Novel Use of Diaphyseal Fibular Autograft for Revision Arthrodesis in Failed Keller Arthroplasty: A Case Report.

This case report describes a unique solution to the complex problem of bone loss and first-ray instability after a failed Keller arthroplasty. The patient was a 65-year-old woman who presented 5 years after undergoing Keller arthroplasty of the left first metatarsophalangeal joint for hallux rigidus with a chief complaint of pain and inability to wear regular shoes. The patient underwent first metatarsophalangeal joint arthrodesis with diaphyseal fibula used as structural autograft. The patient has been followed for 5 years and has full resolution of previous symptoms without complications using this previously undescribed autograft harvest site.

Staged Revision Arthrodesis with Interposition of Tricortical Iliac Crest Autograft to Address an Infected Nonunion of the First Metatarsophalangeal Joint: A Case Report.

A 55-year-old woman with a complicated infected nonunion after first metatarsophalangeal joint arthrodesis is presented. The patient initially underwent cross-screw fixation for the treatment of hallux rigidus that resulted in joint infection and hardware loosening. A staged surgical approach was undertaken by means of initial hardware removal with implementation of an antibiotic cement spacer followed by revision arthrodesis with interposition of tricortical iliac crest autograft. This case report aims to highlight an accepted surgical approach to address an infected nonunion at the level of the first metatarsophalangeal joint.

Tratamiento del hallux valgus rigidus con osteotomía tipo Mitchell modificada. Descripción de la técnica quirúrgica y evaluación funcional a mediano plazo / Modified Mitchell's osteotomy for the treatment of hallux valgus rigidus. Description of the surgical technique and medium-term functional evaluation

Objetivo: Describir la técnica quirúrgica de Mitchell modificada para el tratamiento del hallux valgus rigidus grado 2, y evaluar los resultados a mediano plazo.materiales y métodos:Estudio prospectivo observacional. Entre agosto de 2015 y enero de 2019, 21 pacientes (23 pies) con hallux valgus rigidus grado 2 fueron sometidos a una osteotomía tipo Mitchell modificada.Resultados: Se comunican los resultados sobre la base de la edad, el sexo, el seguimiento posoperatorio, el puntaje de la AOFAS, el pie afectado, la pérdida de reducción, el colapso de la cabeza del metatarsiano, el dolor residual y la necesidad de plantillado para el alta. El puntaje de la AOFAS a los 18 meses fue de 94,78. Los pacientes retornaron a su actividad laboral, en promedio, a los 16.6 días y a sus actividades previas, a los 3.43 meses.Conclusión:Presentamos una técnica quirúrgica que combina los beneficios de la osteotomía de Chevron y la de Mitchell, con excelentes resultados clínicos y funcionales. Nivel de Evidencia: IV

Objective: To describe the modified Mitchell's surgical technique for the treatment of grade II hallux valgus rigidus, and to evaluate medium-term outcomes. materials and methods: Prospective observational study. Between August 2015 and January 2019, 21 patients (23 feet) with grade II hallux valgus rigidus were treated. All underwent a modified Mitchell's osteotomy. Results: The results are reported based on age, gender, postoperative follow-up, AOFAS score, affected foot, loss of reduction, metatarsal head collapse, residual pain, and whether the patient needed insoles to be discharged. The AOFAS score at 18 months was 94.78. On average, the patients returned to work after 16.6 days and to their usual activities after 3.43 months. Conclusion: We present a surgical technique that combines the benefits of the Chevron and Mitchell osteotomy, with excellent functional clinical outcomes. osteotomy. Level of Evidence: IV

First Metatarsophalangeal Arthrodesis for the Failed Hallux.

Hallux metatarsophalangeal joint (MTPJ) arthrodesis was first described in 1894 by Clutton, who recommended ankylosing the MTPJ to treat painful hallux valgus (HV). He used ivory pegs to stabilize the MTP joint. Surgeons over the last century have modified the procedure and added indications, including hallux rigidus, rheumatoid arthritis, and revision of failed surgeries. This article addresses many common yet challenging clinical scenarios, and a few hot topics, related to hallux MTPJ arthrodesis, including matarsus primus elevatus, severe hallux valgus, avascular necrosis, and infections. The article provides a condensed evidence-based discussion on how to manage these challenges using MTPJ arthrodesis.

