Arthrodesis of the hallux interphalangeal joint using a diagonally placed 2-mm. cortical bone screw

Arthrodesis of the interphalangeal joint of the hallux is quite often needed in conjunction with first metatarsophalangeal joint interpositional arthroplasty. With the exception of two cited techniques, the authors believe all previously described methods of achieving interphalangeal joint arthrodesis are inconsistent in their results and in their ability to be performed in conjunction with first metatarsophalangeal joint procedures. The authors, therefore, sought a more practical, efficacious method of achieving hallux interphalangeal joint arthrodesis in the presence of first metatarsophalangeal joint implants, while still using ASIF-AO compressive technique. Presented is their technique of hallux IPJ arthrodesis using a diagonally placed 2-mm. cortical bone screw.     

Biomechanical comparison of two fixation methods for first metatarsophalangeal joint arthrodesis

PURPOSE: The aim of this study was to compare the mechanical stability of two methods of fixation for arthrodesis of the hallux metatarsophalangeal joint: 1. a technique using an intramedullary screw and 2. a standard technique using crossed interfragmentary compression screws. METHODOLOGY: The metatarsophalangeal joint was mechanically evaluated in cantilever bending using a servohydraulic testing machine. Differences in stiffness and strength parameters between the two techniques were checked for significance (P<0.05) using a paired t-test. RESULTS: Fixation provided by the intramedullary screw was stiffer and stronger than that from crossed compression screws. CONCLUSIONS: The stronger and stiffer intramedullary screw technique offers mechanical advantages over the crossed interfragmentary screw technique.     

Single absorbable polydioxanone pin fixation for distal chevron bunion osteotomies

The distal chevron osteotomy is a well-established technique for correction of symptomatic mild to moderate metatarsus primus varus with hallux valgus deformity. Fixation of the osteotomy ranges from none to bone pegs, Kirschner wires, screws, or absorbable pins. We evaluated one surgeon's (J.K.D.) results of distal chevron osteotomy fixation with a single, nonpredrilled, 1.3-mm poly-p-dioxanone pin and analyzed any differences in patients with unilateral or bilateral symptomatic metatarsus primus varus with hallux valgus deformities. All osteotomies healed without evidence of infection, osteolysis, nonunion, or necrosis. Equal correction was achieved in unilateral and bilateral procedures. The technique is quick and easy, and adequate fixation is achieved.     

An alternative fixation technique when performing hallux interphalangeal joint fusions

Fusion of the hallux interphalangeal joint has classically been performed by means of cancellous bone screws or crossed Kirschner wires. Although these techniques may be suitable for uncomplicated fusions, they may not be amenable to those cases requiring simultaneous total first metatarsophalangeal joint implant arthroplasty; therefore, a new technique is discussed that utilizes the Micks' external fixator.     

Usefulness of bioabsorbable thread pins after resection arthroplasty for rheumatoid forefoot reconstruction

BACKGROUND: Bioabsorbable thread pin has been used for internal fixation of bone. The results of resection arthroplasty of the lesser metatarsophalangeal (MTP) joints using internal intramedullary fixation with bioabsorbable pins have not been reported. METHODS: Resection arthroplasty of the MTP joints of the lesser toes with poly-L-lactic acid (PLLA) thread pins or Kirschner wires was performed at random in reconstruction of the 87 rheumatoid forefeet (62 patients) with a grommet-protected silicone-rubber implant insertion of the first MTP joint. Clinical symptoms, the state of radiographic changes, and complications were assessed 5-10 years (average, 7.7 years) postoperatively. RESULTS: The mean American Orthopaedic Foot and Ankle Society clinical scores at the preoperative and latest points were 31 and 91, respectively, in the operated patients with PLLA pins, while the mean scores were 32 and 82, respectively, in the operated patients with Kirschner wires. The lesser toes treated by bioabsorbable pins did not become rigid, although they were stable. Recurrent dorsal subluxation of the lesser MTP joints was visible on radiographs in three of the 46 feet with PLLA pins, while two feet had three dislocated MTP joints and one subluxated MTP joint postoperatively and recurrent dorsal subluxation of the lesser MTP joints was visible in four of the 41 feet with Kirschner wires. The postoperative hallux valgus did not progress to the preoperative level during the follow-up period in both groups. Two of the 46 feet with PLLA pins and two of the 41 feet with Kirschner wires had radiographic evidence of silicone synovitis without pathological fracture. Three patients with Kirschner wires had wire-track infection, and one patient had severe circulation disturbance of the corrected lesser toes necessitating wire removal. CONCLUSIONS: A new trial of internal fixation with bioabsorbable pins may lead to the establishment of a safe method for enhancing stability of the lesser toes after resection arthroplasty of the lesser MTP joints.     

