Is adjunction of advanced platelet-rich fibrin (A-PRF) useful in first metatarsophalangeal joint arthrodesis? A retrospective cohort study

PurposeFirst metatarsophalangeal (MTPJ1) fusion represents the gold standard treatment for end-stage hallux rigidus (HR). The aim of this study was to assess efficacy and safety of A-PRF in promoting union after MTPJ1 arthrodesis. Our hypothesis was that the use of A-PRF may reduce the non-union rate and the time to fusion in the treatment of HR.Methods14 patients that had undergone MTPJ1 arthrodesis with A-PRF adjunction with 21 standard MTPJ1 fusions were retrospectively reviewed. The fusion rate and time to fusion (clinically and radiographically) were assessed at 6, 12 weeks and at the longest follow-up; the clinical status at final follow-up through forefoot AOFAS, EQ5d, SEFAS and VAS-pain scores; the complication rate.ResultsAt 6-weeks, bony union was achieved in 100% of patients in the A-PRF group compared to 70% in the control group, but this difference was not statistically significant (p = 0.22). At final follow-up (41 months), union rate in the control group reached 92% (one non-union). AOFAS, VAS and EQ-5d scores showed similar results for the two groups (p = 0.86, p = 0.12 and p = 0.61, respectively); only SEFAS score revealed a difference favoring the A-PRF group (p = 0.04). No revision surgery or complication was recorded in any group.ConclusionsA tendency for increased union rate was mainly found at 6 weeks in patients treated with MTPJ1 fusion associated to A-PRF compared to isolated fusion. The use of A-PRF was not associated with an increased complication rate at final follow-up.Level of evidenceLevel 3, therapeutic study, retrospective comparative study.     

Minimally invasive arthrodesis of the first metatarsophalangeal joint for hallux rigidus

BackgroundFirst metatarsophalangeal joint arthrodesis plays a significant role in the management of symptomatic hallux rigidus. Several open and one percutaneous technique have been described in the literature. The authors present a minimally invasive technique, not previously published in the UK with patient-reported outcomes.MethodsA total of 26 cases of are presented in this prospective, continuous series. Clinical outcome and patient satisfaction were assessed by the Manchester-Oxford Foot Questionnaire (MOXFQ) preoperatively and at most recent follow up (maximum 20 months). Radiographic and clinical evaluation of fusion was also assessed with a fusion rate of 93%.ResultsThe MOXFQ score for cases where fusion was achieved improved from a mean of 42 points to 18 points at last follow up (p < 0.05). Patient satisfaction was overall very good.ConclusionsThis minimally invasive technique is simple and can achieve results similar or better than open techniques in experienced hands. Postoperative care requirements are minimal and both clinical and patient-reported outcome show significant improvement in this series.     

Quantitative relationship of first metatarsophalangeal head morphology to hallux rigidus and hallux valgus

Background

Previous qualitative studies have linked first metatarsal head morphology with hallux valgus (HV) and hallux rigidus (HR). This study used a quantitative measurement of 1st MT radius of curvature to assess if HR MT heads were flatter than HV heads.

Salvage arthrodesis for failed first metatarsophalangeal joint arthroplasty: A network meta-analysis

BackgroundWe aim to provide an evidence-based literature review of salvage arthrodesis for failed first metatarsophalangeal joint arthroplasty with a network meta-analysis.MethodsA search of PubMed, Embase and Cochrane databases was conducted in December 2016 which identified 12 relevant articles out of 340 articles assessing the efficacy of salvage arthrodesis for failed joint arthroplasty of the first metatarsophalangeal joint. The 12 studies were assigned a level of evidence (I–V) and interventions were graded a level of recommendation (A–C, I) in support of or against the treatment modality.ResultsThere is fair evidence (grade B) to support salvage arthrodesis with structural bone graft. There is poor evidence (grade C) for salvage arthrodesis without bone graft. There was no good evidence (grade A) to recommend either intervention. Meta-analysis showed that salvage arthrodesis resulted in improved functional outcome over time.ConclusionsSalvage arthrodesis showed good bone union rates and patient satisfaction.Level of Clinical Evidence: III – Systematic Review of Level III studies.     

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.     

