A Consecutive Case Series of 166 First Metatarsophalangeal Joint Fusions Using a Combination of Cup and Cone Reamers and Crossed Cannulated Screws

Fusion of the first metatarsophalangeal joint (MTPJ) is the reference standard surgery for significant hallux rigidus. A number of different techniques for first MTPJ fusion have been reported. We describe our technique of first MTPJ fusion using cup and cone reamers for joint surface preparation and 2 crossed cannulated screws for fixation. To the best of our knowledge, this is the single largest series using this technique. The present study reports on a single-surgeon, consecutive series of 166 consecutive cases in 147 patients who had undergone first MTPJ fusion. The demographic data and comorbidities of the patients were collected from the digital medical records, and the radiographs were evaluated by 2 of us (S.Q., M.A.) independently to document fusion status. Radiologic nonunion was seen in 11 of 166 cases (6.6%). The mean duration of follow up was 60?±?29.5 (minimum 26, maximum 183) days. However, only 4 of the 11 cases (36%) of nonunion were clinically symptomatic and underwent revision using a bone graft and locking plate. A statistically significant difference was found in union rates among males and females (p = .01). Other factors, such as diabetes (p = .2), inflammatory arthritis (p = .5), steroids (p = .6), smoking (p = .5), hallux valgus deformity (p = .5), and concomitant forefoot surgery, did not have a statistically significant (p = .3) effect on union in our study. The union rate of first MTPJ fusion with our technique was comparable to that of others, with the advantage of being simple and less expensive compared with the use of a plate.     

Risk Factors for Nonunion After First Metatarsophalangeal Joint Arthrodesis With a Dorsal Locking Plate and Compression Screw Construct: Correction of Hallux Valgus Is Key

First metatarsophalangeal joint (MTPJ) arthrodesis is currently the gold standard technique for advanced hallux rigidus. This retrospective study aimed to identify the risk factors for nonunion after first MTPJ arthrodesis with a dorsal locking plate and compression screw construct. Between April 2014 and April 2019, 165 consecutive patients (28 men and 137 women; mean age, 60 (range, 28-84) years) who underwent 178 primary first MTPJ arthrodeses were retrospectively reviewed. All arthrodeses were performed using either a dorsal locking plate with an integrated compression screw (Anchorage CP plate, Stryker, n = 97) or a dorsal locking plate (Anchorage V2 plate, Stryker, n = 81) with a separate compression screw (4 mm cannulated ACE screw). Union was defined as bone bridging across the fusion site on at least 2 of the 3 standard foot radiographs (anteroposterior, lateral, oblique) and no MTPJ movement or pain during clinical examination. Potential risk factors for nonunion were analyzed with the use of univariate and multivariate analyses. The overall nonunion rate was 6.2% (11 of 178 cases). The risk factors identified in the univariate analysis included preoperative hallux valgus deformity, postoperative residual hallux valgus deformity, and diabetes (p < .05). Multivariate analysis confirmed that postoperative residual hallux valgus deformity (odds ratio 6.5; p= .015) and diabetes (odds ratio 7.4; p = .019) are independent risk factors for nonunion after first MTPJ arthrodesis. Diabetes is the most important independent risk factor for nonunion after first MTPJ arthrodesis with a dorsal locking plate and compression screw construct. A residual postoperative hallux valgus deformity is associated with a significantly increased risk for nonunion. It is therefore crucial to correct the hallux valgus deformity to a hallux valgus angle of less than 20°.     

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.     