ARTHRODESIS OF THE DISTAL INTERPHALANGEAL JOINT USING A BIOABSORBABLE ROD AS AN INTRAMEDULLARY NAIL

There are several fixation techniques for arthrodesis of the distal interphalangeal joint. Since February 1999 we have used a bioabsorbable (poly-L-lactide, PLLA) rod as an intramedullary nail for arthrodesis of 15 distal interphalangeal joints and one interphalangeal joint of the thumb. The advantages include the absence of protruding hardware that would require removal, and technical simplicity. Preoperative diagnoses included degenerative arthritis in five patients, post-traumatic arthritis in 10 patients, and non-union after arthrodesis with crossed Kirschner wires in one patient. All patients were observed until there was clinical and radiographic evidence of fusion with the mean interval to fusion of 8 weeks (range 6-12). There were two cases of minor intermittent local swelling, which resolved. Fixation with a PLLA rod for arthrodesis of the distal interphalangeal joint is a simple and effective technique.     

Arthrodesis of the distal interphalangeal joint using a bioabsorbable rod as an intramedullary nail.

There are several fixation techniques for arthrodesis of the distal interphalangeal joint. Since February 1999 we have used a bioabsorbable (poly-L-lactide, PLLA) rod as an intramedullary nail for arthrodesis of 15 distal interphalangeal joints and one interphalangeal joint of the thumb. The advantages include the absence of protruding hardware that would require removal, and technical simplicity. Preoperative diagnoses included degenerative arthritis in five patients, post-traumatic arthritis in 10 patients, and non-union after arthrodesis with crossed Kirschner wires in one patient. All patients were observed until there was clinical and radiographic evidence of fusion with the mean interval to fusion of 8 weeks (range 6-12). There were two cases of minor intermittent local swelling, which resolved. Fixation with a PLLA rod for arthrodesis of the distal interphalangeal joint is a simple and effective technique.     

First metatarsal-phalangeal joint arthrodesis: a biomechanical assessment of stability

BACKGROUND: First metatarsal phalangeal joint (MTP) arthrodesis is a commonly performed procedure for the treatment of hallux rigidus, severe and recurrent bunion deformities, rheumatoid arthritis and other less common disorders of the joint. There are different techniques of fixation of the joint to promote arthrodesis including oblique lag screw fixation, lag screw and dorsal plate fixation, crossed Kirschner wires, dorsal plate fixation alone and various types of external fixation. Ideally the fixation method should be reproducible, lead to a high rate of fusion, and have a low incidence of complications. METHODS: In the present study, we compared the strength of fixation of five commonly utilized techniques of first MTP joint arthrodesis. These were: 1. Surface excision with machined conical reaming and fixation with a 3.5 mm cortical interfragmentary lag screw. 2. Surface excision with machined conical reaming and fixation with crossed 0.062 Kirschner wires. 3. Surface excision with machined conical reaming and fixation with a 3.5 mm cortical lag screw and a four hole dorsal miniplate secured with 3.5 mm cortical screws. 4. Surface excision with machined conical reaming and fixation with a four hole dorsal miniplate secured with 3.5 mm cortical screws and no lag screw. 5. Planar surface excision and fixation with a single oblique 3.5 mm interfragmentary cortical lag screw. Testing was done on an Instron materials testing device loading the first MTP joint in dorsiflexion. Liquid metal strain gauges were placed over the joint and micromotion was detected with varying loads and cycles. RESULTS: The most stable technique was the combination of machined conical reaming and an oblique interfragmentary lag screw and dorsal plate. This was greater than two times stronger than an oblique lag screw alone. Dorsal plate alone and Kirschner wire fixation were the weakest techniques. CONCLUSIONS: First MTP fusion is a commonly performed procedure for the treatment of a variety of disorders of the first MTP joint. The most stable technique for obtaining fusion in this study was the combination of an oblique lag screw and a dorsal plate. This should lead to higher rates of arthrodesis.     

