Triplanar Quantitative Radiographic Analysis of the First Metatarsal-Phalangeal Joint in the Hallux Abductovalgus Deformity

Although hallux abductovalgus (HAV) is widely considered to be a triplanar deformity involving the transverse, sagittal, and frontal planes, most of the published literature has focused on evaluating the deformity in only the transverse plane, and we are unaware of any investigation objectively evaluating the relationship among the 3 planes in the setting of HAV deformity. The objective of this investigation was to quantitatively evaluate radiographic measurement of the relationship between the transverse, sagittal, and frontal planes in the HAV deformity. Anteroposterior, lateral, and sesamoid axial radiographs from 42 consecutive feet were evaluated with measurement of the first intermetatarsal angle, hallux abductus angle, metatarsal sesamoid position, first metatarsal inclination angle, sesamoid rotation angle, and tibial sesamoid grade. Variables were graphically depicted against each other on frequency scatter plots with calculation of a regression line and Pearson's correlation coefficient. As transverse plane deformity increased, the frontal plane deformity also tended to increase and the first metatarsal inclination angle tended to decrease. And as frontal plane deformity increased, the first metatarsal inclination angle tended to decrease. To our knowledge, these are the first quantitative and objective data in support of a triplanar component to the HAV deformity, and we believe this reinforces the evaluation of this deformity with emphasis on all 3 planes.     

Sagittal Alignment of the First Metatarsophalangeal Joint after Arthrodesis for Rheumatoid Forefoot Deformity

The present study assessed the midterm results of reconstruction for rheumatoid forefoot deformity with arthrodesis of the first metatarsophalangeal (MTP) joint, scarf osteotomy, resection arthroplasty of the metatarsal head of the lesser toes, and surgical repair of hammertoe deformity (arthrodesis of the proximal interphalangeal joint). Special focus was placed on the sagittal alignment of the first metatarsophalangeal joint after arthrodesis. We retrospectively evaluated the postoperative clinical outcomes and radiographic findings for 16 consecutive female patients (20 feet) with symptomatic rheumatoid forefoot deformities. The mean duration of follow-up was 7.9 (range 4 to 13) years. All first MTP joints and first metatarsal bones were fused successfully. The mean value of the American Orthopaedic Foot and Ankle Society and Japanese Society for Foot Surgery clinical scores significantly improved overall, except for 2 patients (10%), who complained of first toe pain at the final follow-up visit owing to sagittal misalignment of the fused first MTP joint. Sagittal alignment of the first metatarsal varies greatly because of the rheumatoid midfoot and hindfoot deformities. Therefore, inclination of the first metatarsal should be considered when determining the first MTP joint sagittal fusion angle.     

Reduction of Intermetatarsal Angle after First Metatarsophalangeal Joint Arthrodesis in Patients with Hallux Valgus

We present a radiographic review of 94 patients who underwent first metatarsophalangeal joint arthrodesis. The main focus of our review was to assess the change in the intermetatarsal angle (IMA). The change in the IMA was measured for the entire group and for 2 subgroups (IMA 11° to 15° and IMA >15°). The results of the angular measurements for the total data set were as follows: mean preoperative first IMA, 15.32° (range 11° to 24°), mean postoperative IMA, 9.88° (range 3° to 18°), and mean change in IMA of 5.44° (range −2° to 13°; p < .001). Group 1, with an IMA of 11° to 15°, included 52 patients, with a mean change in the IMA of 4.21° (range −2° to 9°; p < .001). Group 2, with an IMA greater than 15° (range 16° to 24°), included 42 patients, with a mean change in the IMA of 6.83° (range 2° to 13°; p < .001). The change in the preoperative to postoperative IMA in group 1 compared with that in group 2 was statistically significant (p < .001). The results of the present study have confirmed the observations of previous investigators that arthrodesis of the first metatarsophalangeal joint for hallux abducto valgus deformity results in a reduction of the IMA and that a proportionately larger reduction can be expected when the IMA is larger.     

Cone Arthrodesis of the First Metatarsophalangeal Joint

An operation for arthrodesis of the first metatarsophalangeal joint described previously has been performed on 85 toes in 68 patients over a 20-year period. The notes and X-rays have been reviewed to determine the incidence of bony fusion and to find out whether the operative position was maintained until union occurred.