Treating Hallux Valgus Associated Metatarsus Adductus by Minimally Invasive Surgery: A Simple Solution for a Difficult Problem

This study aims to assess a novel minimally invasive surgical technique that addresses hallux valgus accompanied by metatarsus adductus.We retrospectively analysed the results of 20 patients (21 feet) that underwent a newly developed percutaneous osteotomy procedure of the lesser metatarsal bones in order to correct hallux valgus deformities accompanied by metatarsus adductus. We used x-ray studies in order to evaluate changes in the hallux valgus angle, the first intermetatarsal angle, and the metatarsal angle (using the modified Sgarlato method). We also compared the pre- and postoperative American Orthopaedic Foot and Ankle Society scores when available. The paired sample t test was used to compare variables.At a 1-y follow-up the mean hallux valgus angle, inter-metatarsal angle and the metatarsal angle have been reduced by 31.62 (-3 to 9), 3.86 (11-52) and 14.69 (4-36) respectively (p < .001 for all). The mean American Orthopaedic Foot and Ankle Society score (n = 15 feet available) has been improved by a mean of 44.53 (22-72, p < .001). In addition, the patient satisfaction rates were high. Patients suffered from mild to moderate midfoot pain during the first few weeks following surgery, which resolved when union occurred. No cases of lesser metatarsal nonunion have been documented.The presented minimally invasive method can be used effectively to correct hallux valgus that is associated with metatarsus adductus. Proximal minimally invasive metatarsal osteotomy can effectively correct hallux valgus accompanied by metatarsus adductus.     

Observed Changes in Radiographic Measurements of the First Ray after Frontal Plane Rotation of the First Metatarsal in a Cadaveric Foot Model

We observed the changes in the angular measurements commonly used in the evaluation of the first metatarsal and first metatarsophalangeal joint in cadaveric specimens before and after frontal plane rotation of the first metatarsal. Measurements of the first and second intermetatarsal angle (IMA), hallux abductus angle, proximal articular set angle, and tibial sesamoid position (TSP) were taken after varying degrees of varus and valgus rotation of the first metatarsal. Standard dorsoplantar radiographs were taken at 0°, 10°, 20°, and 30° of valgus rotation of the first metatarsal and repeated at 10°, 20°, and 30° varus rotation of the first metatarsal. The data were analyzed using a mixed linear model to compare the change in each angle measurement over the range of valgus and varus rotation. The change in the TSP was significant in both valgus and varus rotations (p = .0004 and p = .028, respectively), an increase in valgus rotation causing an increase in the TSP and an increase in varus rotation causing a decrease in TSP. The change in the IMA was significant compared with valgus rotation (p = .028), showing that as the valgus rotation increased, the IMA also increased. However, compared with the varus rotation, the correlation was not significant (p = .18). The proximal articular set angle and hallux abductus angle measurements, compared with metatarsal rotation, showed positive trends but were not statistically significant. From our results and a review of the published data, we have hypothesized that frontal plane rotation of the first metatarsal is an integral component of hallux abducto valgus pathologic features, specifically in relation to the TSP and IMA.     

The Effect of Hallux Valgus Surgery on the Transverse Plane Hallux Proximal Phalanx Position

The objective of this investigation was to evaluate the apparent movement of the hallux proximal phalanx in the transverse plane relative to the second metatarsal following hallux valgus surgery. Pre- and postoperative radiographs of a consecutive series of 45 feet undergoing hallux valgus surgery were analyzed. Significant improvements were observed in the first intermetatarsal angle (12.4 vs 7.5 degrees; p < .001), hallux valgus angle (24.3 vs 13.4 degrees; p < .001), tibial sesamoid position (4.6 vs 2.7; p < .001), and second metatarsal-hallux proximal phalanx angle (80.1 vs 84.6 degrees; p < .001). No difference was observed in the distance between the second metatarsal bisection and the medial aspect of the tibial sesamoid (31.7 vs 31.5 mm; p = .756) nor between the second metatarsal bisection and medial aspect of the hallux proximal phalanx base (34.6 vs 34.2 mm; p = .592). Significant differences were observed between the second metatarsal bisection and the central aspect of hallux proximal phalanx base (26.5 vs 23.9 mm; p < .001) and between the second metatarsal bisection and the lateral aspect of the hallux proximal phalanx base (19.3 vs 15.4 mm; p < .001). A statistically significant difference was observed in the change of distance between the second metatarsal bisection and the medial, central, and lateral aspects of the hallux proximal phalanx base (-0.4 vs -2.6 vs -3.9 mm; p = .002). These results indicate that the hallux proximal phalanx does not translocate in the transverse plane following hallux valgus surgery, but instead pivots about the medial aspect of the joint.     