Hinged External Fixation Distraction for Treatment of First Metatarsophalangeal Joint Arthritis

Treatment for hallux rigidus varies from joint preservation to joint destructive procedures. The objective of the present study was to report an alternative method of treatment of hallux rigidus using hinged external fixation distraction of the first metatarsophalangeal joint and to present our surgical technique. Ten distractions were performed in 9 patients (9 female feet [90%] and 1 male foot [10%]). The mean age at surgery was 41.0 (range 20 to 64) years. All patients had stage II or III hallux rigidus on the Regnauld classification system for hallux rigidus. The patients were evaluated clinically and radiographically before and after the distraction treatment. The mean period of fixation was 16.40 (range 7 to 21) weeks. Six of the patients (60%) with distraction experienced pin tract infections that were treated with oral antibiotics. The reported mean preoperative categorical pain score in 7 patients (7 feet) was 8.2 (range 5 to 10), and the postoperative score was 0.83 (range 0 to 2; p = .001). Of the 6 patients (6 feet) who responded to the remaining portion of the survey, 4 (66.67%) were very satisfied with their results, and 2 (33.33%) were satisfied with their surgical result. None of the patients required additional surgical treatment during the mean 2.2 (range 1.2 to 3.3) years of follow-up. Hinged first metatarsophalangeal joint distraction with external fixation has been shown to be a viable treatment option for joint preservation for stage II and III hallux rigidus in the short term.     

Low-profile Titanium Plate Construct for Early Weightbearing with First Metatarsophalangeal Joint Arthrodesis

First metatarsophalangeal joint arthrodesis is a useful procedure for various first ray pathologic entities. Multiple constructs for fixation have provided successful fusion. A retrospective study of 21 feet (18 patients) was performed after first metatarsophalangeal joint fusion using crossed Kirschner wires or compression fixation with cannulated screws followed by the application of a 2-hole low-profile partially locking titanium plate. The median age was 59 (range 41 to 76) years, and we had 4 smokers and 3 patients with diabetes in our series. Postoperatively, a compression dressing with a posterior splint was applied. The patients then transitioned to a controlled ankle motion walker, and all patients reported full weightbearing by 2 weeks postoperatively. The mean follow-up duration was 11.43 (range 6 to 27) months. The overall primary fusion rate was 95.24% (20 of 21). Two nonunions occurred; one was asymptomatic and successfully consolidated at 12 months. The second nonunion required revisional surgery with an autogenous bone graft to heal successfully. This patient was noncompliant with the postoperative regimen and had a 48-pack year history of tobacco usage. Our results have shown early weightbearing after first metatarsophalangeal joint arthrodesis can be successfully initiated with splintage or lag screw fixation and a 2-hole, low-profile, partially locking titanium plate.     

Disorders of the hallucal interphalangeal joint

Most clinical presentations of the hallux concern the metatarsophalangeal joint; however, interphalangeal joint (IPJ) pathology also may be clinically significant. This article reviews conditions that commonly affect the hallucal IPJ and the appropriate treatment.     

Arthrodesis of the first metatarsophalangeal joint as salvage for the failed Keller procedure

Arthrodesis of the first metatarsophalangeal joint was performed in eleven patients (sixteen feet) after a Keller procedure had failed. Multiple intramedullary threaded Steinmann pins were used to fix the bone at the site of the arthrodesis, and a successful arthrodesis was achieved in each patient. Interposition of a graft of bone from the iliac crest was done in four feet with an excessively short hallux. Lateral metatarsalgia that was due to intractable keratoses on the plantar part of the foot was relieved in eleven (92 per cent) of the twelve feet that had it preoperatively. Cock-up deformity of the hallux was also improved. Residual stiffness of the interphalangeal joints, which was a major preoperative problem, was not improved. Arthrodesis of the first metatarsophalangeal joint is a useful procedure to salvage a failed result of the Keller procedure.     

