Morphology of the first metatarsal head and hallux rigidus: a cadaveric study.

PURPOSE: Treatment options for hallux rigidus include several conservative and surgical measures. The aetiology leading to the disease has not sufficiently been examined so far. MATERIALS AND METHODS: We analysed the anatomical configuration of the first metatarsal head of 120 metatarsal bones of different collectives aiming to find a possible correlation between the geometry of the first metatarsophalangeal joint and manifestation of hallux rigidus. Wet human cadaveric specimens and macerated dry specimens served as material. The relevant parameters used for analysis were an axis running through the metatarsal head, the anatomical longitudinal axis, and the radius of curvature of the first metatarsal bone. RESULTS: A significant difference was found in the radius of curvature of osteoarthritic and healthy subjects. Using the binary logistic regression, we were able to predict the probability of an occurrence of hallux rigidus in dependence of the radius of curvature. Furthermore, we were enabled to calculate a correct prediction for the appearance of osteoarthritis in 85 % of the healthy subjects, and 73 % of the osteoarthritic subjects. CONCLUSIONS: A consolidated view of the factors indicates that persons with a high risk for the appearance of hallux rigidus should be identified by measuring the radius of curvature in conventional radiographs and preventive measures to postpone the occurrence of clinically relevant hallux rigidus considered.

Mid-range outcomes in 64 consecutive cases of multilevel fusion for degenerative diseases of the lumbar spine.

In the treatment of multilevel degenerative disorders of the lumbar spine, spondylodesis plays a controversial role. Most patients can be treated conservatively with success. Multilevel lumbar fusion with instrumentation is associated with severe complications like failed back surgery syndrome, implant failure, and adjacent segment disease (ASD). This retrospective study examines the records of 70 elderly patients with degenerative changes or instability of the lumbar spine treated between 2002 and 2007 with spondylodesis of more than two segments. Sixty-four patients were included; 5 patients had died and one patient was lost to follow-up. We evaluated complications, clinical/radiological outcomes, and success of fusion. Flexion-extension and standing X-rays in two planes, MRI, and/or CT scans were obtained pre-operatively. Patients were assessed clinically using the Oswestry disability index (ODI) and a Visual Analogue Scale (VAS). Surgery performed was dorsolateral fusion (46.9%) or dorsal fusion with anterior lumbar interbody fusion (ALIF; 53.1%). Additional decompression was carried out in 37.5% of patients. Mean follow-up was 29.4±5.4 months. Average patient age was 64.7±4.3 years. Clinical outcomes were not satisfactory for all patients. VAS scores improved from 8.6±1.3 to 5.6±3.0 pre- to post-operatively, without statistical significance. ODI was also not significantly improved (56.1±22.3 pre- and 45.1±26.4 post-operatively). Successful fusion, defined as adequate bone mass with trabeculation at the facets and transverse processes or in the intervertebral segments, did not correlate with good clinical outcomes. Thirty-five of 64 patients (54%) showed signs of pedicle screw loosening, especially of the screws at S1. However, only 7 of these 35 (20%) complained of corresponding back pain. Revision surgery was required in 24 of 64 patients (38%). Of these, indications were adjacent segment disease (16 cases), pedicle screw loosening (7 cases), and infection (one case). At follow-up of 29.4 months, patients with radiographic ASD had worse ODI scores than patients without (54.7 vs. 36.6; P<0.001). Multilevel fusion for degenerative disease still has a high rate of complications, up to 50%. The problem of adjacent segment disease after fusion surgery has not yet been solved. This study underscores the need for strict indication guidelines to perform lumbar spine fusion of more than two levels.