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.     

Medial Locking Plate Versus Screw Fixation for Fixation of the Ludloff Osteotomy

A prospective cohort study of the Ludloff osteotomy, stabilized with either lag screws or a locking plate, was undertaken from May 2001 to November 2010, involving patients treated for hallux valgus with a first intermetatarsal angle greater than 15°. All patients were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) and Roles and Maudsley scores before and after surgery. The cohort included 119 procedures in 112 patients, 91 (76.47%) of which were fixated with lag screws and 28 (23.53%) with locking plates. The participants were categorized as active (n = 69 procedures) or athletic (n = 50 procedures). The overall mean patient age was 45.5 ± 14.2 years. No statistically significant differences were found between the fixation groups relative to age, preoperative AOFAS and Roles and Maudsley scores, and postoperative AOFAS scores. Postoperatively, the mean Roles and Maudsley score for the lag screw group was 1.8 ± 0.6 and that for the locking plate group was 2.2 ± 0.7 (p < .009). In both groups, the AOFAS scores improved significantly (p < .0001) after surgery. The mean interval to return to activity in the athletes was 3.6 ± 1.1 months and was 3.9 ± 1.2 weeks in the active group (p = .16). Also, 4 of the active patients (5.8%) failed to return to their desired activity level. Overall, 6 (5%) recurrent hallux valgus deformities were observed, 5 (4.2%) in the lag screw group and 1 (.8%) in the locking plate group (p = .57). Of the 6 recurrences, 5 occurred (4.2%) in patients older than 50 years (p = .05).     

Relationship between lower limb muscle strength and hallux valgus severity in older people

ObjectiveTo examine differences in lower limb muscle strength between older people with varying degrees of hallux valgus deformity.MethodsMuscle strength was measured at the knee, ankle and foot using hand-held dynamometry and a clinical test of toe strength (the paper grip test) in 157 older people (99 women and 58 men) aged 65 to 91 (mean 74.1, SD 5.9) years. Hallux valgus severity was documented as none, mild, moderate or severe using validated photographs. Differences in muscle strength according to hallux valgus severity were evaluated using analysis of variance, adjusting for age. Paper grip test performance was compared across the hallux valgus severity groups using the chi-square (χ²) statistic.ResultsKnee extension, ankle joint dorsiflexion, ankle joint plantar flexion, ankle joint inversion, ankle joint eversion and lesser toe plantarflexion strength were not significantly different across the four hallux valgus severity groups. However, there was a significant, dose-response reduction in hallux plantarflexion strength with increasing severity of hallux valgus. This persisted after adjustment for age (F₃ = 5.5, p = 0.001) with a medium effect size (partial η² = 0.10). The number of participants who could successfully complete the paper grip test of the hallux significantly reduced across the four hallux valgus categories (χ² = 18.5, p < 0.001).ConclusionsThere is a specific and progressive reduction in hallux plantarflexion strength with increasing severity of hallux valgus in older people. This finding has potential implications for both the aetiology and treatment of this common and disabling condition.     

Arthroscopic Subtalar Arthrodesis: Does the Type of Fixation Modify Outcomes?

The goal of the present study was to analyze a modified American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale score, time to union, and the incidence of fusion after isolated arthroscopic posterior subtalar arthrodesis using either 1 or 2 screws of different diameters. We reviewed a consecutive series of 65 patients, mean age 50.0?±?15.6 years, including 38 males (58.5%) and 27 females (41.5%), who had undergone arthrodesis from May 2004 to February 2011. The mean follow-up duration was 57.5 (range 24 to 105) months. The patients were divided into 3 groups according to the fixation method used: group 1 (n = 12; 18.5%) underwent fixation with one 6.5-mm screw; group 2 (n = 40; 61.5%) with one 7.3-mm screw; and group 3 (n = 13; 20%) with two 7.3-mm screws. An overall statistically significant (p?<.0001) improvement was seen in the modified AOFAS scale score for all 3 fixation groups; however, the difference was not statistically significant (p?=?.79) among the fixation groups. Fusion was achieved in 62 patients (95.4%) after a mean of 12.1 (range 9 to 16) weeks. The difference in the time to union was not statistically significant (p?=?.781) among the fixation groups. Nine patients (13.8%) experienced complications, and nonunion was significantly (p?=?.005) more prevalent in the single 6.5-mm screw group. In conclusion, all 3 screw configurations led to improved modified AOFAS scale scores, although nonunion was more common among patients fixed with a single 6.5-mm screw.     

