Soft-tissue arthroplasty for hallux rigidus

Seven patients (seven feet) were evaluated at an average follow-up of 42 months following soft-tissue interposition arthroplasty of the hallux metatarsophalangeal (MTP) joint for severe hallux rigidus. The technique involved reaming of the base of the proximal phalanx and metatarsal head to decompress the first MTP joint and placement of a soft-tissue tendon bundle as a biologic spacer. Six of seven patients had bilateral disease, and a positive family history of hallux rigidus. At final follow-up, all seven patients rated their result as good or excellent, the level of pain was substantially reduced, and the mean AOFAS score substantially improved from 46 to 86 points. Mild metatarsalgia was noted by four patients and characterized by mild plantar callosities in these cases. The mean MTP dorsiflexion improved from 9 degrees to 34 degrees and patients demonstrated good to excellent plantarflexion strength on manual muscle testing and with toe rise. Physical examination of the involved feet demonstrated no evidence of pes planus, metatarsus primus elevatus, Achilles tendon contracture, or metatarsocuneiform joint hypermobility in any of the seven. The technique of soft-tissue interposition arthroplasty as described gave excellent pain relief and reliable function of the hallux, and is an alternative treatment to MTP arthrodesis in select cases of severe hallux rigidus.     

A Retrospective Analysis of Surgical Treatment in Patients With Symptomatic Hallux Rigidus: Long-Term Follow-Up

The objective of this retrospective study was to analyze the long-term clinical outcomes and patient satisfaction of operative care in patients with symptomatic hallux rigidus. Seventy-seven patients (94 feet) underwent cheilectomy, Keller resection arthroplasty, or arthrodesis between 1990 and 2000. All were invited to return for follow-up evaluation after a minimum of 2 years (mean, 7 years). The average patient age was 53 years (range, 22-77 years). Outcomes were assessed by questioning and examining the patients and by evaluating radiographs according to the Regnauld's classification system. Overall patient satisfaction was good; average visual analogue and American Orthopedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal scores were 1.8 and 81, respectively. Eighty-seven percent stated they would undergo the same procedure again. After cheilectomy, the average visual analogue score was 1.4 for grade I and 2.3 for grade II, and rating scale scores were 87 and 82, respectively. There were comparable results for the Keller resection arthroplasty where visual analogue scores were 0.4 and 1.6, respectively, while AOFAS scores were 94 and 83, respectively. Average visual analogue scores and AOFAS scores in grade III patients after a Keller procedure and an arthrodesis were 2.3; 87 and 2.0; and 73, respectively. In the arthrodesis group, 4 patients required revision because of complications. Cheilectomy is a good choice for patients with grade I and II hallux rigidus because it is a safe and simple joint-preserving procedure. For end-stage hallux rigidus without preexistent metatarsalgia, the Keller procedure was favored over arthrodesis of the first metatarsophalangeal joint.     

Minimal resection interposition arthroplasty of the first metatarsophalangeal joint

BackgroundInterposition arthroplasty of the first metatarsophalangeal (MTP) joint is a viable alternative to fusion in patients with advanced hallux rigidus. The purpose of this study is to evaluate the midterm results of a modification of the technique.MethodsCase series of 18 interposition arthroplasties were performed on 13 female patients with Grade III–IV hallux rigidus. The technique included cheilectomy, bunionectomy when needed, minimal resection of the base of the proximal phalanx and interposition of a fascia lata allograft in the first metatarsophalangeal joint. Mean follow up was nine years (range 75–136 months). Patients were evaluated according to the AOFAS score, the ability to tip toe and their subjective satisfaction.ResultsThere was a significant difference between preoperative (mean 43.2, range 15–83) and postoperative (mean 77.3, range 40–100) AOFAS scores (p < 0.001). The patients were able to tip toe on 12 of the 18 operated feet and 9 of the 13 patients were satisfied from the operation. All dissatisfied patients had a coexistent hallux valgus deformity.ConclusionsThe technique had satisfactory midterm outcomes in older patients with advanced hallux rigidus without hallux valgus. Advantages of the method are the preservation of tip toe function in most patients and a technically easy conversion to fusion when needed.     

