Achieving high union rates after first metatarsophalangeal joint arthrodesis:Radiographic outcomes and technical pitfalls

BACKGROUND Fusion of the first metatarsophalangeal(MTP1)joint is a common surgery performed to correct hallux rigidus,hallux rigidus et valgus and other painful degenerative diseases of the MTP1.AIM To assess outcomes of our surgical technique including non-union rates,accuracy and aims of correction.METHODS Between September 2011 and November 2020 a total 72 of MTP1 fusions were performed using a low profile,pre-contoured dorsal locking plate and a plantar compression screw.Union and revision rates were analyzed with a minimum clinical and radiological follow up of at least 3 mo(range 3-18 mo).The following parameters were evaluated on pre-and postoperative conventional radiographs:Intermetatarsal angle,Hallux-valgus angle,dorsal extension of the proximal phalanx(P1)in relation to the floor and the angle between the Metatarsal 1 and the P1(MT1-P1 angle).Descriptive statistical analysis was performed.Pearson analysis was used to assess for correlations between radiographic parameters and achievement of fusion.RESULTS An overall union rate of 98.6%(71/72)was achieved.Two out of 72 patients did not primarily fuse with one patient suffering from a non-union,whilst the other demonstrating a radiological delayed union without clinical symptoms,with eventually complete fusion after 18 mo.There was no correlation between the measured radiographic parameters and the achievement of fusion.We believe the reason for the non-union was mainly attributed to the patient’s incompliance without wearing the therapeutic shoe leading to a fracture of the P1.Furthermore,we didn`t find any correlation between fusion and the degree of correction.CONCLUSION With our surgical technique,high union rates(98%)can be achieved using a compression screw and a dorsal variable-angle locking plate to treat degenerative diseases of the MTP1.

First Metatarsophalangeal Joint Arthrodesis: Comparison of Mesenchymal Stem Cell Allograft versus Autogenous Bone Graft Fusion Rates

With patients undergoing first time 1st metatarsophalangeal joint arthrodesis using graft material when it was required to fill cystic bone voids, we retrospectively compared the time to fusion (clinical and radiographic), and non-union rate between the patient’s own bone autograft (n = 62) versus a mesenchymal stem cell impregnated allograft group (n = 51). A third control group (n = 52) was included in which an end-to-end arthrodesis was performed and no graft interposition was used or necessary. The non-union rate was 4% (n = 2) in the control group, 5.9% (n = 4) in the autograft group, and 9.5% (n = 5) in the mesenchymal stem cell allograft group. The time for radiographic fusion was 6.46 weeks for the control group, 6.52 weeks for the autograft group, and 6.53 weeks for the mesenchymal stem cell allograft group. The difference in time to clinical and radiographic union and the non-union rate were not found to be statistically significant among all 3 groups. Patient comorbidities and their possible effects on union rates were also analyzed within the populations. Some comorbidities had statistically significantly non-unions within the population, notably smoking (p = 0.024) and Rheumatoid arthritis (p = 0.001), however the populations were fairly small. The use of allogeneic bone graft impregnated with mesenchymal stem cells yields a similar fusion rate as with the use of autologous bone graft harvested from the surrounding area. The allograft impregnated with mesenchymal stem cells is a viable alternative yielding similar results when local autogenous bone graft is not available, not obtainable, or conditions warrant its use.

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.

Why and How Often Is Revision Surgery Necessary after First Metatarsophalangeal Joint Arthrodeses? A Cohort of 120 Consecutive Cases