Relationship between Hallux Valgus and Pes Planus in Adult Patients

This study aimed to determine whether the degree of pes planus was associated with hallux valgus severity and hallux valgus surgery outcomes. A total of 122 feet were retrospectively analyzed after hallux valgus surgery. The hallux valgus angle, inter-metatarsal angle, lateral talo-first metatarsal angle, calcaneal pitch, and talonavicular coverage angle were measured. The Foot and Ankle Outcome Score and Foot Function Index were evaluated. A significant correlation between radiographic parameters of pes planus and hallux valgus severity, radiographic outcomes, Foot and Ankle Outcome Score, and Foot Function Index were not noted. The hallux valgus angle and inter-metatarsal angle changed significantly after the surgery (p < .001 and p < .001, respectively); however, a significant difference was not noted between the pes planus and non-pes planus groups (p = .279 and p = .632, respectively). A significant interaction between the time points and groups was not observed with respect to the hallux valgus angle (p = .311) and inter-metatarsal angle (p = .417). Multivariable logistic regression revealed that none of the radiographic parameters for pes planus affected hallux valgus recurrence. Pes planus in adult patients is not significantly associated with hallux valgus severity and recurrence, radiographic outcomes, or clinical scores.     

Comparison between Pin Fixation and Combined Screw Fixation in Proximal Chevron Metatarsal Osteotomy for Hallux Valgus Deformity Correction

BackgroundProblems associated with hallux valgus deformity correction using Kirschner-wire (K-wire) fixation include pin pullout and loss of stability. These complications are pronounced in the osteopenic bone, and few reports have focused on pin versus screw fixation. We examined the use of additional screw fixation to avoid these problems. The aim of this study was to compare outcomes of K-wire fixation (KW) and a combined K-wire and screw fixation (KWS).MethodsTwo groups with hallux valgus deformity, who were treated with a proximal chevron metatarsal osteotomy (PCMO), were compared based on the fixation method used. The KW group included 117 feet of 98 patients, and the KWS group included 56 feet of 40 patients. Clinically, the preoperative and final follow-up visual analog scale (VAS) pain score, American Orthopedic Foot & Ankle Society (AOFAS) hallux score, and patient satisfaction score were evaluated. Radiographically, hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured.ResultsThe mean VAS score decreased from 6.3 preoperatively to 1.6 postoperatively in the KW group and from 5.7 preoperatively to 0.5 postoperatively in the KWS group (p < 0.001). The mean AOFAS scores of the KW and KWS groups improved from 59.4 and 58.2, respectively, to 88.9 and 95.3, respectively (p < 0.001). Eighty-five percent in the KW group and 93% in the KWS group were satisfied with surgery. Clinical differences were not significant. The mean HVAs decreased from 34.7° to 9.1° in the KW group and from 38.5° to 9.2° in the KWS group (p < 0.001). The mean IMA decreased from 14.5° (range, 11.8°–17.2°) to 6.4° (range, 2.7°–10.1°) in the KW group and from 18.0° (range, 14.8°–21.2°) to 5.3° (range, 2.5°–8.1°) in the KWS group (p < 0.001). When IMA values at the 3-month postoperative and the final follow-up were compared, the IMA was significantly increased only in the KW group (p < 0.001) and no difference was found in the KWS group (p = 0.280).ConclusionsWe found a statistically significant difference in the decrease in IMA between the 2 groups. We recommend the combined pin and screw fixation in PCMO to enhance fixation stability and prevent potential hallux valgus correction loss.     