第1跖趾关节融合结合外侧足趾旋转Weil截骨治疗重度跖内收型拇外翻

目的：探讨第1跖趾关节融合结合外侧足趾旋转Weil截骨治疗重度跖内收型拇外翻临床疗效。方法：回顾性分析自2017年3月至2021年8月接受第1跖趾关节融合结合旋转Weil截骨治疗的重度跖内收型拇外翻患者37例（69足）,男8例（11足）,女29例（58足）;年龄67～83(70.03±2.87)岁;左侧3例,右侧2例,双侧32例。分别于术前、术后6周及末次随访时,采用疼痛视觉模拟评分（visual analogue scale,VAS）进行疼痛缓解程度评价。术前及末次随访时采用美国骨科足踝外科学会（American Orthopaedic Foot and Ankle Surgery,AOFAS）前足评分对患足功能进行评价。并测量手术前及末次随访时拇外翻角（hallux valgus angle,HVA）,第1、2跖间角（intermetatarsal angle,IMA）的变化情况。结果：37例（69足）患者获得随访,时间12～48 (22.8±0.6)个月。术后7～10(8.00±1.21)周第1跖趾关节处达到骨愈合,无延迟愈合及不愈合发生。术前HVA (44.30±2.84)°与...     

Long term results of the Toefit-Plus replacement for first metatarsophalangeal joint arthritis

Hallux rigidus is osteoarthritis affecting the metatarsophalangeal joint of the first toe. Patients often complain of pain and stiffness with pain being aggravated by walking, particularly during toe-off in the gait cycle. Osteoarthritis of the metatarsophalangeal joint is commonly treated with arthrodesis or resection arthroplasty. Metallic replacement of this joint is used sometimes but is not widely accepted. The use of silastic joints has problems with synovitis and implant failure. The authors used titanium implants, which can be screwed into the metatarsal and phalanx, allowing good fixation without the use of bone cement. Release of the tight plantar capsule and tissues is necessary to achieve better range of movement and correct implant positioning.Fifty five cases of arthritis of the first metatarsophalangeal joint were treated surgically with Toefit-Plus™ joint replacement. The implant consists of both metatarsal and phalangal components and a fixed-bearing polyethylene insert. All patients had a release of tight soft tissues on the plantar side. Follow up occurred at 84 to 144 months after surgery (mean of 134 months), and the results showed increasing numbers of implant failures and revisions (21%) of Toefit-Plus™ implants. 47 patients were available for review. Twenty four (51%) out of 47 patients reported satisfactory results with Toefit-Plus™ arthroplasty. Ten of these patients (21%) had removal of implants and further surgical procedures were needed due to implant failure. Eleven (23%) out of 47 patients still complained of pain despite having joint replacement with the Toefit-Plus ™ implant.There is a high rate of complications with the Toefit-Plus™ implant resulting in revision surgery. Patients should have the risks associated with arthroplasty clearly explained, including the risk of revision, and the option of arthrodesis should be discussed when planning surgery. Further trials and redesign of implants may help to improve results. The authors would not recommend the Toefit-Plus™ implant due to poor results seen in one third of patients.     

Metallic hemiarthroplasty or arthrodesis of the first metatarsophalangeal joint as treatment for hallux rigidus: A systematic review and meta-analysis

BackgroundArthrodesis and metallic hemiarthroplasty are two surgical interventions for the treatment of end-stage osteoarthritis of the first metatarsophalangeal (MTP1) joint. This systematic review and meta-analysis aims to compare the two operations with regards to patient-reported outcomes, pain reduction, complications and revision rates.MethodsA systematic literature search identified all relevant studies. The methodological quality was assessed using two validated tools. Data of interest were derived and presented. For non-comparative studies, data was assessed for trends, while for comparative studies pooling statistics were performed.ResultsA total of 33 studies were included for analysis. The majority of studies (>75%) reported an AOFAS-HMI score greater than 80 points after both metallic hemiarthroplasty and arthrodesis. The lowest VAS pain score was observed after arthrodesis (weighted mean difference -1.58, 95% confidence interval (CI) ?2.16 to ?1.00 P< 0.00001). Comparable numbers of complications (odds radio 1.48, 95% CI 0.81 to 2.73, P = 0.21, favoring: hemiarthroplasty) and revisions (odds ratio 1.16, 95% CI 0.62 to 2.15 P = 0.64, favoring: hemiarthroplasty) were observed after both interventions. The included non-comparative studies seem to confirm these findings of the comparative studies.ConclusionMetallic hemiarthroplasty and arthrodesis have excellent clinical outcomes and acceptable complication- and revision rates. Arthrodesis seems to be superior in pain reduction, while metallic hemiarthroplasty is a suitable alternative for patients performing activities that requires motion in the first metatarsophalangeal joint.     