Dorsiflexory Phalangeal Osteotomy for Grade II Hallux Rigidus: Patient-Focused Outcomes at Eleven-Year Follow-Up

Dorsiflexory phalangeal osteotomy has been shown to be an effective treatment for mild to moderate hallux rigidus in short- to medium-term follow-up studies. It is speculated that the procedure alters the mechanical function of the joint and reduces the demand for hallux dorsiflexion by elevating the proximal phalanx into a more dorsiflexed position. However, it has been demonstrated that the first metatarsophalangeal (MTP) joint space and joint range of motion are reduced by the procedure, calling into question the long-term effectiveness of the operation. This study reviewed 27 dorsiflexory phalangeal osteotomy cases at an average of 11 years postoperatively. Twenty-one (77%) patients reported that they were completely satisfied with the results of their surgery; 4 (15%) patients reported that they were satisfied with reservations; and 2 (7%) patients reported that they were dissatisfied. The patients who were satisfied with reservations complained of interphalangeal (IP) joint pain or stiffness. One patient developed second MTP joint metatarsalgia after surgery, and in 1 patient first MTP joint pain returned at 24 months after surgery. One dissatisfied patient complained of second MTP joint metatarsalgia, and a second patient required revision excisional arthroplasty for continued joint pain. Ten patients (38%) reported stiffness of the first MTP joint, but only 2 patients reported any restriction of activity. Footwear restrictions were reported by 15 (58%) patients preoperatively and by 9 (35%) patients at final follow-up. Dorsiflexory phalangeal osteotomy maybe a reliable long-term treatment for grade II or moderate hallux rigidus and is a safe and effective alternative to first MTP joint fusion in joints where movement is still present and joint cartilage is viable.     

Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length

We treated 24 patients (18 women, six men; average age, 46.4 years; (range, 28 to 66 years) with fusion of the hallux metatarsophalangeal (MTP) joint using bone graft for the restoration of the length of the first ray. This procedure was performed after bone loss subsequent to previous surgeries for the correction of hallux valgus and hallux rigidus with: silastic arthroplasty (11), bunionectomy and distal metatarsal osteotomy (six), Keller resection arthroplasty (five), and total joint replacement (two). The indication for performing the arthrodesis with bone graft was a short first metatarsal, and associated metatarsalgia of the lesser metatarsals in addition to a painful MTP joint with or without deformity. This bone loss was associated with avascular necrosis of the first metatarsal (nine patients) and with osteomyelitis (seven patients). Of the 24 patients, 14 underwent additional concurrent surgery for correction of hammer toes (10), excision of a Morton's neuroma (two), and lesser metatarsal osteotomy (two). All patients were examined clinically and radiographically at a mean interval of 62.7 months after surgery (range, 26 to 108 months). The patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux and MTP 100-point outcome scale. Arthrodesis occurred in 19/24 patients (79.1%) at a mean of 13.3 weeks (range, 11 to 16 weeks), and the first ray was lengthened by a mean of 13 mm (range, 0 to 29 mm). Of the five nonunions, two were asymptomatic, and three were subsequently revised successfully, with arthrodesis occurring at a mean of 10.7 weeks. Complications included one deep infection requiring intravenous antibiotics for treatment of osteomyelitis and two minor superficial wound infections. The mean AOFAS score improved from 39 points (range, 22 to 60 points) to 79 points (range, 64 to 90 points). All patients were satisfied with the final outcome of treatment and stated that they would undergo the surgical procedure again. We concluded that arthrodesis of the hallux MTP joint with bone graft to restore bone loss and length of the first ray may be a worthwhile procedure despite the technical difficulty and the high rate of nonunion.     

Is interposition arthroplasty a viable option for treatment of moderate to severe hallux rigidus? — A systematic review and meta-analysis