Second metatarsophalangeal joint fusion: A new technique for crossover hammertoe deformity. A preliminary report

The author reports on second metatarsophalangeal joint arthrodesis for the severe crossover hammertoe deformity. Eleven patients underwent an arthrodesis of the second metatarsophalangeal joint with a.062 Kirschner wire intramedullary fixation and a dorsal small bone staple and resection of the proximal phalangeal head of the second digit. Outcomes were retrospectively reviewed at average follow-up time of 19 months. A subjective patient satisfaction survey along with a clinical and radiographic evaluation was undertaken in the postoperative period. Ten of 11 patients scored good to excellent results based on the patient subjective survey at final follow-up. Ten of 11 patients obtained primary arthrodesis. One patient experienced an asymptomatic nonunion. This new technique appears to be reliable for the maintenance of long-term correction of a crossover second toe with arthrodesis of the second metatarsophalangeal joint.     

Migration of a broken Kirschner wire from an acromioclavicular joint into the neck: a case report

Migration of Kirschner wires and Steinmann pins when they are used for internal fixation of the shoulder girdle is a known complication, which could sometimes result in life threatening situations. A case of pin breakage used for fixation of an acromioclavicular joint dislocation with subsequent migration of its medial end into the neck is presented emphasizing the fact that bending the outer end of the wire doesn’t guarantee safety and wire migration is possible after its breakage. It seems that the most reliable way to avoid this complication is close radiographic follow up of the patient and removal of wire or pin at an appropriate time.     

Arthrodesis for degenerative disease of the hallux metatarsophalangeal and interphalangeal joints

Arthrodesis of the hallux metatarsophalangeal (MTP) or interphalangeal (IP) joint is a sound surgical solution to degenerative disease of these joints. Where conservative measures have failed, MTP or IP arthrodesis can alleviate pain and normalize gait. Preoperative planning should include evaluation of the skin, bone quality, and range of motion of the involved and adjacent joints. The technique of joint preparation described allows for easily individualized fusion position and maintenance of length. In patients with adequate bone stock, the fixation techniques described provide for compression and obviate the need for removal for most patients. Where bone stock is questionable, plate fixation can provide stability, improving results. With careful patient selection, preoperative planning, and conservative postoperative care, predictable results can be obtained with these techniques.     

Follow-up results 17 years after resection arthroplasty of the great toe

Resection arthroplasty of the first metatarsophalangeal joint is a well-known operation. The follow-up results more than 17 years after arthroplasty for hallux valgus are reported and discussed. Between 1971 and 1980, 335 resection arthroplasties were performed on 205 patients. The sole indication for resection arthroplasty of the great toe in this study was hallux valgus. The technique involved removal of the proximal one-third of the phalanx with interposition of a capsular flap, occasionally including temporary Kirschner wire fixation. After 17.6 years on average, 102 patients were re-examined clinically and radiographically. Questionnaire assessment revealed a significantly prolonged walking distance, and 70% of the patients were pain-free at follow-up investigation, whereas 67% suffered from severe pain before the operation. Clinical evaluation showed diminished weight-bearing of the great toe during walking and a reduced range of motion of the resected first metatarsophalangeal joint. Radiographic shortening of the proximal phalanx was 37%. The average hallux valgus anlge was 23° at follow-up and 34° prior to surgery. The unacceptably high rate of hallux valgus relapse, especially due to a high intermetatarsal angle, emphasizes the unsatisfactory long-term results of the resection arthrosplasty. We now recommend this operation for older patients only, and a differentiated approach using reconstructive procedures according to the clinical and radiographical situation for younger patients. Received: 29 September 1997     

The floating metatarsal: first metatarsophalangeal joint dislocation with associated lisfranc dislocation

The authors report a case of an irreducible dorsal dislocation of the first metatarsophalangeal joint, with concomitant Lisfranc dislocation and fractures of the second, third, and fourth metatarsals. This combination has been reported only once in the literature. This extremely rare combined injury results in a floating metatarsal. Open reduction of the metatarsophalangeal joint dislocation and fixation of Lisfranc joint and metatarsal fractures with Kirschner wires was performed. One year after surgery, the patient is active and the first metatarsophalangeal joint is asymptomatic, but there is mild pain in the Lisfranc joint.     