Arthrodesis was achieved in 83 (97.6 per cent) of the toes operated on. Where there had been no previous surgery to the metatarsophalangeal joint the incidence of bony union was 100 per cent.

As determined by certain defined criteria there is a strong indication that the technique maintained the operative position until bony union occurred.     

First Tarsometatarsal Joint Derotational Arthrodesis—A New Operative Technique for Flexible Hallux Valgus without Touching the First Metatarsophalangeal Joint

No operative technique for hallux valgus has been introduced in which the first metatarsophalangeal joint is not touched. We report the first tarsometatarsal joint derotational arthrodesis in which we mimic the function of the peroneus longus tendon without involving the first metatarsophalangeal joint, allowing function of the windlass mechanism without interference. We treated 66 patients (62 women and 4 men) with 84 flexible hallux valgus feet using our new operative technique. Preoperative and postoperative follow-up weightbearing radiographs were evaluated. Most patients had a pronation type foot (78%) preoperatively, and mean correction in hallux valgus and intermetatarsal angle was 20° and 9°, respectively (p < .001). The LaPorta classification showed a median change of 2.5 U (p < .001). We have described a new operative technique for flexible hallux valgus. The first tarsometatarsal joint derotational arthrodesis showed notable correction angles in hallux valgus, although the first metatarsophalangeal joint was left intact.     

Effects on the Metatarsophalangeal Joint After Simulated First Tarsometatarsal Joint Arthrodesis

A first tarsometatarsal (TMT) arthrodesis is a common procedure; however; the biomechanical effects on the first metatarsophalangeal (MTP) joint are not well understood. Instant centers of rotation range of motion have been used as biomechanical parameters to determine function of the first MTP joint. The effects that a simulated first TMT joint arthrodesis has on the distribution of instant centers of rotation and resistance to dorsiflexion the first MTP joint were investigated. Five lower extremity limbs were mounted onto a custom-loading frame. A 3-dimensional tracking system was placed along the first ray. A tilting platform that simulates propulsion was used to calculate the instant centers of rotation. A hinged platform was used to determine the motion of the first MTP joint at 40 N of force. Both parameters were measured before and after simulated first TMT joint arthrodesis. Instant centers of rotation were mathematically calculated with a modified Reuleaux method. The standard deviation between instant centers of rotation was found to be significantly reduced (P = .05) after the simulated first TMT arthrodesis. There was an average of a 25% (P = .01) increase in dorsiflexion of the MTP joint after a simulated first TMT arthrodesis. The findings of this study suggest that first TMT arthrodesis does not have a negative effect on the first MTP joint. There was no reduction of the intrametatarsal angle and plantar flexion or shortening of the metatarsal. Thus, the change in biomechanics of the first MTP joint can only be attributed to elimination of the first TMT joint motion.     

Quality of Early Union After First Metatarsophalangeal Joint Arthrodesis

The aim of the present retrospective cohort study was to assess the quality of union and the clinical outcomes in patients who had undergone first metatarsophalangeal joint (MTPJ) fusion using a dorsal plate and plantar lag screw. From March 2011 to December 2012, the clinical and radiographic data of 39 patients (41 feet) who had undergone first MTPJ fusion using a compressive locking plate were retrospectively reviewed. All patients had undergone postoperative computed tomography at 6 weeks postoperatively to assess union. The average metatarsophalangeal angles improved from 23° ± 16° preoperatively to 14° ± 5° postoperatively. The dorsiflexion of the hallux at the preoperative assessment averaged 17° ± 11° and 23° ± 5° postoperatively. At 6 weeks postoperatively, the computed tomography scans demonstrated 3 complete fusions (7.3 %) and 38 partial unions (92.7%). Also at 6 weeks, the mean ± standard deviation joint bridging was 54% ± 14.6%. The forefoot American Orthopaedic Foot and Ankle Society scale score had improved significantly from 50 ± 13 preoperatively to 80 ± 7 at >1 year of follow-up (p = .001). Hardware removal was performed in 8 cases because of pain in 7 and infection in 1. Revision arthrodesis was required in 2 cases because of nonunion. At 6 weeks postoperatively, partial bony joint bridging could be observed in most cases after arthrodesis of the first MTPJ with the dorsal fusion plate.     