Background: Little is known about the rate and reasons for revision after primary Metatarsophalangeal (MTP1) arthrodesis with the latest implants. While it is commonly assumed that nonunion accounts for most reoperations, we hypothesized that malposition is the leading cause of revision. The aim of this study was to determine the rate and reasons for revision after MTP1 arthrodesis using cup- and cone-reamers and the latest locking plate technology. Method: Between 2015 and 2017, 120 consecutive MTP1 fusions in 114 patients were performed with a low profile, pre-contoured titanium dorsal locking plate and a plantar metatarsophalangeal screw. The rate and reasons for revision within a minimum one-year follow-up period (average 16 months [12 - 26]) after index procedures were documented and analyzed. The revision was defined as any reoperation following the index procedure excluding hardware removal. Results: Seventeen of 120 feet (14%) underwent revision. Four patients developed a nonunion (3.3%) and needed revision, and 11 feet (9%) required revision for painful malposition;insufficient extension and excessive valgus accounted for the majority. Two patients required medial sesamoidectomy. No infection or wound healing problems occurred. Twelve patients requested hardware removal. Conclusions: Nonunion revision rate after MTP1 fusion with the latest locking plate technology is low. The leading cause of revision is malposition followed by nonunion. Excessive valgus and insufficient extension account for most symptomatic malposition. A recommendation of 0 - 10 degrees of valgus in the horizontal plane may contribute to diminishing revision rates;no conclusions could be drawn regarding an optimal position in the sagittal plane.

Outcomes following minimally invasive dorsal cheilectomy for hallux rigidus:A systematic review

BACKGROUND Cheilectomy of the 1^(st)metatarsophalangeal joint(MTPJ)is one of the most common procedures for the management of hallux rigidus.However,there is no consensus regarding outcomes following minimally invasive dorsal cheilectomy(MIDC)for the management of hallux rigidus.AIM To evaluate outcomes following MIDC for the management of hallux rigidus.METHODS During November 2023,the PubMed,EMBASE and Cochrane Library databases were systematically reviewed to identify clinical studies examining outcomes following MIDC for the management of hallux rigidus.RESULTS Six studies were included.In total,348 patients(370 feet)underwent MIDC for hallux rigidus at a weighted mean follow-up of 37.9±16.5 months.The distribution of patients by Coughlin and Shurna's classification was recorded in 4 studies as follows:Ⅰ(58 patients,27.1%),Ⅱ(112 patients,52.3%),Ⅲ(44 patients,20.6%).Three studies performed an additional 1^(st)MTPJ arthroscopy and debridement following MIDC.Retained intra-articular bone debris was observed in 100%of patients in 1 study.The weighted mean American orthopedic foot and ankle society score improved from a preoperative score of 68.9±3.2 to a postoperative score of 87.1.The complication rate was 8.4%,the most common of which was persistent joint pain and stiffness.Thirty-two failures(8.7%)were observed.Thirty-three secondary procedures(8.9%)were performed at a weighted mean time of 8.6±3.2 months following the index procedure.CONCLUSION This systematic review demonstrated improvements in subjective clinical outcomes together with a moderate complication rate following MIDC for the management of hallux rigidus at short-term follow-up.A moderate reoperation rate at short-term follow-up was recorded.The marked heterogeneity between included studies and paucity of high quality comparative studies limits the generation of any robust conclusions.

Metallic resurfacing hemiarthroplasty of the first metatarsophalangeal joint combined with first metatarsal osteotomy for the treatment of hallux rigidus with hallux valgus in China

Hallux rigidus occurs mainly at the first metatarsophalangeal （MTP） joint,causing localized pain and degenerative arthritis.1 This condition frequently occurs together with hallux valgus and is difficult to treat.For hallux rigidus affecting only one joint,the treatment choices include articular debridement,resection arthroplasty,prosthetic arthroplasty,and arthrodesis,depending on the degree of arthritis.

The Human Ankle-Foot Complex as a Multi-Configurable Mechanism during the Stance Phase of Walking