Hallux rigidus: current concepts review and treatment algorithm with special focus on interposition arthroplasty.

BACKGROUND AND AIM OF THE WORK: Hallux rigidus represents a surgical challenge, with a multitude of possible surgical options, but with no ideal procedures.  The propose of this paper was to review the actual knowledge on the operative techniques, paying particular attention to the evolution of interposition arthroplasties, as an alternative to arthrodesis and prosthesis in the advanced stages of the disease. METHODS: A comprehensive literature PubMed search was performed, and the actual literature regarding hallux rigidus was overviewed. The operative and nonoperative options for HR were described. Studies on interposition arthroplasty were classified by publication year, summarizing the operative technique, results and complications. RESULTS: Among the various techniques for interposition arthroplasty, the Modified Oblique Keller Interposition Arthtoplasty (MOKCIA) showed the lower complication rate. It does not sacrifice the insertion of the flexor halluces brevis, maintaining the stability, length and strength of the big toe. CONCLUSIONS: Although long-term randomized controlled trials are lacking for interposition arthroplasties, the reported results are comparable to the other alternatives for the treatment of end-stage hallux rigidus, making this technique a valid alternative also in the young active patient, without precluding other end-stage procedures in case of failure. Based on the current knowledge, a treatment algorithm was developed, according to the Coughlin classification.

Foot pain and inflammatory markers: a cross sectional study in older adults.

BACKGROUND: Foot disorders may limit independence and reduce quality of life for older adults. Obesity is a risk factor for foot conditions; both mechanical load and metabolic effects may contribute to these conditions. This study determined cross-sectional associations between inflammatory markers and foot disorders. METHODS: Participants were drawn from the Framingham Foot Study (2002-2008). C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNF-α) were each examined for associations with foot pain, forefoot pain, hindfoot pain, hallux valgus, hallux rigidus, and toe deformities (claw, hammer, or overlapping toes). Unadjusted and adjusted (age, body mass index, physical activity, smoking status) sex-specific logistic regression was performed. RESULTS: Of 909 participants, 54% were women (mean age 65 [Formula: see text] 9 years), 20% had foot pain, 29% had hallux valgus, 3% had hallux rigidus, and 27% had toe deformities. In unadjusted models, higher CRP (OR [95% CI] = 1.5 [1.1, 2.0]) and IL-6 (OR [95% CI] = 1.8 [1.2, 2.6]) were associated with foot pain among men; higher CRP was associated with foot pain (OR [95% CI] = 1.3 [1.0, 1.5]) among women. Higher CRP (OR [95% CI] = 1.9 [1.1, 3.2]) and IL-6 (OR [95% CI] = 2.4 [1.2, 4.7]) were associated with forefoot pain in men. Higher CRP was associated with hindfoot pain ([95% CI] = 1.8 [1.2, 2.6]) in women. After adjustment, CRP ([95% CI] = 1.5 [1.1, 2.0]) and IL-6 ([95% CI] = 1.8 [1.2, 2.6]) remained associated with foot pain in men, and IL-6 with forefoot pain ([95% CI] = 2.9 [1.4, 6.1]) in men. No associations with structural foot disorders were observed. CONCLUSIONS: Inflammation may impact foot pain. Future work assessing whether inflammation is part of the mechanism linking obesity to foot pain may identify areas for intervention and prevention.

Surgical Treatment of Plantar First Metatarsal Ulcerations in High-Risk Patients: A Case Series.