A Qualitative Study of the Functional Outcomes Following First Metatarsophalangeal Joint (MTPJ) Arthrodesis Based on a Procedure Focused Questionnaire

Hallux rigidus is the second most common condition to affect the first ray with an incidence of 2.5% in those above 50 years. Metatarsophalangeal Joint (MTPJ) arthrodesis remains the standard surgery. There are currently no patient-reported outcome measures or functional outcome measures specific to first MTPJ arthrodesis. Finding out what patients can and cannot do after surgery would help surgeons appropriately consent patients and manage expectations pre- and postsurgery. A pilot group of 15 patients postarthrodesis agreed on the suitability of the questions developed by the authors. As no further changes were made, a further 35 patients were recruited. Median age was 68 years, 78% were females, and 68% of patients were retired. Median follow-up was 64.5 months. Complete or almost complete pain relief was reported by 92% of patients. No major difficulty was reported by 97% of patients using ladders, 95% of patients driving, 90% of patients standing, 86% of patients wearing shoes without heels. Fifty-seven percent of patients reported extreme difficulty running and 48% of patients reported moderate or extreme difficulties wearing shoes with heels. None of the men reported difficulty with shoe wear without heels compared to 18% of women (p = .01). None of the men reported any difficulty in driving compared to 18% of women (p = .06). Difficulty in walking was reported in 44% of women compared to 9% of men (p = N/S). Our study is the first to reflect patients’ own long term experiences following first MTPJ arthrodesis. Based on our study, following first MTPJ arthrodesis the majority of patients did not have trouble with pain, walking, standing, and driving. More than half of patients did not have trouble wearing shoes without heels; up to a third didn't have trouble wearing heels. More women experienced difficulty compared to men wearing shoes without heels, driving, and walking.     

First Metatarsophalangeal Joint Distraction Arthrodesis With Bicortical Calcaneal Autograft

First metatarsophalangeal joint (MTPJ) arthrodesis is a surgical treatment option for failed first MTPJ procedures. In cases of failed MTPJ arthroplasty, removal of failed implants and necrotic bone can cause shortening and biomechanical insufficiency of the first ray. Distraction arthrodesis with bone grafting can be used to maintain first ray length. We describe a technique of autograft harvest from the ipsilateral calcaneus. We present a retrospective case series of clinical and radiographic outcomes of distraction arthrodesis with bicortical calcaneal autograft in patients with failed procedures of the first MTPJ. We achieved a 100% osseous union rate. There was an insignificant change in first ray length from preoperative to postoperative (P = .2402). First ray length was maintained with a median autograft length of 10 (range 5 to 14) mm. We were able to correct first ray deformity with a significant reduction in preoperative to postoperative intermetatarsal angle and hallux abduction angle (P = .0156, P = .0068, respectively). Seven (88%) of 8 patients with available subjective follow-up were satisfied with the outcome of the procedure and would undergo the procedure again. Our results indicate that first MTPJ distraction arthrodesis with calcaneal autograft is a viable option for failed first MTPJ procedures. Surgeons who implement our techniques can expect high rates of osseous union, deformity correction, and patient satisfaction.     

A Multicenter Retrospective Cohort Study of First Metatarsophalangeal Joint Arthrodesis

In this multicenter study, we evaluated commonly used methods of fixation and 2 methods of joint preparation for first metatarsophalangeal joint fusion, in terms of radiological union and revision rates. Included were 409 consecutive fusions in 385 patients. The overall union rate was 91.4% (34/409). About 29.4% (10/34) of our nonunions were symptomatic. Preoperative hallux valgus showed a statistically significant relation to nonunion (odds ratio [OR] = 9.33, p = .017). Other potential contributing factors like gender (OR 1.9, p = .44), diabetes (OR = 0, p = .99), steroid use (OR = 2.07, p = .44), inflammatory arthritis (OR = 0, p = .99), and smoking (OR = 2.69, p = .34) did not attain statistical significance. Further, the methods of fixation like solid screws (OR = 0, p = .99), plate (OR = 3.6, p = .187), or cannulated screws (OR = 0.09, p = .06) showed no correlation with incidence of nonunion. We compared 2 techniques of joint preparation and found no significant difference in union rates (chi-square = 1.0426, p = .30). Our crude comparison of costs showed the average saving to the trust per year could be 33,442.50£ by choosing screws over plates. To conclude, only hallux valgus had a statistically significant relation to nonunion. All other variables had no significant impact on the union. Solid screw seems to be economically the most viable option and a valid alternative.     

