Point-Counterpoint: Hallux Rigidus Surgery In Active Adults: Implant Arthroplasty Or First MPJ Arthrodesis?
This author notes positive results with metatarsal head resurfacing and points out that many active patients reject the first MPJ arthrodesis option due to concern about loss of joint mobility.
By Brian Carpenter, DPM, FACFAS
The hallux is the most common area for arthritis in the foot and hallux rigidus affects one out of 40 patients older than age 50.1 There is controversy about the treatment of advanced stages of hallux rigidus. Despite inherent disadvantages associated with the procedure, many authors have advocated arthrodesis. While joint fusion is only accepted as a salvage procedure in other joints, physicians have touted metatarsophalangeal joint (MPJ) arthrodesis partly due to the mixed results of surgical alternatives such as total joint replacement or phalangeal based hemi-arthroplasty.2-5
Although one can achieve reproducible pain control with arthrodesis, many patients do not accept the loss of mobility, which is especially true of patients with an active lifestyle or profession. When active patients are confronted with treatment options for advanced stages of hallux rigidus, many reject surgical treatment via arthrodesis.
Patient education is crucial, given that some patients do not understand terms like “fusion” or “arthrodesis.” This misunderstanding can result in a postoperative surprise when the joint is “permanently stiff.” Accordingly, one needs to convey to patients that fusion of the joint is an end stage procedure, which has been associated with many other complications including non-union, progressive degeneration of adjoining joints, restrictions in shoe wear, hardware failure and an extended postoperative recovery time.6-8
What The Research Reveals About Implant Arthroplasty And Metatarsal Head Resurfacing
In a meta-analysis, Cook and colleagues noted high patient satisfaction in over 3,000 first MPJ implant arthroplasty procedures with a mean 61.48 month follow-up.9 The authors noted that 85.7 percent of patients were satisfied with the procedure. When adjusting for lower quality studies with less than five years’ follow-up, this satisfaction rate increased to 94.5 percent.
A majority of patients presenting with hallux rigidus have numerous degrees of cartilage defects that primarily involve the metatarsal head. In 2004, surgeons started using metatarsal head resurfacing in order to preserve the joint, address pain and improve the limitations in range of motion associated with the pathology.10
The HemiCAP Metatarsal Head Resurfacing system (Arthrosurface) features a titanium tapered cannulated screw and a cobalt chrome articular component. Hasselman and Shields discussed the results of metatarsal head resurfacing from the first series of patients.11,12 After a mean follow-up of 20 months, the range of motion of the joint in 25 patients increased postoperatively by 42 degrees. The patients’ mean American Orthopedic Foot and Ankle (AOFAS) score was 82.1 while the SF-36 questionnaire score was 96.1. All patients were satisfied with the results and indicated they would have the surgery again.
Hasselman and colleagues contacted patients from the initial series of 30 implants (26 patients, four bilateral) and used a questionnaire to assess patients’ current symptoms and satisfaction five years after the procedure.13 All patients reported continued excellent satisfaction, with none indicating that they were “limited daily” or had “severe limitations” in their daily and recreational activities. The implant survivorship was 88 percent at five years.
Out of the initial patient series of 30 implants, there were four revision procedures (including a patient who had bilateral procedures).13 All four revisions were indicated due to phalangeal pathology and occurred at the three-year mark. All metatarsal head implants were well incorporated without any signs of loosening.