BACKGROUND: Plantar first metatarsal ulcerations pose a difficult challenge to clinicians. Etiologies vary and include first metatarsal declination, cavus foot deformity, equinus contracture, and hallux limitus/rigidus. Our pragmatic, sequential approach to the multiple contributing etiologies of increased plantar pressure sub-first metatarsal can be addressed through minimal skin incisions. METHODS: A retrospective review was performed for patients with surgically treated preulcerations or ulcerations sub-first metatarsal head. All of the patients underwent a dorsiflexory wedge osteotomy, and the need for each additional procedure was independently assessed. Equinus contracture was treated with Achilles tendon lengthening, cavovarus deformity was mitigated with Steindler stripping, and plantarflexed first ray was treated with dorsiflexory wedge osteotomy. RESULTS: Eight patients underwent our pragmatic, sequential approach for increased plantar pressure sub-first metatarsal, four with preoperative ulcerations and four with preoperative hyperkeratotic preulcerative lesions. The preoperative ulcerations were present for an average of 25.43 weeks (range, 6.00-72.86 weeks), with an average size of 0.19 cm3 (median, 0.04 cm3). Procedure breakdown was as follows: eight first metatarsal osteotomies, four Achilles tendon lengthenings, and six Steindler strippings. Postoperatively, all eight patients returned to full ambulation, and the four ulcerations healed at an average of 24 days (range, 15-38 days). New ulceration occurred in one patient, and postoperative infection occurred in one patient. There were no ulceration recurrences, dehiscence of surgical sites, or minor or major amputations. CONCLUSIONS: The outcomes in patients surgically treated for increased plantar first metatarsal head pressure were evaluated. This case series demonstrates that our pragmatic, sequential approach yields positive results. In diabetic or high-risk patients, it is our treatment algorithm of choice for increased plantar first metatarsal pressure.

The Cotton Osteotomy as an Adjunct Procedure in Hallux Valgus and Hallux Limitus Surgery.

The Cotton osteotomy, as described in 1936 by Frederic Cotton, consisted of a medial cuneiform opening base wedge osteotomy. This Cotton osteotomy served to restore the "triangle of support" of the foot. In his address to the New England Surgical Society, he described this osteotomy as being multipurpose; it can be used for plantarflexion in hallux valgus surgery and has use in hallux rigidus conditions. Since its inception, the procedure has become a popular adjunct to aid in the restoration of the medial column deformity present in pes planus. Recently, there has been renewed interest in the use of the procedure to aid in the correction of deformities involving metatarsus primus elevatus, specifically, hallux valgus and hallux limitus. The advantage of the use of this procedure as opposed to others is that it allows for the preservation and/or restoration of first ray length and the preservation of motion at the medial column. In retrospective review, the authors evaluated seven cases with a 1-year follow-up. In this series of cases, the Cotton osteotomy was performed as an adjunct to common hallux valgus procedures or hallux limitus corrections. Radiographic review was also performed evaluating for initial evidence of radiographic bone-graft healing and patient weightbearing. Although not without its own limitations, the Cotton osteotomy offers several advantages with minimal complications, proving to be a valuable underused resource in the foot and ankle surgeon's toolkit.

Complications of Hallux Rigidus Surgery.

Hallux rigidus can be treated with a variety of surgical procedures, including joint preserving techniques, arthrodesis, and arthroplasty. The most commonly reported complications for joint preserving techniques consist of progression of arthritis, continued pain, and transfer metatarsalgia. Although good outcomes have been reported for arthrodesis overall, careful attention must be paid to technique and positioning of the toe to avoid nonunion or malunion. Arthroplasty preserves motion but in the case of failure can present the additional challenge of bone loss. In these scenarios, the authors recommend distraction bone block arthrodesis with structural autograft.

Comparison of the efficacies of peloid therapy and paraffin treatment given as an adjuncts to exercise therapy in patients with hallux rigidus: a randomized, uncontrolled, prospective study.

