First metatarsophalangeal joint (MPJ) arthrodesis has shown effective results for stages III and IV hallux rigidus as it can help restore normal foot function and has high patient satisfaction. Accordingly, these authors offer a guide to surgical technique, compare literature results of arthrodesis with those of implants, and present a couple of enlightening case studies.
Arthrodesis of the first metatarsophalangeal joint (MPJ) has been considered the “gold standard” for advanced hallux rigidus. The procedure also has served as the workhorse for revision and salvage of conditions associated with deformity, bone loss and destabilization.
While Clutton originally described the procedure as hallux arthrodesis in 1894, Thompson and McElvenny first popularized MPJ arthrodesis.1,2 They used this surgical approach in patients with poliomyelitis, tuberculosis, hallux valgus and rigidus.2 The two major indications for first MPJ arthrodesis are stage III and IV hallux limitus/rigidus as well as revision and salvage.
There have been many proposed systems to classify hallux limitus/rigidus and the most commonly used systems are the grading systems described by Erdil, Coughlin, Oloff, Drago and their respective co-authors.3-6
The options for surgical management of stage III and IV joints include resection arthroplasty, interpositional arthroplasty, metatarsal head resurfacing, hemi-arthroplasty, total joint arthroplasty, arthrodiastasis and arthrodesis.4,7-19 Each of these procedures has its own advantages and disadvantages. However, in regard to postoperative complications and procedural consequences, the resection interposition arthroplasty remains the treatment to which surgeons compare all other surgical methods. Various authors have compared the outcomes of these other procedures to resection interposition arthroplasty in regard to instability, weakness at push off and first ray shortening.3,10,15
Implant Versus Arthrodesis For Stage III And IV Hallux Limitus/Rigidus
Controversy exists in the podiatric and orthopedic communities as to the best approach for the treatment of stage III and IV hallux limitus/rigidus. The dilemma is whether to fuse the first MPJ or use a joint replacement. Even though the podiatric community has had more than 30 years of experience with the use of joint replacements, these procedures have not had the best long-term results in comparison to the larger joint hip and knee replacement procedures.20,21
A recent multicenter retrospective review of outcomes by Kim and colleagues compared arthrodesis, hemi-metallic joint implant and resectional arthroplasty.22 The article noted AOFAS scores of 90/100 for arthrodesis, 80/100 for hemi-implant and 92/100 for the resection arthroplasty group. These subjective results were not statistically significant. However, patient postoperative complaints were more numerous in the hemi-implant and resectional arthroplasty groups.
The mobility of the first MPJ allows a normal gait pattern and action of the windlass mechanism, which assists in balance, impact reduction and normal stance. It also allows the patient a choice in fashionable footwear.6 These are a few of the reasons it may be preferable for a surgeon and patient to choose implant over arthrodesis.
Silastic implants were developed to achieve these goals. However, the major problem with MPJ implant arthroplasty stems from the frequent need to revise or replace the endoprosthesis. The first-generation Silastic implants have had high failure rates due to the high shear forces on the prosthetic’s hinge.3,23
To solve this problem, double-stem silicone implants with titanium grommets were designed.3,24 Despite these technical improvements, the implants were still susceptible to these stresses and silicone debris leading to foreign body reactions, synovitis and the persistence of bony erosion.3,25 Total joint replacement via two-component metallic hemi-implants with non-constrained articulations yielded better results.3,26 However, these implants still had problems such as subluxation, infection and early loosening.
Once implant failure occurs, the subsequent conversion to arthrodesis becomes more complex. This is due to bone loss created by the original implant insertion. When there is associated osteolysis, complex bone grafting is required.27-29
A recent report by Brewster compared the functional results of total joint replacement versus arthrodesis.30 This literature review showed significant improvement in results from pre- to post-op status in both groups. Median scores were 83/100 for total joint replacement versus 82/100 for the arthrodesis group. However, the revision rate for the total joint replacement group was 7 percent in comparison to 0 percent for the arthrodesis group.