Association between preoperative dynamic plantar pressures and clinical outcomes at 6 months after hallux valgus surgery

BackgroundThe influence of preoperative plantar pressures on clinical outcomes following hallux valgus surgery has not been yet established. This study aimed to assess the relationship between preoperative dynamic plantar pressure measurements and clinical outcomes following hallux valgus surgery.Material and methodsA prospective cohort study where patients attending the foot and ankle unit between 2016 and 2017, diagnosed of hallux valgus requesting surgical correction were recruited consecutively and preoperative plantar pressure were measured. At 6-months after surgery, the foot condition and foot pain were measured, through the American Orthopedic Foot and Ankle Society Score (AOFAS), and using Visual Analog Scale (VAS), respectively. A multivariate logistic model was used to estimate the magnitude of the associations between the explanatory variables and outcomes.Results114 patients were included in the study. Significant differences between patients with and without pain at 6-months after surgery were found in mean force on first toe, peak pressure on third and fourth metatarsal head, and maximum force on fourth and fifth metatarsal head (p < 0.05). The multivariate logistic model showed significant association between the preoperative peak pressure on fourth metatarsal head (OR:0.996, p = 0.003), walking (OR:7.430, p < 0.001), orthopedic shoe after surgery period (OR:0.754, p = 0.019) and preoperative AOFAS (OR:0.947, p = 0.006), and the appearance of pain at 6-months after surgery.ConclusionThe presence of pain at six months after surgery was significantly associated with the preoperative peak pressure under the fourth metatarsal head.     

Effectiveness of the First Metatarsophalangeal Joint Arthrodesis Versus Arthroplasty for Rheumatoid Forefoot Deformity: A Systematic Review and Meta-Analysis of Comparative Studies

To compare the clinical outcomes of resection arthroplasty of metatarsals 2-5 with either first metatarsophalangeal joint arthrodesis or arthroplasty for rheumatoid forefoot deformity treatment. Comparative studies on the clinical effects of resection arthroplasty of metatarsals 2-5 with either first metatarsophalangeal joint arthrodesis or arthroplasty for the treatment of rheumatoid forefoot deformity were systematically reviewed and a meta-analysis conducted. A total of 337 patients (459 feet) with rheumatoid forefoot deformity from 6 comparative studies were included, with the mean follow-up times ranging from 25 to 80 months in the arthrodesis group and 35 to 102 months in the arthroplasty group. Postoperative pain, satisfaction, hallux valgus angle, the 1^st –2^nd intermetatarsal angle, adverse events mainly including non-union and the reoperation rate, and pedobarographic data were reported. In the pooled analysis, there were no significant pain score differences between 1^st metatarsophalangeal joint arthrodesis and arthroplasty groups (SMD = 0.04, p = .734; I² = 43.7%, p = .149), but the hallux valgus angle and the 1^st –2^nd intermetatarsal angle showed significant differences between these 2 groups (For hallux valgus angle, SMD = -0.439, p = .002; I² = 96.6%, p = .000; for 1^st –2^nd intermetatarsal angle, SMD = -0.569, p = .000; I² = 98.2%, p = .000). The rate of non-union varied from 0% to 26% in the arthrodesis group. The reoperation rate varied from 3% to 9.6% in the arthrodesis group and from 4% to 11.6% in the arthroplasty group. A comparison of the procedures showed that first metatarsophalangeal joint arthrodesis with resection arthroplasty of the lesser rays produced similar postoperative pain relief and better maintenance of the hallux valgus angle and the 1^st –2^nd intermetatarsal angle for rheumatoid forefoot deformity. However, the results should be interpreted with caution due to the high heterogeneity and relatively low quality of the reviewed articles.     