Although it is thought that peloid and paraffin treatments may have positive effect on pain, functional status, and quality of life in patients with hallux rigidus (HR), there are no comprehensive and comparative studies with a high level of evidence. We aimed to compare peloid and paraffin treatments in symptomatic hallux rigidus patients. A total of 113 patients diagnosed with HR between May 2019 and June 2021 were included in the study. After exclusion criteria, the remaining 90 patients were randomly divided into two groups: the peloid therapy group (peloid therapy + home exercise) and the paraffin therapy group (paraffin therapy + home exercise). Peloid and paraffin treatments were applied for 2 weeks (5 days a week for a total of 10 sessions). Patients were evaluated before treatment, at the end of treatment, and one month after treatment. The groups were compared in terms of pain, functional status, quality of life, and joint range of motion. In the final analysis, 40 patients in each treatment group were compared. Statistically significant improvements were achieved for all parameters at the end of treatment and at follow-up, and the treatments were found to be highly effective. As a result of the comparison, the methods were not found to be superior to each other. The present study is the first randomized study comparing peloid therapy and paraffin therapy given as an adjuncts to exercise therapy. Exercise therapy plus peloid and exercise therapy plus paraffin treatments seem to have similar effects on HR; however, controlled trials are necessary for confirmation of our results.

Preoperative Risk Factors for Primary Metatarsophalangeal Arthroplasty Revision to MTP Arthrodesis for Hallux Rigidus.

BACKGROUND: Revision or conversion to arthrodesis following metatarsophalangeal (MTP) joint arthroplasty are salvage procedures to manage complications of MTP joint arthroplasty. The purpose of this study is to use a national administrative database to characterize nationwide trends of patients undergoing hallux MTP arthrodesis vs arthroplasty for hallux rigidus. Additionally, the authors sought to evaluate demographic trends and evaluate influence of patient-related risk factors in those undergoing MTP arthroplasty revision to arthrodesis. METHODS: Patients who underwent MTP arthroplasty for diagnosis of hallux rigidus from 2010 to 2019 were identified in the Mariner subset of the PearlDiver database. Patients were included if they had undergone MTP arthroplasty for the diagnosis of hallux rigidus. Notably, the database lacks resolution about critical features of the arthroplasty design and materials. The revision cohort encompassed patients who underwent subsequent ipsilateral MTP arthrodesis or arthroplasty within 2 years of index arthroplasty procedure. Demographic characteristics and medical comorbidities were examined as potential patient-related risk factors for arthroplasty revision or revision to fusion. Univariate analyses were performed to analyze differences in patient demographics, comorbidities, and risk factors. A multivariate regression analysis was subsequently conducted to control for confounding variables. RESULTS: 2750 patients underwent primary MTP arthroplasty for diagnosis of hallux rigidus. Of these, 44 (1.6%) underwent revision arthroplasty and 188 patients (6.8%) were revised to arthrodesis within the first 2 years after the index procedure. Multivariate regression analysis indicates that obesity (odds ratio [OR] 1.48, 95% CI 1.05-2.09), depression (OR 1.59, 95% CI 1.15-2.20), and steroid use (OR 2.94, 95% CI 1.30-6.65) were associated with a statistically significant increase in revision to arthrodesis from primary arthroplasty. CONCLUSION: Revision arthrodesis following primary MTP arthroplasty for hallux rigidus within 2 years was found to be a relatively common occurrence in this national insurance database study. Risk factors for revision arthroplasty to arthrodesis within 2 years of primary arthroplasty include obesity, depression, and steroid use. LEVEL OF EVIDENCE: Level III, case-control study.

Validation of the Artificial Floor Technique in First Metatarsophalangeal Joint Arthrodesis.