The objective of this study is to investigate the biomechanical functions of the human ankle-toot complex during the stancephase of walking. The three-dimensional (3D) gait measurement was conducted by using a 3D infrared multi-camera system anda force plate array to record the Ground Reaction Forces (GRF) and segmental motions simultaneously. The ankle-foot complexwas modelled as a four-segment system, connected by three joints: talocrural joint, sub-talar joint and metatarsophalangeal joint.The subject-specific joint orientations and locations were determined using a functional joint method based on the particleswarm optimisation algorithm. The GRF moment arms and joint moments acting around the talocrural and sub-talar joints werecalculated over the entire stance phase. The estimated talocrural and sub-talar joint locations show noticeable obliquity. Thekinematic and kinetic results strongly suggest that the human ankle-foot complex works as a mechanical mechanism with twodifferent configurations in stance phase of walking. These lead to a significant decrease in the GRF moment arms therebyincreasing the effective mechanical advantages of the ankle plantarflexor muscles. This reconfigurable mechanism enhancesmuscle effectiveness during locomotion by modulating the gear ratio of the ankle plantarflexor muscles in stance. This studyalso reveals many factors may contribute to the locomotor function of the human ankle-foot complex, which include not only itsre-configurable structure, but also its obliquely arranged joints, the characteristic heel-to-toe Centre of Pressure (COP) motionand also the medially acting GRF pattern. Although the human ankle-foot structure is immensely complex, it seems that itsconfiguration and each constitutive component are well tuned to maximise locomotor efficiency and also to minimise risk ofinjury. This result would advance our understanding of the locomotor function of the ankle-foot complex, and also the intrinsicdesign of the ankle-foot musculoskeletal structure. Moreover, this may also provide implications for the design of bionicprosthetic devices and the development of humanoid robots.

Hallux rigidus: Joint preserving alternatives to arthrodesis- a review of the literature

Hallux rigidus describes the osteoarthritis of the firstmetatarsophalangeal joint. It was first mentioned in 1887. Since then a multitude of terms have been introduced referring to the same disease. The main complaints are pain especially during movement and a limited range of motion. Radiographically the typical signs of osteoarthritis can be observed starting at the dorsal portion of the joint. Numerous classifications make the comparison of the different studies difficult. If non-operative treatment fails to resolve the symptoms operative treatment is indicated. The most studied procedure with reproducible results is the arthrodesis. Nevertheless, many patients refuse this treatment option, favouring a procedure preserving motion. Different motion preserving and joint sacrificing operations such as arthroplasty are available. In this review we focus on motion and joint preserving procedures. Numer-ous joint preserving osteotomies have been described. Most of them try to relocate the viable plantar cartilage more dorsally, to decompress the joint and to increase dorsiflexion of the first metatarsal bone. Multiple studies are available investigating these procedures. Most of them suffer from low quality, short follow up and small patient numbers. Consequently the grade of recommendation is low. Nonetheless, joint preserving procedures are appealing because if they fail to relief the symptoms an arthrodesis or arthroplasty can still be performed thereafter.

Hallux rigidus treated with adipose-derived mesenchymal stem cells:A case report

BACKGROUND First metatarsophalangeal joint arthritis(FMTPA),also known as hallux rigidus,is the most frequent degenerative disease of the foot.Diagnosis is made through both clinical and radiological evaluation.Regenerative medicine showed promising results in the treatment of early osteoarthritis.The aim of the present study was to report the results of a case of FMTPA treated with the injection of autologous adipose-derived mesenchymal stem cells.CASE SUMMARY A gentleman of 50 years of age presented with a painful hallux rigidus grade 2 resistant to any previous conservative treatment(including nonsteroidal antiinflammatory drugs and hyaluronic acid injections).An injection of autologous adipose-derived mesenchymal stem cells into the first metatarsophalangeal joint was performed.No adverse events were reported,and both function and pain scales improved after 9 mo of follow-up.CONCLUSION The FMTP joint injection of mesenchymal stem cells improved symptoms and function in our patient with FMTPA at 9 mo of follow-up.

Mineralized collagen artificial bone repair material products used for fusing the podarthral joints with internal fixation—a case report

In this study,we reported a case with collapse and subluxation of metatarsal-cuneiform joint,navicular-cuneiform joint with subluxed the right first metatarsophalangeal joint.The injured medial column was internally fixed with compression arthrodesis.The fusion site was firmed up with BonGoldVR Bone Sponge and Bone Putty.The prognosis of fused navicular-cuneiform joint and metatarsal-cuneiform joint were examined by X-ray shortly after surgical operation and followed up 2,4,6,9 and 13 weeks after the surgical operation.Themedial column was perfectly fused by compression arthrodesis.These results justified and favored the application of mineralized collagen as an excellent alternative to autograft in fusing the podarthral joints with internal fixation.