Biomechanical Comparison of Internal Fixation Techniques for the Akin Osteotomy of the Proximal Phalanx

The Akin osteotomy is performed at the proximal phalanx for correction of an abducted great toe in a hallux abducto valgus deformity. Several internal fixation techniques have been widely advocated; however, their respective stabilities have not been compared. A biomechanical analysis was performed comparing 5 commonly used fixation techniques for the Akin osteotomy to determine the strongest method in simulated weightbearing in sawbone models. An Akin osteotomy was uniformly performed on 25 sawbones and fixated with 5 different internal fixation types, including a 2-hole locking plate and locking screws, a heat-sensitive memory staple (8 mm × 8 mm), a 28-gauge monofilament wire, 2.7-mm bicortical screws, and crossed 0.062-in. Kirschner wires. The results of simulated weightbearing load to failure rates with an Instron compression device demonstrated the following mean load to failures: crossed Kirschner wire, 57.05 N; 2-hole locking plate, 36.49 N; monofilament wire, 35.69 N; heat-sensitive memory staple, 34.32 N; and 2.7-mm bicortical screw, 13.66 N. Statistical analysis demonstrated the crossed Kirschner wire technique performed significantly better than the other fixation techniques (p < .007); the 4 other techniques were found not to be significantly different statistically (p = .041) from each another. Our study results suggest a crossing Kirschner wire construct significantly increases the stability of the Akin osteotomy in a sawbone model. This might be clinically extrapolated in an effort to improve patient outcomes because these osteotomies can undergo nonunion and malunion, resulting in postoperative pain and swelling.     

Observed Changes in Radiographic Measurements of the First Ray after Frontal and Transverse Plane Rotation of the Hallux: Does the Hallux Drive the Metatarsal in a Bunion Deformity?

It is well known that the pathologic positions of the hallux and the first metatarsal in a bunion deformity are multiplanar. It is not universally understood whether the pathologic changes in the hallux or first metatarsal drive the deformity. We have observed that frontal plane rotation of the hallux can result in concurrent positional changes proximally in the first metatarsal in hallux abducto valgus. In the present study, we observed the changes in common radiographic measurements used to evaluate a bunion deformity in 5 fresh frozen cadaveric limbs. We measured the tibial sesamoid position, 1-2 intermetatarsal angle, and first metatarsal cuneiform angle on anteroposterior radiographs after frontal and transverse plane manipulation of the hallux. When the hallux was moved into an abducted and valgus position, a statistically significant increase was found in the tibial sesamoid position (p = .016). However, we did not observe a significant increase in the intermetatarsal angle (p = .070) or medial cuneiform angle (p = .309). When the hallux was manipulated into an adducted and varus position, a statistically significant decrease in the intermetatarsal angle (p = .02) and a decrease in the tibial sesamoid position (p = .016) was seen, with no significant change in the medial cuneiform angle (p = .360). We also observed a consistent rounding of the lateral aspect of the first metatarsal head and an increase in the concavity of the lateral metatarsal shaft, with valgus rotation of the hallux. From these observations, it is possible that the hallux could drive the proximal changes in the first ray that lead to metatarsus primus adducto valgus deformity.     

Surgery Performed by Supervised Trainees Does not Affect Outcome in First Metatarsophalangeal Joint (MTPJ) Arthrodesis

First metatarsophalangeal joint (MTPJ) arthrodesis is an index procedure for orthopedic trainees in the United Kingdom. There is an absence of evidence as to the outcome of surgery when performed by supervised trainees. The aim of this study is to compare the incidence of fusion, complication rate and radiographic outcomes in first MTPJ arthrodesis performed by supervised orthopedic trainees with consultants. This is a retrospective cohort study of 117 patients undergoing first MTPJ arthrodesis from August 2015 to December 2017 in our institute for hallux valgus (HV) deformity with first MPTJ arthrosis or for hallux rigidus. Patients were followed to a minimum of 1-year postsurgery and were given an open appointment thereafter. In the hallux rigidus group, there was no significant difference between the complication rate (p = .477), incidence of fusion (p = .663), postoperatively HVA (p = .763), and postoperative intermetatarsal angle (p = .539) between trainees and consultants. There was a significant difference in mean tourniquet time (p = .563) between trainees and consultants. In the hallux valgus group, there was no significant difference in the complication rate (p = .519), incidence of fusion (p = .786), tourniquet time (p = .075), postoperative HVA (p = .423), and postoperative intermetatarsal angle (p = .143) between the trainees and consultants. This is the first MTPJ fusion series that demonstrates good results can be achieved by supervised trainees performing the procedure. This would suggest that first MTPJ arthrodesis remains an opportunity for trainees to continue learning to perform under supervision whilst ensuring no change in outcome for the patient.     