IntroductionWhen conservative therapy for hallux rigidus fails, surgical options such as arthrodesis and interposition arthroplasty can be considered. Although arthrodesis of MTP joint is the gold standard treatment. However patients desiring MTP joint movement may opt for either interposition arthroplasty or implant arthroplasty to avoid the movement restrictions of arthrodesis. The purpose of this systematic review was to investigate clinical outcomes and complications following interposition arthroplasty for moderate to severe hallux rigidus, for patietns who would prefer to maintain range of motion in the MTP joint.MethodsA systematic search on MEDLINE, EMBASE and Cochrane library database was performed during February 2018. Demographics, surgical techniques, clinical outcomes, radiological outcomes and complications were recorded from each included study. Pooled statistics performed for variables with homogenous data across the studies. A linear regression model used to compare the clinical outcomes between autogenous vs allogenous material interposition arthroplasty.ResultsFifteen articles were included in the systematic review. Mean AOFAS scores improved from preoperative 41.35 to postoperative 83.17. Mean pain, function, and alignment score improved from preoperative values of 14.9, 24.9, and 10 to postoperative values of 33.3, 35.8, and 14.5. Mean dorsiflexion increased from 21.27° (5–30) to 42.03° (25–71). Mean ROM improved from 21.06° to 46.43°. Joint space increased from 0.8 mm to 2.5 mm. The most common postoperative complications included metatarsalgia (13.9%), loss of ground contact (9.7%), osteonecrosis (5.4%), great toe weakness (4.8%), hypoesthesia (4.2%), decreased push off power (4.2%), and callous formation (4.2%).ConclusionInterposition arthroplasty is an effective treatment option with acceptable clinical outcomes in patients with moderate-severe hallux rigidus who prefer to maintain range of motion and accept the risk of future complications.Level of Evidence: IV.     

The management of the painful first metatarsophalangeal joint in the older patient. Arthrodesis or Keller's arthroplasty?

We report a prospective randomised trial comparing Keller's arthroplasty and arthrodesis of the first metatarsophalangeal joint for the management of symptomatic hallux valgus and hallux rigidus in the older patient. In 81 patients (110 feet), with a minimum of two years follow-up, both procedures gave a similar degree of patient satisfaction and symptom relief. The incidence of metatarsalgia was also similar. As there were no obvious advantages to arthrodesis, and since six out of 50 arthrodesed toes required revision, we suggest that Keller's arthroplasty is the better operation in these patients.     

Keller’s arthroplasty for hallux rigidus: A systematic review

BackgroundSeveral surgical procedures have been described to treat hallux rigidus. Keller arthroplasty is a joint-sacrificing procedure proposed in 1904. Considering the current trends to mini-invasiveness and the debate about the technique’s suitability, this review intends to state Keller arthroplasty results and the conditions where it could be still adopted in the treatment of hallux rigidus.MethodsSelected articles were reviewed to extract: population data, surgical indications, different surgical techniques, clinical and radiological outcomes, and complications.ResultsSeventeen retrospective studies were selected, counting 508 patients. Mean age at surgery was 55 years. Patients were affected by moderate-severe hallux rigidus. Three modified Keller arthroplasty were identified. Good clinical and radiological outcomes were reported. Metatarsalgia was the most frequent complication (12%).ConclusionDespite for many authors KA seems a viable surgical treatment for middle aged and elderly patients affected by moderate-severe hallux rigidus, the available literature provides little evidence on the real efficacy and safety of the technique. A non-negligible percentage of complications may occur, and therefore is essential to set correct indications through an accurate patients’ selection.     

Treatment of End-Stage Hallux Rigidus Using Total Joint Arthroplasty: A Short-Term Clinical Study

The treatment of advanced hallux rigidus remains controversial. Only a few studies have analyzed the short- and mid-term results of metatarsophalangeal (MTP) joint arthroplasty to treat patients with advanced hallux rigidus. We present the short-term follow-up results of patients who underwent MTP joint arthroplasty. We reviewed the medical records of 15 consecutive patients (3 males and 12 females) who had had grade 3 or 4 hallux rigidus diagnosed according to the Coughlin and Shurnas classification. The age range at surgery was 44 to 74 (mean 61.6) years. The mean follow-up period was 21.7 (range 18 to 28) months. The mean change in the overall American Orthopaedic Foot and Ankle Society Hallux-First Ray scale score was from 26.9 ± 2.3 preoperatively to 78.7 ± 8.8 postoperatively (p < .005). The mean change in the overall visual analog scale score was from 8.3 ± 0.8 preoperatively to 1.7 ± 0.7 postoperatively (p < .005). The mean preoperative first MTP joint range of motion was 22.3° ± 7.7° (range 15° to 45°), which had increased to 77° (range 65° to 90°) at the final follow-up visit. No patient required revision surgery or removal. These results indicate that for patients with advanced-stage hallux rigidus refractory to conservative treatment, total joint arthroplasty can lead to good satisfaction and good functional results in the short term.     