Severe Hallux Valgus Angle Attended With High Incidence of Nonunion in Arthrodesis of the First Metatarsophalangeal Joint: A Follow-Up Study

The incidence of nonunion after first metatarsophalangeal joint (MTP-1) arthrodesis was found to be high in our clinic. By raising awareness for the problem, making a uniform surgical treatment protocol, banning the commonly used convex-concave reamers, and promoting solely the use of hand instruments to prepare the joint for arthrodesis, we tried to decrease the numbers of nonunion. This prospective cohort study included all patients who underwent MTP-1 fusion between January 2018 and March 2019. Patients were treated according to a standardized protocol, using hand instruments to prepare the joint for fusion. Anthropometric and therapy-related data were collected and compared with an earlier 2015–2016 cohort that was retrospectively assessed. Furthermore, the frequency of nonunion between convex-concave reamers and hand instruments was compared. A total of 53 patients underwent MTP-1 fusion surgery. The incidence of nonunion was 3.8%, significantly lower than the 24.1% in 2015 to 2016 (p = .002). Multivariate regression analysis showed a 7.11 times higher risk of nonunion in 2015 to 2016 compared with 2018 to 2019 (95% confidence interval [CI] 1.55 to 32.55) (p = .012). Furthermore, an increase of 10° in HVA showed a 1.52 risk of occurrence of nonunion (95% CI 1.07 to 2.17) (p = .021). The use of convex/concave reamers was univariately associated with a 3.61 times higher risk of nonunion (95% CI 1.14 to 11.43) (p = .029); however, after correction for preoperative HVA, the preparation method was no longer associated with the occurrence of nonunion (p = .108). Patients suffering from severe hallux valgus had nonunion in 32.1% of cases. Incidence of nonunion after MTP-1 arthrodesis was significantly reduced by raising awareness and by standardizing the treatment protocol. There was no significant difference in nonunion frequency between the methods of joint surface preparation. Severe hallux valgus is prone to nonunion, and more research into this indication for MTP-1 fusion and outcome is needed.     

Clinical Outcomes After First Metatarsophalangeal Joint Arthrodesis by Flat Cut Joint Preparation With Individual Adjustment for Sagittal Alignment

Sagittal misalignment is a major cause of patient dissatisfaction and re-operation after first metatarsophalangeal (MTP) joint arthrodesis. The stereotypical application of the fixed angle would be undesirable, especially in cases of flat or cavus foot. We retrospectively reviewed 31 cases (27 patients) in which first MTP joint arthrodesis was performed using the flat cut joint preparation technique with reference to the plantar clearance beneath the pulp of the toe while simulating weightbearing by pushing a board against the sole. The most common underlying cause of surgery was rheumatoid arthritis (22 cases [71%]). Clinical outcomes were evaluated by the Japanese of Surgery of the Foot (JSSF) hallux scale and the self-administered foot evaluation questionnaire (SAFE-Q). Twenty-three cases were also examined by pedobarography to evaluate postoperative walking plantar pressure. At the most recent follow-up of a mean 19.6 months, the toe-to-floor distance of the hallux in static standing posture was a mean of 2.5 mm (range, 0-10 mm). All but 1 foot (97%) achieved bone union. There were no complications or revisions due to misalignment of the fused MTP joint. JSSF hallux scales improved significantly from 47 preoperatively to 82 postoperatively. All subscale scores except general health and well-being in the SAFE-Q improved significantly at final follow-up versus preoperative period. Plantar pressure under the hallux was correlated with the toe-to-floor distance but not radiographic parameter. In conclusion, first MTP joint arthrodesis achieved good clinical outcomes when using toe-to-floor distance and Kirschner wire template for flat cut joint preparation.