Does arthrodesis of the first metatarsophalangeal joint correct the intermetatarsal M1M2 angle? Analysis of a continuous series of 208 arthrodeses fixed with plates.

INTRODUCTION: First-ray metatarsophalangeal arthrodesis is a classic surgical procedure in the treatment of severe hallux valgus, hallux rigidus, revision surgery, and inflammatory arthritis. The objective of this study was to verify if metatarsophalangeal plate arthrodesis could correct the M1M2 intermetatarsal angle. MATERIAL AND METHODS: This prospective and continuous series (June 2007 to March 2011) included 208 patients (48% severe and/or arthritic hallux valgus, 18% hallux rigidus, 16% rheumatoid forefoot, 13% surgical revision of the first ray, 5% hallux varus), with a mean age of 62.4±9.9 years (range, 19-87 years). All the patients were operated on by a senior surgeon with the same technique: spherical avivement of the joint surfaces using reamers, osteosynthesis with an anatomic plate (Fyxis-Biotech™) in Ti.6Al.4 V alloy prebent to 5° with a phalangeal arm to receive an oblique metatarsophalangeal screw in compression, in addition to four 2.7-mm nonlocking dorsal screws. The full-scale preoperative and intraoperative angle measurements were taken on AP and lateral X-rays of the weightbearing foot, as related to the etiology and the severity of the preoperative metatarsus varus (M1M2<15°, M1M2 15-19°, M1M2≥20°). The statistical analysis was done using the StatView software. RESULTS: The mean follow-up was 18.6±12.4 months (range, 2-76 months). Nearly all of the arthrodesis patients (97%) achieved bone union, and 5% of the plates were removed. The M1P1 angle decreased from 33.8±19.7° (range, -45° to -67°) preoperatively to 13.3±5.3° (range, 0-32°) at the last follow-up, and the M1M2 angle from 14.2±5.4°(range, 0-26°) to 6.5±2.3° (range, 0-12°). The preoperative M1M2 angle was <15° in 97 patients, 15-19° for 78 patients, and ≥20° for the 33 others; at the last follow-up it was 5.8±2.1° (range, 0-10°), 6.7±2.2° (0-10°), and 8.1±2.4° (3-12°), respectively. No correction of the metatarsus varus was demonstrated in relation to etiology. The M1M2 angle was >10° in only two patients (one case of rheumatoid arthritis and one case of severe hallux valgus): 0.9%. DISCUSSION: These results show that isolated metatarsophalangeal arthrodesis of the first ray can correct metatarsus varus even in substantial deformations in any etiology. LEVEL OF PROOF: Level II cohort study.

Comparison of quality of life following total ankle arthroplasty and ankle arthrodesis: Retrospective study of 54 cases.

INTRODUCTION: The benefit of ankle arthroplasty compared to arthrodesis continues to be debated, but the quality of life after these two interventions has rarely been assessed. We conducted a case-control study to compare quality of life and functional and athletic ability. HYPOTHESIS: Functional results, athletic ability, and quality of life after total ankle arthroplasty (TAA) are better than after ankle arthrodesis. MATERIAL AND METHODS: Two continuous series of 59 TAAs and 46 arthrodeses (operated on between 1997 and 2009) were evaluated retrospectively using a questionnaire including the functional items of the AOFAS score, the Foot Function Index (FFI) score, the Foot Ankle Ability Measure (FAAM), and the SF-36. RESULTS: Eighty-three responses (79% of the overall series) were matched in two groups: 32 TAAs [age at the intervention, 51.4years (range, 21-63years); follow-up, 52.2months (range, 30-146months); age at revision, 55.8years (range, 26-67years); BMI, 27.7 (range, 21.7-36.7)] and 22 arthrodeses [age at intervention, 50.1years (range, 24-72years); follow-up 57.9months (range, 12-147months); age at revision 54.9 years (range, 31-75years); BMI, 26.8 (range, 17.6-37)] (NS on all items between the two groups). The pain results were better after TAA, but with no statistically significant difference: AOFAS pain, (/40) 28.1±8.2 vs. 24.5±9.6; FFI pain, 16.6±18.8 vs. 24.3±21.5. The overall FFI score (/100) was better (P=0.048) after TAA (16.2±16.5 vs. 24.8±18.2). The overall mean athletic level compared to the state prior to the injury was relatively low in both groups, but significantly (p=0.007) higher in the TAA group: FAAM sports score (/100), 49.5±24.4 vs. 29.8±26.2. The quality-of-life scores, SF-36 physical health, mental health, and general health were not significantly different after TAA and arthrodesis: mental health score, 63.1±14.7 vs. 57.8±21.5; physical health score, 61.3±17.8 vs. 53.7±23.9, overall score, 63.2±16.4 vs. 55.9±23.5. DISCUSSION: Very few publications describe activities and quality of life after TAA and arthrodesis. Despite weaknesses, this comparative study demonstrates a tendency toward better functional results after TAA than after ankle arthrodesis, without the difference between the two groups being very significant. On the other hand, there was no difference in terms of quality of life. After the doubts raised by publications on severe periprosthetic osteolysis at the intermediate term with certain TAA models, these results encourage pursuit of implantation and development of TAA. LEVEL OF PROOF: Comparative retrospective. Level III study.

Histologic study of periprosthetic osteolytic lesions after AES total ankle replacement. A 22 case series.

INTRODUCTION: Medium-term results for total ankle replacement (TAR) are in general satisfactory, but there is a high redo rate for periprosthetic osteolysis associated with the AES implant. HYPOTHESIS: Comparing radioclinical findings and histologic analysis of implant revision procedure specimens can account for the elevated rate of osteolysis associated with the AES TAR implant. MATERIAL AND METHOD: In a prospective series of 84 AES TAR implants (2003-2008), 25 underwent revision for osteolysis (including three undergoing revision twice) at a mean 59.8 months. Eight patients had hydroxyapatite (HA) coated models and the others had titanium-hydroxyapatite (Ti-HA) coatings. Radiographs were systematically analyzed on Besse's protocol and evolution was monitored on AOFAS scores. The 94 specimens taken for histologic analysis during revision were re-examined, focusing specifically on foreign bodies. RESULTS: Macroscopically, no metallosis or polyethylene wear was found at revision. AOFAS global and pain scores fell respectively from 89.7/100 at 1 year postoperatively to 72.9 before revision and from 32.5/40 to 20.6/40, although global scores were unchanged in 25% of patients. Radiologically, all patients showed tibial and talar osteolytic lesions, 45% showed cortical lysis and in 25% the implant had collapsed into the cysts. All specimens showed macrophagic granulomatous inflammatory reactions in contact with a foreign body; the cysts showed necrotic remodeling. Some of the foreign bodies could be identified on optical histologic examination with polyethylene in 95% of the specimens and metal in 60% (100% of HA-coated models and 33.3% of Ti-HA-coated models). Unidentifiable material was associated: a brownish pigment in Ti-HA-coated models (33.3%) and flakey bodies in 44.4% of the HA-coated models and 18.2% of the Ti-HA-coated models. DISCUSSION: The phenomenon of periprosthetic osteolysis is still poorly understood, although implant wear debris seems to be implicated. All the patients with HA-coated implants with modular tibial stem had metal particles in the tissue around the implant, although their exact nature could not be determined. The double-layer Ti-HA coating may induce delamination by fretting while the biological bone anchorage is forming. LEVEL OF EVIDENCE: Prospective cohort study - Level IV.