Minimally Invasive Retrocapital Osteotomy of the First Metatarsal in Hallux Valgus Deformity

OBJECTIVE: Percutaneous retrocapital distal osteotomy of the first metatarsal for surgical treatment of hallux valgus. INDICATIONS: Mild to moderate hallux valgus deformity in both juveniles and adults. Recurrent hallux valgus deformity after previous surgery. CONTRAINDICATIONS: Severe degenerative changes of the first metatarsophalangeal joint (hallux valgus et rigidus). Previous Keller's procedure. SURGICAL TECHNIQUE: A percutaneous distal linear osteotomy of the first metatarsal is performed and stabilized with a Kirschner wire. The surgical technique follows these steps: distal Kirschner wire insertion; skin incision; sparse periosteal detachment; distal retrocapital osteotomy of the first metatarsal; correction of the first intermetatarsal angle by lateral displacement of the capital fragment; stabilization with Kischner wire insertion into the proximal metatarsal; postoperative taping. RESULTS: The patients were satisfied following 107 (91%) of 118 consecutive percutaneous procedures with a follow-up of 35.9 months (range 24-78 months). According to the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale for the clinical assessment, a mean score of 88.2 +/- 12.9 was obtained at follow-up. The clinical results can be compared to those obtained with open techniques, with the advantages of a minimally invasive procedure.     

Stabilization of atlantoaxial instability

Eight patients with atlantoaxial instability were treated by arthrodesis of the first and second cervical spine. Internal fixation was achieved by passing two 18 gauge stainless steel wires beneath the posterior arch of the atlas and around a threaded Steinmann pin which was drilled through the base of the spinous process of the axis. The wires were tightened over a preshaped iliac bone graft. A solid fusion was achieved in all patients. The risk of compression of the cord is decreased with this technique because the wires are not passed under the lamina of the axis. The lateral placement of the wires provides an excellent internal fixation and control of the forward flexion and rotation.     

Incidence of nonunion of first metatarsophalangeal joint arthrodesis for severe hallux valgus using crossed, flexible titanium intramedullary nails and a dorsal static staple with immediate weightbearing in female patients

Myriad forms of fixation have been proposed for arthrodesis of the first metatarsophalangeal joint (MTPJ). Regardless of fixation type, nonunion of the arthrodesis site has been purported as a common complication. The authors performed a retrospective analysis of all patients undergoing arthrodesis of the first MTPJ for severe hallux valgus with 2 crossed, flexible titanium intramedullary nails and a dorsal static 10-mm titanium staple followed by immediate protected weightbearing. Patients were included if they had: surgery for severe hallux valgus of the first MTPJ; undergone the exact internal fixation technique described; not undergone bilateral surgery in the same setting; weightbearing preoperative radiographs; at least 6-week postoperative weightbearing radiographs; initiated weightbearing on the operative foot immediately postoperative in a protective shoe; been followed up clinically for at least 6 months' time postoperatively; and documentation of any complications. One hundred fifty-six female patients (195 feet) with a mean age of 67 ± 9.3 years met the inclusion criteria. Complications due to technical error during insertion of the crossed, flexibe titanium intramedullary nails occurred in 22 (11.3%) feet, but none led to revision surgery. There were 5 (2.6%) asymptomatic nonunions and 1 (0.5%) delayed union, but this ultimately united. The incidence of nonunion after arthrodesis of the first MTPJ using the specific internal fixation construct presented here for severe hallux valgus is lower than the historic mean for most other fixation techniques. However, there is still a need for methodologically sound prospective cohort studies that compare the technique presented here with other modern osteosynthesis techniques.