Arthrodesis of the first metatarso-phalangeal joint with convex and concave drills

The arthrodesis of the metatarso-phalangeal joint of the hallux remains a reliable method in the treatment of the severe deformities caused by rheumatoid affection, recurrences of hallux valgus, iatrogenic varus and arthrosic hallux valgus (hallux rigidus). This operation is not crippling since the talocrural and interpahalangeal joints are preserved. The technique using a set of concentric drills allows a better positioning of the great toe, however it seems to generate a higher partial fusion rate but without repercussions on the final functional result. The metatarso-phalangeal arthrodesis of the great toe is a tried-and-tested method described by Groulier et al. [1]. A certain number of studies, mostly Anglo-Saxon, report it as early as the end of last century. Its merits have been gradually emphasized for the revisions or to treat the severe deformities of the great toe, either with arthrosis complications, painful stiffening or metatarsalgiae. The arthrodesis of the metatarso-phalangeal of the hallux was first stated in 1894 as a successful treatment, achieving good and stable results in case of severe hallux valgus. Varied techniques of arthrodesis of the metatarso-phalangeal of the hallux have been described and 60 different types have been listed.     

第一跖楔关节融合治疗(足母)外翻合并第一跖楔关节不稳

目的探讨第一跖楔关节融合重建足横弓治疗外翻合并第一跖楔关节不稳的疗效。方法2003年1月至2005年6月,手术治疗合并第一跖楔关节过度活动、足横弓塌陷的外翻患者23例32足,均为女性;年龄46～72岁,平均(60.3±9.3)岁。第一跖骨头下压、外移及旋后并与失稳的第一跖楔关节融合,融合关节采用AO“T”形钢板固定。外翻畸形采用改良McBride软组织手术矫形。术后石膏固定6周,随后部分负重2周。结果20例患者28足获得完整随访,随访时间6～22个月,平均13.3个月。X线片显示第一跖楔关节均获得良好融合。外翻角从术前的平均51°±12°减小到术后的平均22°±6°;第一、二跖骨间角从术前的平均15°±5°减小到术后的平均9°±4°。患者主观评价,优15足,良9足,可4足,优良率为85.7%。患者前足底疼痛均有明显好转,4足有不同程度的第一跖趾关节疼痛,1足足中部不适,取内固定后消失。结论第一跖楔关节融合治疗外翻合并第一跖楔关节不稳能很好地纠正足横弓的塌陷、第一跖骨内翻畸形,对恢复第一跖骨头的负重功能有较好的治疗效果。采用钢板内固定能有效提高融合部位的稳定,利于前足的早期负重。     

第一跖楔关节融合治疗拇外翻合并第一跖楔关节不稳

目的探讨第一跖楔关节融合重建足横弓治疗拇外翻合并第一跖楔关节不稳的疗效。方法2003年1月至2005年6月，手术治疗合并第一跖楔关节过度活动、足横弓塌陷的拇外翻患者23例32足，均为女性；年龄46-72岁，平均（60．3±9．3）岁。第一跖骨头下压、外移及旋后并与失稳的第一跖楔关节融合，融合关节采用AO“T”形钢板固定。拇外翻畸形采用改良McBride软组织手术矫形。术后石膏固定6周，随后部分负重2周。结果20例患者28足获得完整随访，随访时间6-22个月，平均13．3个月。X线片显示第一跖楔关节均获得良好融合。拇外翻角从术前的平均51°±12°减小到术后的平均22°±6°；第一、二跖骨间角从术前的平均15°±5°减小到术后的平均9°±4°。患者主观评价，优15足，良9足，可4足，优良率为85．7％。患者前足底疼痛均有明显好转，4足有不同程度的第一跖趾关节疼痛，1足足中部不适，取内固定后消失。结论第一跖楔关节融合治疗拇外翻合并第一跖楔关节不稳能很好地纠正足横弓的塌陷、第一跖骨内翻畸形，对恢复第一跖骨头的负重功能有较好的治疗效果。采用钢板内固定能有效提高融合部位的稳定，利于前足的早期负重。     