BACKGROUND: Patient function after arthrodesis of the first metatarsophalangeal joint (MTPJ) relies on proper positioning of the first MTPJ. To maximize the likelihood of good postoperative function, the dorsiflexion angle, referred to as the fusion sagittal angle, should range between 20° and 30°, corresponding to 10° to 15° of dorsiflexion off the weightbearing axis. However, achieving appropriate sagittal alignment intraoperatively is challenging. The artificial floor technique (AFT) uses a rigid, flat surface to simulate the weightbearing position of the foot intraoperatively to accurately position the first MTPJ without fluoroscopy. This technique has been previously described and is commonly used but, to our knowledge, it has never been validated. QUESTIONS/PURPOSES: (1) Is the AFT a valid and repeatable technique for positioning the fusion sagittal angle between 20° and 30° of dorsiflexion from the first metatarsal? (2) Does the fusion sagittal angle obtained using the AFT vary with foot size? METHODS: In this retrospective study, a search was performed using Current Procedural Terminology codes for patients undergoing first MTPJ arthrodesis by one surgeon between June 2012 and June 2020. The surgical technique used during this time did not vary and consisted of the use of a rigid, flat, sterile surface. The entire foot was placed flat on the surface, simulating the weightbearing position and allowing for an evaluation of the fusion sagittal angle of the first MTPJ. The target sagittal alignment was achieved when the soft tissue of the plantar surface at the distal-most aspect of the proximal phalanx was measured (using a sterile ruler) as 1 cm off the artificial floor. The recommended fusion sagittal angle falls within a range of 20° to 30°, which allows for 1-mm to 2-mm variations in measuring the elevation of the proximal phalanx off the artificial floor. Fixation was achieved with two 2.8-mm threaded, double-pointed Steinmann pins placed through the intramedullary canal of the proximal and distal phalanges and into the first metatarsal. Once fixation was achieved, the fusion sagittal angle was confirmed with the AFT without using fluoroscopy. Postoperatively, patients were allowed to bear weight fully on their heels in a postoperative, rigid-soled shoe. During the study period, 117 patients (135 feet) underwent first MTPJ arthrodesis utilizing the AFT for either first MTPJ arthritis/hallux rigidus, hallux valgus, or inflammatory arthropathy. Of those, we considered patients with preoperative AP and lateral weightbearing radiographs and patients with AP and lateral weightbearing radiographs at 3 months postoperatively after the removal of the internal fixation construct as eligible for analysis. Based on these criteria, 84% (113 of 135) of feet were included in the final radiographic analysis. Sixteen percent (22 of 135) of the feet were excluded because postoperative radiographs demonstrating the removal of the internal fixation construct were absent from the Picture Archiving and Communication System (PACS) in these cases. The length of the whole foot, first metatarsal, and proximal phalanx were measured on preoperative weightbearing radiographs. In addition, fusion sagittal angles were measured on weightbearing radiographs after removal of internal fixation construct at a minimum of 3 months postoperatively (mean 3.5 ± 2.2 months). No patients were lost to follow-up before obtaining those radiographs. Two qualified reviewers independently evaluated each radiograph. We ascertained inter- and intraobserver reliability using intraclass correlation coefficients (ICCs). We determined whether the fusion sagittal angle obtained using the AFT varied with foot size by using a multiple linear regression model. RESULTS: In the entire study group, the mean fusion sagittal angle using the AFT was 27° ± 4°. The interobserver ICC of the fusion sagittal angle measurements was 0.92 (95% confidence interval [CI] 0.56 to 0.97; p < 0.001). The intraobserver ICC for reviewer 1 was 0.95 (95% CI 0.92 to 0.97; p < 0.001) and the intraobserver ICC for reviewer 2 was 0.97 (95% CI 0.88 to 0.98; p < 0.001). Ninety-one percent (103 of 113) of the study group fell within the acceptable range of 20° to 30° ± 2°. The multiple linear regression analyses demonstrated that the preoperative lengths of the whole foot (ß =-0.05 [95% CI -0.12 to 0.02]; p = 0.16), proximal phalanx (ß =-0.13 [95% CI -0.46 to 0.20]; p = 0.44), and first metatarsal (ß = 0.13 [95% CI -0.10 to 0.35]; p = 0.27) were not independently associated with the postoperative fusion sagittal angle. CONCLUSION: The AFT allows for accurate and reproducible positioning of the first MTPJ within the appropriate functional range of dorsiflexion, regardless of foot size. Additionally, this technique can be performed without fluoroscopy and so avoids radiation exposure to the patient and the surgical team. LEVEL OF EVIDENCE: Level III, therapeutic study.

