate outcomes following 1st MTPJ arthrodesis in obese vs non-obese patients. Methods: A retrospective cohort study of 94 patients undergoing first MTPJ fusion over the age of 18 with a diagnosis of hallux valgus or hallux rigidus was performed. Surgical and postoperative outcomes, Visual Analog Pain scale (VAS), and Short Form 36 (SF-36) surveys were examined and stratified into 2 patient groups: BMI &lt; 30 and 3 30, with sub-analyses conducted between Obesity class I (30-34.9) and Obesity class II (35-39.9) patients. Continueous, normally distributed data were compared with independent sample t-tests, while comparisons of categorical data were made using chi-squared tests. Alpha and beta were assumed to be 0.05 and 0.8, respectively. Results: Average overall VAS and SF-36 physical component scores improved significantly at 6 months (P&lt; 0.0001, 0.006) and 1- year postoperative visits (P &lt;0.0001, 0.007) following 1st MTP fusion in the cohort as a whole. No differences in VAS or SF-36 scores were found between the obese (BMI &gt; 30) or non-obese cohorts. Amongst BMI classified subgroups, significantly greater changes in preoperative to 6-month and 1-year postoperative VAS pain were observed in the Obesity class I patients vs. Obsesity class II or greater (P=0.043, 0.022). Conclusion: Our study showed first MTPJ fusion reliably improves pain and physical quality-of-life in arthritic obese and non- obese patients without differences in nonunion, complications, or patient-reported measures. Additionally, we observed that obese patients experienced comparable improvements in VAS pain and SF-36 physical function scores as their non-obese peers. Our findings asset that first MTPJ fusion is an effective procedure for correction of MPTJ pathology in the obese.

Prospective Randomized Study Evaluating the Effect of Postoperative Ketorolac on Bone Healing and Opioid Consumption after First Metatarsophalangeal Joint Fusion

Category: Midfoot/Forefoot Introduction/Purpose: Amid the opioid crisis, the use of non-narcotic pain medication post-operatively has garnered increased interest. Nonsteroidal anti-inflammatory drugs (NSAIDs) have the potential to serve as an adjunct treatment to opioid medications in the post-operative period but have been viewed with hesitancy due to associations with delayed bone healing. This prospective randomized study aimed to evaluate the use of ketorolac on postoperative pain, opioid requirements, patient satisfaction, complication/reoperation rates, and delayed and/or nonunion rates in patients undergoing fusion of their first metatarsophalangeal joint (1st MTPJ) for treatment of end-stage arthritis. We hypothesized that the use of postoperative ketorolac would decrease opioid medication use and improve patient satisfaction with regards to their pain control, while having no effect on clinical or radiographic healing. Methods: Eighty-eight patients undergoing 1st MTPJ fusion were randomized before surgery to treatment with or without ketorolac for 5 days after surgery. A once-daily survey was distributed via email on postoperative days (POD) 1-7. Unblinded participants were asked to report opioid consumption, VAS pain level, satisfaction with pain management using a 6-point Likert scale, perceived frequency of pain using a 5-point Likert scale, pain interference with sleep, and side effects using VAS. Clinical healing was assessed by the treating surgeon based on patient's ability to ambulate comfortably at 12 weeks post-operatively. Radiographic healing at 12-weeks was assessed by two fellowship-trained orthopedic foot and ankle surgeons blinded to the patient's name and cohort assignment. Intention-to-treat analysis was performed. Results: Seventy-two patients completed at least 4 out of the 7 postoperative surveys. Average was 60.7 +- 8.39 years with 58.3% female (42/72), and a mean BMI of 28.6 +- 5.77. Between groups, there were no significant differences in age, BMI, sex, smoking status, inflammatory arthritis, or diabetes (p&gt;0.05). Across all POD, there were no significant differences in VAS-pain scores and satisfaction with pain management. Morphine milligram equivalents (MME) consumed (36.2 +- 24.7 vs. 26.2 +- 24.2, p=0.119) and number of opioid pills taken (5.78 +- 2.86 vs. 3.93 +- 2.06, p=0.055) were slightly, but not significantly, lower among patients who received ketorolac on POD 2. There were no differences in MME consumed on the other postoperative days. Overall, 94.4% (68/72) returned for 12-week radiographic evaluation and there were no differences in radiographic healing between the two groups with a Kappa-Fleiss value of 0.559, indicating moderate agreement between reviewers. Conclusion: The use of postoperative ketorolac led to slightly, but not significantly, less opioid consumption in the acute postoperative period following 1st MTPJ fusion, while not causing a negative effect on radiographic healing of the fusion at 12- weeks postoperatively.

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.