Flexion location of the first metatarsophalangeal joint and the location of forefoot bend in general purpose women’s footwear

BackgroundGeneral purpose footwear could have a built-in flexion location which may not match the anatomical fulcrum location for an individual’s foot. Mismatched fulcra impact on joint function, and may delay healing of an injured first metatarsophalangeal joint (first MP joint). This study compared the location of the first MP joint in an asymptomatic sample of the South African female population to the bend location set within the lasts (used by footwear manufacturers) to find whether mismatches of the flexion locations of the joint to the bending location of the footwear were likely.MethodsThe study used a three dimensional foot measurement database of 453 female participants to find the fulcrum location of the first MP joint. The distance between the heel and the first MP joint was expressed as a percentage of the overall length of the unshod foot. Similar measures for sandals and closed shoes were derived, and all were compared to manufacturer last data.ResultsThe location of first MP joint ranged from 70% to 79% of total foot length, significantly different from last design specifications of 63% or 66% (p < 0.0001). The range of first MP joint fulcrum locations in the same size feet occurred in a wide 24 mm mediolateral band under the forefoot, termed a flexion zone.ConclusionsThe first MP joint cannot properly function as a fulcrum unless footwear has a matching flexion location. Footwear designs should incorporate a wide flexion zone located under the forefoot to permit the range of first MP joint flexion locations. Recommendations to patients are to select appropriate flexible footwear to prevent shear forces, reduce strain, prevent injury and enable range of motion function and healing of injury.     

类风湿性关节炎前足畸形重建手术的近期疗效

目的探讨类风湿性关节炎前足畸形的手术治疗方法及近期疗效。方法 2007年1月-2009年8月,采用第1跖趾关节融合术联合第2～5跖趾关节成形术治疗7例类风湿性关节炎前足畸形女性患者。年龄56～71岁,平均62岁。病程5～30年,平均16年。患者均表现为双足外翻,第2～5趾合并锤状趾或槌状趾畸形,其中5足合并第2跖趾关节半脱位。根据美国矫形足踝协会(AOFAS)改良标准评分为(36.9±6.4)分。术前负重位X线片测量,第1跖趾关节外翻角度(46±5)°,第1、2跖骨间夹角(12±2)°。结果术后切口均Ⅰ期愈合。术后3～4个月X线片复查示第1跖趾关节达骨性融合。7例均获随访,随访时间2～4年,平均2.9年。患者跛行步态均较术前明显改善,行走时足部疼痛明显缓解。术后3个月X线片测量第1跖趾关节外翻角度为(17±4)°,第1、2跖骨间夹角为(11±2)°,与术前比较差异均有统计学意义(P<0.05)。术后2年根据AOFAS改良标准评分为(85.3±5.1)分,与术前比较差异有统计学意义(t=4.501,P=0.001)。1例于术后4年前足转移性跖骨痛复发,继续随访中未作特殊处理。结论第1跖趾关节融合术联合第2～5跖趾关节成形术治疗类风湿性关节炎前足畸形,可获得较好外翻矫形,重塑前足负重面,有效缓解行走时疼痛。     

Dorsal cheilectomy of the first metatarsophalangeal joint in the treatment of hallux rigidus

Hallux rigidus is a spectrum of osteoarthritis of the first metatarsophalangeal joint. Clinical assessment of the extent of joint involvement and the radiographic findings will lead the surgeon to the appropriate surgical procedure. An isolated dorsal cheilectomy does appear to give good functional results and pain relief in a selected patient population at the early stage of the disease process. Additional studies are necessary to evaluate the longer term outcomes of the cheilectomy procedure, as well as combined procedures such as the cheilectomy and Moberg osteotomy.     