Relationship Between Preoperative PROMIS Scores and Postoperative Outcomes in Hallux Rigidus Patients Undergoing Cheilectomy.

BACKGROUND: Previous studies have demonstrated that preoperative patient-reported outcome measures are associated with postoperative outcomes in foot and ankle surgery, and also in specific procedures such as bunionectomy, flatfoot reconstruction, and total ankle replacement. The primary purpose of this study was to determine if preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function, pain interference, pain intensity, and depression scores were associated with the ability of patients undergoing cheilectomy for hallux rigidus to achieve a minimal clinically important difference (MCID) of improvement. METHODS: This retrospective study included preoperative and ≥2-year postoperative PROMIS physical function, pain interference, pain intensity, and depression scores for 125 feet in 118 patients undergoing cheilectomy collected from an institutional review board (IRB)-approved foot and ankle registry database. MCIDs were established using distribution-based methods to determine clinical significance of improvements in PROMIS scores. Receiver operating characteristic (ROC) curves and area under the curve analyses were used to determine which preoperative PROMIS scores were associated with patients meeting the MCID. RESULTS: ROC analysis found statistically significant areas under the curve (AUCs) for the physical function domain (AUC 0.71), pain intensity (AUC 0.70), and depression (AUC 0.79) PROMIS domains. Subsequent analyses were unable to identify clinically useful 95% sensitivity and specificity preoperative thresholds, with the exception of the 95% sensitivity PROMIS physical function threshold. A preoperative physical function score of greater than 53.2 resulted in a 63% probability of achieving the MCID. The pain interference PROMIS domain did not demonstrate a statistically significant AUC. CONCLUSION: Preoperative PROMIS physical function, pain interference, pain intensity, and depression scores are minimally associated with preoperative to 2-year postoperative improvement in patients undergoing cheilectomy. It may be difficult to determine which patients improve from a cheilectomy based on the severity of symptoms they exhibit preoperatively. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Characteristics and research trends of 50 most-cited hallux rigidus papers.

BACKGROUND: The bibliometric studies in the field of orthopaedics have gained popularity since they can determine the characteristics and research trends of most influential papers in specific subjects. This study aimed to evaluate the 50 most-cited articles related to hallux rigidus, and analyze possible factors associated with increased citation counts. METHODS: The available literature about hallux rigidus on Web of Science database until January 2021 were analyzed and the 50 most-cited articles were determined. The characteristics of the papers were documented and analyzed for any relationship or correlation with total citation or citation per year (citation density) values. RESULTS: The average citation number and citation density were 52.8 (range: 26-243) and 3 (range: 0.8-12.8), respectively. The average author number was 3.4, while the average institution number was 1.9. The USA had the highest number of articles with 29. Twenty-six papers were case-series, only 3 studies had level 1 and only 2 had level 2 evidence. The highest number of articles were published in Foot and Ankle International with 22 papers. Forty papers were clinical studies while 10 were reviews. Five studies were multicentric. CONCLUSION: This study provided the general characteristic and research trends of 50 most influential hallux rigidus papers. The number of institutions and references were positively correlated with citation density, indicating a higher chance of getting cited for papers with collaborations from different institutions and papers using more references from other works. Publication year was also positively correlated with citation density, indicating the better performance of more recent articles. LEVEL OF CLINICAL EVIDENCE: Level 3.

Keller's arthroplasty for hallux rigidus: A systematic review.