Finite Element Analysis for First Metatarsophalangeal Joint Arthrodesis Demonstrates Reduction in Stress Across Bio-Integrative Fixation Over Traditional Metal Fixation

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: During each step-in gait, the first metatarsophalangeal joint (MTPJ) is stressed by 90% of body weight, while loading the metatarsal head and base with up to 29% (228N/80Kg patient) of body weight (188N) during each foot push-off. To withstand these high mechanical forces, a successful fusion is dependent on joint preparation and rigid fixation. In this study we assessed a novel bio-integrative fiber-reinforced screw and nail construct. This material technology may provide improved mechanical fixation profile through its high flexural strength and flexural modulus that is closely matched to that of cortical bone. Finite Element Analysis (FEA) was performed to evaluate the mechanical strength and stress concentrations acting on the 1st MTPJ fusion following the use of these implants, compared to conventional metal fixation. Methods: CT-based FEA of the 1st MTPJ fusion fixed by two fixation methods was simulated for mechanical strength and stress concentrations acting on the surrounding cortical bone. The 1st MTPJ of an adult male weighing 80kg was segmented from a left foot CT scan (120 KVP, SL 1mm) and was incorporated in a 3-dimensional CAD model. Bio-integrative fiber-reinforced 4.0mm partially threaded headless compression screw, and a 3.0mm fiber-reinforced cannulated nail were inserted in this computational model in crossed fashion (Fig. 1A). The bio-integrative implants are composed of continuous reinforcing mineral fibers (50% w/w), comprised of elements found in native bone and bound together by a degradable polymer [poly (L-lactide-co- D,L-lactide), PLDLA]. Two 4.0mm partially threaded headless titanium screws were inserted in similar trajectories and served as control (Fig. 1B). The FEA algorithm was based on published known forces acting on the first ray during push-off. Post-processing was performed on FEA results. Results: The relative displacement between the Metatarsal and Phalangeal heads upon simulated loading was 1.6mm for metal fixation and 0.2mm for the fiber-reinforced bio-integrative fixation, demonstrating this technology to be mechanically stable at least as conventional metal fixation. In both models, the Von-Mises maximum stresses were found between the implant thread and shank. However, maximum localized stresses in cortical bone regions interacting with the metal implants were substantially higher (up to 8 times) compared to the bio-integrative implant-bone interactions. Moreover, stresses in the implant body were remarkably higher with metal implants compared to bio-integrative fixation (Fig. 1C, D&amp;E). These results indicate that for physiological loading conditions applied on the 1st MTPJ, the use of bio-integrative fixation construct may reduce stress concentrations at the implant-cortical bone interface. Conclusion: FEA results indicate that bio-integrative screw-nail construct provides equivalent mechanical fixation strength to metal fixation, while resulting in lower bone-implant stress concentrations. The closely matched flexural modulus of the bio- integrative material to that of cortical bone, decreases implant-bone resistance level and the probability of bone/implant failure and risk for implant loosening, all common complications in foot and ankle surgery. This study demonstrates a new methodology of CT-FEA for the evaluation of 1st MTPJ fusion arthrodesis and suggests the bio-integrative screw-nail combination as an alternative to traditional metal fixation. This model is currently being investigated in an ongoing clinical series.

How Much Angular Offset is Acceptable to Achieve Minimum Contact for a Successful First Metatarsophalangeal Joint Fusion?

First metatarsophalangeal joint (MTPJ) fusion is a surgery to treat severe joint arthritis and pain following failure of conservative treatment. A first MTPJ fusion can be performed open or via a percutaneous approach with joint fixation achieved using various techniques including dorsal plate and screw fixation. Variability in the angulation of the guide wire used for reaming during joint resurfacing and the plate angulation can compromise the amount of bony contact needed for successful fusion. The objective of the current study was to utilize a 3-dimensional computational, geometric model to quantitatively analyze the effects of guide wire placement and subsequent bone resurfacing on the achievement of bony contact criteria using 3 dorsiflexion plates in joint fixation. A superposed ideal hemisphere model of the joint interface following resurfacing of the articulating surfaces was the basis for computational analysis. A custom-written code quantified angular offset limits for selected conditions. The angular offset from the central long axis of each bone represents initial guide wire placement error, impacting subsequent fixation and union.For 60% bony contact achieved in the joint interface for 0°, 5°, and 10° dorsiflexion plates angular offset limits for both the sagittal and transverse planes were 21.6°, 20.3°, and 19.0°, respectively. These analyses provide surgical guidance by quantifying the influence of dorsiflexion plate angles for ambulation and guide wire placement on the success of a first MTPJ fusion. The computational model presented can be readily adapted for varying joint geometries and may facilitate the development of a surgical guide prototype.