Outcome Following Autogenous Soft Tissue Interpositional Arthroplasty for End-Stage Hallux Rigidus: A Systematic Review

Autogenous soft tissue interpositional arthroplasty has been proposed as an alternative to arthrodesis and other forms of arthroplasty for treatment of end-stage hallux rigidus because of the perceived safety and efficacy. The author undertook a systematic review of electronic databases and other relevant sources to identify material relating to the outcomes following autogenous soft tissue interpositional arthroplasty for end-stage hallux rigidus. Information from peer-reviewed journals, as well as from non–peer-reviewed publications, abstracts and posters, textbooks, and unpublished works, were also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing isolated autogenous soft tissue interpositional arthroplasty for the treatment of end-stage hallux rigidus, evaluated patients at mean follow-up of 12-months' duration or longer, included pre- and postoperative range of motion of the first metatarsal-phalangeal joint, determined pre- and postoperative outcomes using a scoring system, and documented any complications. Two studies involving a total of 28 autogenous soft tissue interpositional arthroplasties for end-stage hallux rigidus were identified that met the inclusion criteria. There were 12 men (52%) and 11 women (48%) with a mean age of 58.2 years followed for a mean of 21.6 months. Both studies used the AOFAS First Metatarsal-Phalangeal-Hallux Scoring System, which had a mean of 26.0 preoperatively rising to 89.4 postoperatively. First metatarsal-phalangeal joint dorsiflexion had a mean of 16.7° preoperatively rising to 51.1° postoperatively. Complications occurred in 4 (14.3%) feet and no feet required surgical revision. The results of this systematic review demonstrate improvement in patient outcomes and first metatarsal-phalangeal joint dorsiflexion, as well as few complications following autogenous soft tissue interpositional arthroplasty for end-stage hallux rigidus. However, there is still a need for methodologically sound prospective cohort studies that compare autogenous soft tissue interpositional arthroplasty with other forms of arthroplasty and arthrodesis for end-stage hallux rigidus.     

Keller's arthroplasty in adults with hallux valgus and hallux rigidus

BackgroundThe role of Keller's resection arthroplasty in the management of adult hallux valgus with hallux rigidus is debatable. There are no studies addressing this particular problem.MethodsThis study is a retrospective review of 32 patients (49 feet), conducted by an independent assessor. Subjective and objective criteria were used to assess the results of surgery. There were 30 women and 2 men with an average age at surgery of 62.5 years.ResultsThe results of surgery in terms of relief of pain, cosmesis and use of regular footwear were satisfactory. Excellent and good subjective results were obtained in 39% and 37% of cases respectively. Radiological analysis revealed decrease in the intermetatarsal and first metatarsophalangeal angle in a significant number of cases. Final results assessed by Vallier's modification of Bonney and MacNab criteria, revealed excellent to good results in 87% of feet. A significant number of complications were noted but there was no association between the occurrence of complications and the final result or the subjective functional grade. There was no association between the amount of resection of proximal phalanx and occurrence of metatarsalgia or the final outcome.ConclusionThe results of this study suggest that Keller's arthroplasty has a role in patients with adult hallux valgus associated with degenerative changes in the first metatarsophalangeal joint.     

Prosthetic replacement arthroplasty as a salvage operation for failed procedures of the first metatarsophalangeal joint: A small series and literature review

BackgroundA number of complications have been associated with Keller resection arthroplasty and arthrodesis of the first metatarsophalangeal joint for hallux rigidus. Salvage may be by arthrodesis (conversion to or revision). However, the optimal alignment is technically difficult to achieve and even if the fusion is successful, the procedure may still result in transfer metatarsalgia.ObjectiveTo assess the viability of prosthetic replacement arthroplasty as a salvage procedure for the first metatarsophalangeal joint.MethodsFour patients were identified who had undergone prosthetic replacement arthroplasty (one titanium hemiarthroplasty and three Moje prostheses) as a salvage procedure for failed surgery to the first metatarsophalangeal joint. Mean follow-up was 29.3 months (range 15–46). Patients were assessed with the American Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal–Interphalangeal Score, subjective patient satisfaction and current radiographs.ResultsAll patients who had a Moje press-fit ceramic arthroplasty reported subjective improvement of pain and function and achieved arcs of movement of between 20° and 50°. Mean AOFAS score was 63 (range 57–73). Radiographs revealed lucency around the prostheses in some patients.ConclusionsWe feel that the Moje arthroplasty as a salvage procedure is a viable alternative to that of arthrodesis, especially if preservation of movement is desired.     