The dowel technique for first metatarso-phalangeal joint arthrodesis in revision surgery with bone loss

Background

The operative management of failed first metatarso-phalangeal joint (MTPJ) surgery is often complicated by bone loss and shortening of the hallux. Restoration of first ray length and alignment often cannot be achieved with in situ fusion and reconstruction techniques with bone graft are therefore required. We present a novel technique of longitudinal (proximo-distal) bone dowel arthrodesis for first MTPJ arthrodesis with bone loss.

The ability to wear heeled footwear following first metatarsophalangeal joint fusion

IntroductionFusion remains the gold standard treatment for symptomatic first metatarsophalangeal joint (MTPJ) arthritis. Surgeons have traditionally advised female patients during the consenting process that they would have limitations or be unable to wear heeled footwear following first MTPJ fusion due to the loss of dorsiflexion at the first MTPJ. Anecdotally, surgeons have found that some patients were still able to continue wearing heeled footwear post fusion surgery. Heeled footwear has long been a trendy fashion accessory dating back from ancient Egyptian times and are regularly worn by a significant proportion of women today. Given the lack of literature in this matter, this study was conducted to investigate the effect of first MTPJ fusion surgery on the ability to wear heeled footwear, to aid in the consenting process.MethodsA retrospective review of 50 female patients who have had an isolated first MTPJ fusion between 2004 and 2015 at the authors’ institution was undertaken with a follow-up telephone survey which included questions on ability to wear heeled footwear pre and post-operatively, duration, and the height of heels they could wear.ResultsThis study included 50 patients (62 feet) with a mean age of 63 years (range 43–78 years) at the time of surgery, with a mean follow-up of eight years (range 5–16years) from surgery. Of the 42 patients who wore heeled footwear pre-surgery, 26 (62%) continued wearing them. The majority of them (n = 23, 88%) were able to wear the same height heels. Patients could use heeled footwear from 30 min to eight hours continuously (mean=3 h) and, 88% were able to wear heel heights of 1.5 in. or higher. None of the patients wearing heeled footwear returned to the clinic with midfoot/hindfoot symptoms, one returned for worsening of pre-existing first IPJ (interphalangeal joint) symptoms.ConclusionThis study has important implications for information given to patients during the consent process for this operation. The results have shown that many patients continue to wear heeled footwear following first MTPJ fusion with minimal or no symptoms in neighbouring joints.     

足底压力测试系统在第1跖楔关节融合术后的疗效评价

目的 :探讨足底压力测试系统对第1跖楔关节融合术后疗效的分析评价。方法:2013年6月至2014年1月,采用第1跖楔关节融合术治疗16例(20足)拇外翻伴第1序列不稳定患者,均为女性;年龄42~52岁,平均(46.5±2.9)岁;病程3~5年,平均2.5年。另选取20名健康女性为正常对照组,只选取单侧1足,共20足,年龄41~55岁,平均(46.8±4.5)岁。手术前后采用AOFAS评分系统对患足的功能。采用Foot Scan足底压力测试系统,记录并比较手术前后患足及正常对照组足第1~5跖骨头下的动态峰值压力、压强及冲量指标。结果:所有患者获得随访,时间24~30个月,平均27.4个月。术后患足拇外翻畸形得到纠正,第2跖骨头下痛性胼胝体消失。术前患足AOFAS评分(45.55±12.28)与术后(85.45±6.76)比较差异有统计学意义(P0.05);患足第1跖骨头下峰值压力、压强术前较正常组减少,差异有统计学意义(P0.05);患足第2骨头下峰值压力、压强及冲量术前较正常对照组增加,差异有统计学意义(P0.05);患足第1跖骨头下峰值压力、压强术后较术前增加,差异有统计学意义(P0.05),但与正常对照组比较差异无统计学意义(P0.05);患足术后第2跖骨头下3项指标较术前明显减少,差异有统计学意义(P0.05),与正常对照组比较差异无统计学意义(P0.05);手术前后第4、5跖骨头与正常组比较无统计学意义(P0.05)。结论:第1序列不稳定患足第1、2跖骨头下的压力与正常足有明显区别,行第1跖楔关节融合术可恢复第1、2跖骨头下正常的足底压力,而通过足底压力分析可进一步评价手术疗效。