BACKGROUND: Several surgical procedures have been described to treat hallux rigidus. Keller arthroplasty is a joint-sacrificing procedure proposed in 1904. Considering the current trends to mini-invasiveness and the debate about the technique's suitability, this review intends to state Keller arthroplasty results and the conditions where it could be still adopted in the treatment of hallux rigidus. METHODS: Selected articles were reviewed to extract: population data, surgical indications, different surgical techniques, clinical and radiological outcomes, and complications. RESULTS: Seventeen retrospective studies were selected, counting 508 patients. Mean age at surgery was 55 years. Patients were affected by moderate-severe hallux rigidus. Three modified Keller arthroplasty were identified. Good clinical and radiological outcomes were reported. Metatarsalgia was the most frequent complication (12%). CONCLUSION: Despite for many authors KA seems a viable surgical treatment for middle aged and elderly patients affected by moderate-severe hallux rigidus, the available literature provides little evidence on the real efficacy and safety of the technique. A non-negligible percentage of complications may occur, and therefore is essential to set correct indications through an accurate patients' selection.

The ability to wear heeled footwear following first metatarsophalangeal joint fusion.

INTRODUCTION: Fusion 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. METHODS: A 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. RESULTS: This 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. CONCLUSION: This 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.

Evaluation of Radiographic Features Including Metatarsus Primus Elevatus in Hallux Rigidus.

The etiology of hallux rigidus remains a controversial issue in foot and ankle surgery, i.e., the relationship between metatarsus primus elevatus (MPE) and hallux rigidus. The purpose of this study was to evaluate several radiographic parameters including first metatarsal elevation in patients with hallux rigidus compared to a matched control group. A retrospective case control study was performed including 50 feet, 25 feet with and 25 feet without hallux rigidus. In the patients with hallux rigidus, the first metatarsal was more elevated than in the control group (8.3 ± 1.7 mm vs 3.0 ± 2.0 mm, p < .001) and in 60% of patients with hallux rigidus MPE was diagnosed, compared to zero patients in the control group (p < .001). The lateral 1 to 2 intermetatarsal angle was higher in patients with hallux rigidus (3.6 ± 2.5 vs -0.7 ± 2.8; p < .001). The first metatarsal declination angle was not different between the 2 groups. Intraclass correlation coefficient between 2 observers for measuring the first metatarsal elevation was 0.929 (p < .001). In the current study, increased elevation of the first metatarsal, a higher incidence of MPE and increased lateral 1 to 2 intermetatarsal angle were found in patients with hallux rigidus compared to the control group. These findings support the theory of an association between MPE and hallux rigidus. Further high reliability of first metatarsal elevation measurement was found in our study.

Interpositional Arthroplasty in the Treatment of Hallux Rigidus: A Systematic Review.

Hallux rigidus is the most common arthritic condition of the foot. Interpositional arthroplasty (IPA) is indicated for advanced-stage hallux rigidus and attempts to maintain joint motion through insertion of a biologic spacer into the joint. However, the data evaluating the effectiveness of IPA are limited. The purpose of this study was to systematically review the outcomes of IPA in the treatment of hallux rigidus. MEDLINE, EMBASE, and Cochrane Library databases were systematically reviewed based on the preferred reporting items for systematic reviews and meta-analyses guidelines. Outcomes collected and analyzed included: American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal (HMI) score, visual analogue scale score, short-form 36 score, range of motion (ROM), radiographic parameters, and postoperative complications. The level and quality of clinical evidence were recorded and assessed. Sixteen studies with a total of 428 patients met inclusion/exclusion criteria. The mean AOFAS-HMI score improved from 51.6 ± 10.1 (range 35.0-64.2) preoperatively to 86.0 ± 7.7 (range 71.6-95.4) postoperatively (p ≤ .001) at weighted mean follow-up of 58.0 ± 34.5 (range 16.5-135.6) months. The preoperative weighted mean total ROM was 39.3° ± 9.6° (range 24.2-49.9) and the postoperative weighted mean total ROM was 61.5° ± 4.8° (range 54.0-66.5) (p ≤ .001). The complication rate was 21.5% with metatarsalgia as the most commonly reported complication. One study was level 3 and 15 studies were level 4 clinical evidence. This systematic review demonstrates improvement in functional and ROM outcomes following IPA procedure at mid-term follow-up. The procedure however has a moderate complication rate. In addition, there is a low level and quality of evidence in the current literature with inconsistent reporting of data.