Long term results of the Keller-Brandes method of hallux rigidus surgery]

Between the years 1971 and 1975 a surgical treatment of hallux rigidus according to Keller Brandes was performed on 293 patients. From 100 patients with 137 operated feet a clinical and roentgenological examination was evaluated 12 to 16 years after surgery. The subjective assessment showed in 92% of the feet very good or good results. Important for the success of the operation is the correct amount of bone removal of the proximal phalanx (between 1/3 and 1/2) and the resultant width of the nearthrotic joint space. The analysis of the podographic examination and the amount of retraction of the sesamoids showed no correlation to the incidence of postoperative metatarsalgia, which we found in 31 feet (29%). Nevertheless, X-Ray Evaluation of all patients with metatarsalgia showed a posterior shift of the sesamoids.     

Clinical Outcomes after Isolated Periarticular Osteotomies of the First Metatarsal for Hallux Rigidus: A Systematic Review

Isolated periarticular osteotomy of the first metatarsal has been proposed for treatment of hallux rigidus due to the perceived ability to “decompress” the first metatarsophalangeal joint through axial shortening, as well as plantar displacement of the first metatarsal head to correct purported elevation. Additionally, isolated periarticular osteotomy of the first metatarsal has been proposed for treatment of hallux rigidus because of the perceived safety and efficacy. Furthermore, it has been proposed that undergoing isolated periarticular osteotomy of the first metatarsal does not prevent the ability to perform revision surgery. The author undertook a systematic review of electronic databases and other relevant sources to identify material relating to the clinical outcomes and need for surgical revision after isolated periarticular osteotomy of the first metatarsal for hallux rigidus. Information from peer-reviewed journals, as well as from non-peer–reviewed publications, abstracts and posters, and unpublished works, was also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing isolated periarticular osteotomy of the first metatarsal for hallux rigidus, involved a prospective study design, included some form of objective and subjective data analysis, evaluated patients at a mean follow-up ≥12 months’ duration, and included details of complications requiring surgical intervention. Four studies involving 93 isolated periarticular osteotomies of the first metatarsal followed up for a weighted mean of 18.6 months were identified that met the inclusion criteria. Peak dorsiflexion range of motion of the first metatarsophalangeal joint for the entire cohort of 93 patients increased 10.4°. The American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scoring Scale for the entire cohort of 93 patients increased 39 points from a weighted mean of 47.2 preoperatively to 86.2 postoperatively. For the two studies that included it, complete satisfaction or satisfaction with reservations was reported in only 55/75 (73.3%) patients, with the remainder being dissatisfied. A total of 21 (22.6%) procedures underwent surgical revision in the form of hardware removal (n = 8), lesser metatarsal surgery for intractable postoperative metatarsalgia (n = 7), no mention of revision procedure (n = 3), Keller resection arthroplasty (n = 2), and treatment of infection with revision of non-union (n = 1). Two studies specified the grade of hallux rigidus that underwent revision surgery after isolated periarticular osteotomy of the first metatarsal as follows: grade I, 16.7% (n = 3/18) and grade II, 30.5% (n = 18/59). Finally, a total of 30.5% (n = 18/59) of patients developed postoperative metatarsalgia or stress fracture. Additional prospective studies involving validated subjective and objective outcome measurement tools with computerized gait analysis and long-term follow-up after isolated periarticular osteotomy of the first metatarsal for the various grades of hallux rigidus, as well as with comparison with isolated cheilectomy and Valenti arthroplasty, would be beneficial. Based on the high incidence of complications until these studies can be completed, routine use of isolated periarticular osteotomy of the first metatarsal for hallux rigidus should be performed with caution or not at all.     

Intermediate to long-term follow-up of medial-approach dorsal cheilectomy for hallux rigidus