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 1^st 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 1^st MTP joint, namely delayed union, nonunion, malunion, irritating hardware, etc.      

Does the length of the plate affect the failure rate of hallux MTP joint arthrodesis for severe hallux valgus?

PurposeThe purpose of this study was to investigate the effect of the length of the dorsal locking plate on the failure rate of first MTP joint arthrodesis for severe hallux valgus deformities.MethodsA retrospective review was conducted for all patients who underwent first MTP joint arthrodesis using solely a specific locked plating system (Depuy-Synthes, Raynham, MA) for severe hallux valgus deformities between January 2014 to June 2017. Patients were divided into subgroups according to the length of the plate and the failure rate was investigated. Furthermore, radiographic parameters including intermetatarsal angle (IMA) and hallux valgus angle (HVA) were evaluated in weightbearing AP foot radiographs.ResultsA total of 25 patients were included in this study. There were 16 (64%) patients in the medium-sized plate cohort and 9 (36%) patients in the small-sized plate cohort. We found a significant difference in the failure rate between the two groups; only 1 (6.25%) failure case occurred in the medium-sized plate cohort while 4 (44.44%) failure cases occurred in the small-sized plate cohort (P = .040, Odds ratio (OR) = 12.000, 95% Confidence Interval (CI) = 1.074, 134.110). The mean postoperative IMA and HVA were significantly improved in both cohorts. However, significant differences were found between the two cohorts in final follow-up IMA and HVA (P = .002 and P < .001, respectively).ConclusionsFor severe hallux valgus deformities, the use of longer plates to gain additional purchase in the diaphyseal bone may help mitigate the increased stresses placed on the fixation constructs for first MTP joint arthrodesis and decrease failure rate.Level of EvidenceLevel III, case control study.     

Crossed Screw Fixation Versus Dorsal Plating for First Metatarsophalangeal Joint Arthrodesis: A Retrospective Cohort Study

Multiple fixation techniques for first metatarsophalangeal joint arthrodesis have been described with an average fusion rate of 93.5%. This retrospective cohort study assesses the association between crossed screws (vs dorsal plating) and medical comorbidities and the outcome radiographic union. Bivariate tests of association and multivariable logistic regression were employed to assess differences across fixation type and outcomes. We identified 305 patients who underwent a first metatarsophalangeal joint arthrodesis during the study period. Crossed screw fixation was used in 158 (51.8%) patients while dorsal plating (tubular or anatomic locking plate) was used in 147 (48.2%) patients. Dorsal plating was utilized more often in patients with rheumatoid arthritis (p = .019) and history of smoking (p = .044). At 12 weeks post-operatively there were no significant differences in fusion rates between the two groups (crossed screw group = 95.3% vs dorsal plate group (referent) = 93.5%, Adjusted odds ratio (AOR) 1.39, 95% confidence interval [CI] 0.45-4.26). Not smoking was associated with a greater odds of fusion at 12 weeks (96.2% for nonsmokers vs 75.0% for smokers (referent), AOR 0.07, 95% CI 0.02-0.28). Lower body mass index was associated with a greater odds of fusion at 12 weeks (AOR 0.90, 95% CI 0.82-0.99). Surgeons allowed weightbearing earlier with dorsal plate fixation (2 weeks (interquartile range [IQR] 2.6) versus 5 weeks (IQR 2.6) for crossed screw fixation, p = .001). Patients with multiple medical comorbidities were more likely to require revision surgery than patients having 0-1 comorbidities (p < .05). Crossed screws can provide an inexpensive yet effective option for first metatarsophalangeal joint arthrodesis.