Emerging Insights On The First MPJ Arthrodesis

Author(s): 
Shelby Swanson, BA, Andrea Dyack, BS, BA, and Michael S. Lee, DPM, FACFAS

Arthrodesis of the first metatarsophalangeal joint (MPJ) was first advocated in 1894 by Clutton for severe, painful hallux valgus.1 McKeever refined the technique in 1952 using intramedullary screw fixation, which is currently the gold standard for treatment of advanced arthritis and/or significant deformities of the hallux.2 Common indications for arthrodesis include stage 3 hallux rigidus (osteoarthritis), rheumatoid arthritis, failed first MPJ implants, severe hallux valgus deformities and post-traumatic arthritis.3,4

   Joint preparation, position, internal fixation and stabilization of the first MPJ are critical to the success of this procedure. While some fixation methods are favored over others, no consensus exists on the optimal technique. Fixation methods include Kirschner wires/Steinmann pins, two crossing screws, dorsal plates or memory staples.4-7 Union rates continue to increase as technique and fixation methods continue to improve. Current studies report fusion rates greater than 90 percent.3-5,7,8

   In 2005, Gibson and Thomson performed a randomized control trial to compare the clinical outcomes of arthrodesis with total joint arthroplasty in 63 patients with first MPJ osteoarthritis.9 All patients who underwent arthrodesis fused with few complications while six of the 39 patients in the arthroplasty group required implant removal postoperatively.

   At 24 months, there was a significantly greater reduction in pain in the arthrodesis group.9 Overall, only 3 percent of patients in the arthrodesis group said they would not have undergone the same surgery again in comparison to 40 percent of patients in the arthroplasty group.

   Functionally, a big concern with patients is the maintenance of their activity level after surgery. In 2005, Brodsky and co-workers followed up with 53 patients 12 months after first MPJ arthrodesis with screw fixation.10 Ninety-eight percent of patients returned to their preoperative jobs/activities with no restrictions and 94 percent could kneel and squat without difficulty.

   In another study by Van Doeselaar and colleagues, 62 patients with hallux rigidus underwent successful treatment with fusion of the first MPJ.8 After a median follow-up of 30 months, all patients received the Dutch Foot Function Index (FFI) questionnaire to measure foot function as well as a Visual Analogue Score (VAS) to evaluate pain and patient satisfaction. The FFI scores improved significantly from 38 to 8 and the median VAS pain and VAS satisfaction scores were 6.5 and 5.5 respectively.

   According to these studies, first MPJ arthrodesis provides patients with the level of activity, relief of pain and postoperative satisfaction they desire.

   Recent literature advocates the use of screw fixation with or without a dorsal plate. In 2008, Sharma and co-workers compared the use of a single interfragmental compression screw versus a screw supplemented with plate fixation in regard to clinical and radiologic fusion of the first MPJ.7

   The authors found that the addition of the dorsal plate did not confer any increase in stability or shorten the time to fusion.7 They also noted no difference of statistical significance in patient satisfaction or complications between the two methods. Using a single screw alone provided a union rate of 100 percent in the study.

Comments

I am happy to report 100% fusion rate with my great toe joint fusions. I'd like to share my technique and present a case I am considering doing currently:

Here are my surgical pearls for fusion of the first metatarsal phalangeal joint:

Like the authors, I use a technique to remove cartilage from the two bones with a rotary burr. I find it very helpful to have a baby lamina spreader to assist in distraction of the joint in order to simplify access. My instrument of choice is the Synthes brand baby lamina spreader.

I fenestrate the bones with a 0.045 wire, which allows more holes than a 0.062 wire.

I prefer using cross 3.0 mm cannulated screws.

I too use the lid of the screw set to ensure the proper 15 to 20 degrees of dorsiflexion. I temporarily fixate with cross guide wires and an additional 0.062 k-wire.

I prefer to put the plantar screw in from proximal medial to distal lateral and then add the more dorsal screw from distal medial to proximal lateral.

I find this to be a very rewarding surgery as most patients are in a lot of pain prior to performing this surgery, hence the need for this aggressive joint destructive procedure.

Here is an interesting case. I have a 64-year-old female with posterior tibial tendon dysfunction secondary to back surgery with a unilateral flat foot and severe hallux abducto valgus. She underwent a distal osteotomy for hallux valgus four years ago. In under one year, her hallux valgus was back as bad as before surgery.

She has an IM angle of 14 degrees, a short first met and HA of 60 degrees.

I am considering an opening base wedge osteotomy with a Wright Medical plate and staging three to six months later a fusion of the first MPJ. I feel as though an opening wedge osteotomy will work but the forces due to her posterior tibial tendon dysfunction and severe pronation will cause the bunion to return like after her last surgery.

Any experience combining a first metatarsal osteotomy with an arthrodesis? Any insight would be appreciated.

Lawrence Silverberg, DPM
blog: www.bestpodiatristnyc.com
bestpodiatristnyc@gmail.com

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