Dorsal cheilectomy of the hallux metatarsophalangeal (MTP) joint through a medial approach can effectively provide long-term relief of pain and improve function in symptomatic mild-to-moderate hallux rigidus, despite progression of generalized first MTP joint arthritic degeneration and/or loss of motion. Fifty-seven patients (75 feet) with arthritis of the first MTP joint underwent dorsal cheilectomy through a medial approach for hallux rigidus failing nonoperative management. Excision of the dorsal articular surface of the first metatarsal head and dorsal osteophytes was performed through a medial approach that also allowed for plantar capsular release and removal of lateral osteophytes. Minimum follow-up was 3 years (average, 63 months; range, 37-92 months). Fifty-two patients (68 feet) returned for clinical and radiographic evaluation. American Orthopaedic Foot and Ankle Society Hallux Rating scores improved from a preoperative average of 45 to 85 points at follow-up. Average dorsiflexion improved from 19 degrees to 39 degrees, and the average range of motion improved from 34 degrees to 64 degrees. Preoperative radiographic grade of arthritic degeneration was grade I in 17 feet, grade II in 39 feet, and grade III in 12 feet; at follow-up, the radiographic grade was grade I in 2 feet, grade II in 26 feet, and grade III in 40 feet. Thirty-two feet worsened one grade, 6 feet worsened two grades, and 28 feet demonstrated no change (12 of 28 were grade III, preoperatively). A dorsal spur recurred in 21 feet, 9 of which were symptomatic. Complications included two superficial wound infections and four transient paresthesias of the hallux, all of which resolved uneventfully.     

Long term efficacy of minimal incision osteotomy for hallux abducto valgus

Objective: To observe and evaluate the long‐term results of minimal incision osteotomy for hallux abducto valgus. Methods: From February 1995 to May 1999, 372 cases (705 feet) with hallux abducto valgus were treated with minimal incision osteotomy. Seventy‐nine patients (150 feet) were followed up for more than five years (mean 7.5; range, 5.3–13.2 years) after surgery. The preoperative and postoperative hallux abducto valgus angles (HVA), intermetatarsal angles (IMA), tibial sesamoid position (TSP), American Orthopaedic Foot And Ankle Society (AOFAS) score, range of movement of the first metatarsophalangeal joint and lateral metatarsalgia were observed, measured and evaluated. Results: Based on clinic curative effect evaluation criterion, 56 feet (37.3%) were excellent, 88 feet (58.7%) good, 6 feet (4.0%) fair. The postoperative mean AOFAS score was 84.20 ± 4.32 points. The mean HVA decreased from 33.28^o to 12.31^o and the mean IMA1‐2 from 11.75^o to 6.80^o. The TSP was corrected from an average preoperative grade of 4.29 to a grade of 3.07 by final follow‐up. There was no nonunion or delayed union, no avascular necrosis, no infection, and no hallux varus. Numbness in the big toe was found in 4 feet (2.7%). The range of motion of the first metatarsophalangeal joint decreased from 70.20^o to 69.53^o. Of 97 feet (64.7%) with pre‐operative 2–5 metatarsalgia, this had disappeared in 35 feet, improved in 54 feet and was aggravated in 8 feet postoperatively. Conclusion: Minimal incision osteotomy is a simple and reliable technique for treating hallux abducto valgus with minimal complications.     

Long-term follow-up of silastic joint replacement of the first metatarsophalangeal joint

Aim: To assess long-term outcome of silastic joint replacement of the first metatarsophalangeal joint.Methods: Thirty-two patients (42 feet) with double-stem silicone implant arthroplasty of the first metatarsophalangeal joint were reviewed at an average of 8 years (range 4–19 years). Surgery was for hallux rigidus in 25 cases and for hallux valgus with degenerative osteoarthritis in 17 cases. Patients with rheumatoid arthritis were excluded. Mean patient age was 64 years.Results: Twenty-eight of the 32 patients were very satisfied with the procedure. No patients were dissatisfied. Pain relief was subjectively excellent or good in 28 patients. Three of the four patients with fair or poor relief of pain had surgery for hallux valgus with degenerative osteoarthritis.Radiographs showed sclerosis around all prostheses having cysts with bony erosions in 17 cases. Twelve had clinical features of silicone synovitis in the early postoperative period but this was not present at final review despite radiological findings of new bone formation (57%) and localised osteolysis (40%). Two patients had transfer metatarsalgia with a stress fracture. No patient required revision surgery.Conclusion: Our long-term study shows patients to have very good subjective and objective results despite poor radiological results. There is a role for double-stemmed silicone implant arthroplasty in low demand patients.     

Scarf and Weil osteotomies for correction of rheumatoid forefoot deformities: A review of 20 cases

The forefoot is commonly affected in rheumatoid arthritis. Little has been written of the results of metatarsophalangeal joint preservation in rheumatoid arthritis. We describe the results of the Scarf and Weil osteotomy for correction of forefoot deformities in patients with rheumatoid arthritis. Between 1996 and 1999, 17 patients (20 feet) underwent a Scarf osteotomy for their hallux valgus deformity and in 17 feet a Weil osteotomy of the lesser metatarsophalangeal joints. Radiographic examination was performed preoperatively and at a mean follow up of 65 months. A questionnaire was used at a minimum follow up of 6 years. The hallux valgus angle improved from 41° to 28° at follow up. The majority of the patients (79%) were satisfied with the result during follow-up. We found no wound infections, neuralgia or osteonecrosis of the first metatarsal. In three patients, a fusion of the first MTP joint was performed at follow up.In conclusion, the Scarf and Weil osteotomy is a useful method for MTP joint preserving surgery in rheumatoid forefoot deformities without severe impairment of the MTP joints.     

Recreational sport activity after total replacement of the first metatarsophalangeal joint: a prospective study

First metatarsophalangeal joint replacement is an alternative surgical procedure to arthrodesis in the treatment of moderate-to-severe hallux rigidus. However, few studies have been published about functional outcome after joint reconstructive procedures for hallux rigidus. The purpose of this study was to assess clinical, radiological and functional outcome, with special regard to recreational and sports activity, after first metatarsophalangeal joint replacement in patients affected by hallux rigidus grade III. Twenty-three patients who had undergone total joint replacement of the first metatarsophalangeal joint were examined preoperatively and three, six, 12 and 18 months postoperatively. All patients (mean age of 57.0 ± 3.7 years) received a non-cemented TOEFIT-PLUS™ implant by one surgeon. Clinical scores (AOFAS score and VAS), radiological examination, patient satisfaction and sport participation were used to evaluate treatment outcome and radiolucent lines. The mean AOFAS score showed a significant improvement from 44.6 ± 7.2 points preoperatively to an average of 82.5 ± 14.4 points at last follow-up (p < 0.001). The mean total ROM of the first MTP joint increased from 28.1 ± 4.9 degrees preoperatively to 52.7 ± 15.7 degrees postoperatively (p < 0.001). After surgery, 91.3% of the patients were able to resume at least one recreational activity. Total arthroplasty for the treatment of hallux rigidus in an active patient population revealed good clinical and functional results. However, postoperative recreational sport activity showed a decrease in comparison to the pre-arthritic state. Further follow-up is necessary to quantify loosening risk in active patients after total hallux arthroplasty.     

Cross-sectional study to evaluate radiological parameters in hallux rigidus

BackgoundHallux rigidus (HR) is a common condition with X-rays used to evaluate its pathology, grade joint changes and to inform treatment.MethodA cross-sectional study was undertaken to evaluate radiological foot parameters in HR. In 110 subjects (180 feet) aged 18–70 years (mean 52 years) standard weight-bearing X-rays were examined using dorsal plantar and lateral views.ResultsSeventy (64%) subjects had bilateral HR and 73 (66%) were female. The mean onset of HR (denoted by first metatarsophalangeal (MTP) joint restriction/pain) was 44 (14–68 years) years and median HR duration was 6 years (1–33 years). Flat or chevron-shaped metatarsal heads presented in 131 (73%) feet and a history of first MTP joint trauma in 22% (74% of whom had unilateral HR). In 74% of feet hallux abductus interphalangeus angle (HAI°) was greater than normal (≤10°). Correlations between first MTP joint narrowing and sclerosis (r = 0.76, p = 0.01) and increased HAI° and first MTP joint narrowing (r = 0.34, p = 0.01) was found. The mean hallux equinus angle of 11° was outside the normal range (16–18°). Abnormal sesamoid morphology presented in 117 (65%) feet (30% irregular or hypertrophic). Proximal sesamoid displacement was greater than that seen in non-HR. Metatarsus primus elevatus was within normal range (≤8 mm) in 160 (89%) feet. The first metatarsal was longer than the second metatarsal in 66 (37%) feet although the first metatarsal was longer than the third metatarsal in 131 (73%) feet and may be responsible for altered forefoot function in HR.ConclusionsHR was associated with female gender, bilateral involvement, older age groups, flat or chevron-shaped metatarsal head, longer proximal phalanx, increased HAI° and a first metatarsal longer than the third metatarsal. For radiological parameters to be considered valid for inclusion in a classification of HR their content validity needs to be established by formal research.