Several studies have shown that the first MPJ arthrodesis is a predictable and excellent option providing high success rates in pain relief and restoration of function. However, this procedure is not without its disadvantages. Researchers have documented loss of motion, shoe wear problems, a long recovery period, metatarsalgia, difficulty kneeling, hardware irritation, delayed unions and non-union as problems.7 Other concerns include having to be non-weightbearing for up to six weeks.
The pursuit of successful joint replacements is due to the biomechanical advantages that a mobile hallux offers.30 The first MPJ arthrodesis has consistently been the gold standard in the orthopedic community due to its ability to relieve pain, achieve good cosmesis and alignment, and maintain the medial column and toe length. Ultimately, the patient retains restoration of normal foot function but at the sacrifice of joint movement.30 This is often a major concern to the patient.
Despite this, there has been high patient satisfaction with first MPJ arthrodesis. Sung and coworkers showed a union rate of 94.8 percent (55 of 58 patients).31 In a prospective study of 49 patients who underwent arthrodesis, Goucher and Coughlin noted a 96 percent satisfaction rate with a 92 percent union rate.32 Significant improvements occurred in both pain and AOFAS clinical rating scores.
Pertinent Insights On Arthrodesis Technique
One may prepare the first MPJ surface with a transverse osteotomy of the first metatarsal head and base of the proximal phalanx. This is usually an option in severe hallux abducto valgus correction, in which dislocation of the joint requires shortening for realignment. In most conditions, this technique makes it difficult to obtain desired amounts of valgus/varus, dorsiflexion/plantarflexion and adduction/abduction of the hallux. Adjusting the alignment is variable and can result in further bone resection. This can result in first ray shortening, causing an undesired cosmetic and pathologic side effect.1
Another common technique for arthrodesis site preparation is the utilization of power conical reamers to produce a cup to cone apposition or a ball and socket. By maintaining the contoured convex metatarsal head and concave proximal phalanx, surface contact areas for fusion increase. This allows for tri-planar “dialed in” positioning of the hallux to the metatarsal head. The optimum position is 15 to 20 degrees of dorsiflexion and 10 to 20 degrees of abduction.33 Intraoperatively, the hallux should lay parallel to the second toe with the foot fully loaded on the rigid flat surface (a basin) to simulate weightbearing and the ankle joint at 90 degrees. The hallux should also contact the surface.
Various authors have described numerous methods of internal fixation, including Kirschner wires, intramedullary Steinmann pins, staples and screws.1 The use of modern osteosynthesis constructs has decreased the non-union rate and allowed early weightbearing and a more rapid recovery.
Fusion success rates have been as great as 92 percent to 100 percent.3 Roukis and colleagues looked at three main configurations: compression screws, dorsal plate and screws, and staples.34 The authors found the overall incidence of non-union using one of these modern techniques was 5.4 percent. In another study by Dening and colleagues, a retrospective analysis of plate versus screw fixation showed MPJ fusion with single oblique lag screw fixation at 71 percent, crossing lag screws at 90 percent, a low contoured dorsal plate at 100 percent, and a dorsal plate with a plantar screw at 93 percent.35 The study authors allowed early weightbearing in all cases.
The most frequent form of osteosynthesis is low-contoured dorsal plating with or without a lag screw. Without the use of a lag screw, performing eccentric drilling of the screw hole most proximal to the joint on the metatarsal side can accomplish compression. Surgeons most often use traditional non-locking plates unless there is osteopenia. In cases of osteopenia, one can use a locking plate. If you are not using a lag screw or it is not appropriate to do so because of bone consistency, position a non-locking eccentric screw within the plate before inserting the locking screws. In cases of significant osteopenia, the surgeon can omit a compression screw. Contact of the joint surfaces with plate stabilization provides adequate fixation.
Key Considerations For Interphalangeal Joint Arthritis
Propulsive activity after first MPJ arthrodesis depends on proper positioning of the hallux in the sagittal plane and mobility of the interphalangeal joint to obtain assisted dorsiflexion in propulsion. In the presence of interphalangeal arthritis, one may avoid arthrodesis and consider implant arthroplasty.
Other options exist. One consideration is positioning the hallux in the transverse plane in 20 degrees abduction or more.33 Surgeons can also consider arthrodesis of the interphalangeal joint but this will require bone resection at the MPJ arthrodesis site to shorten the first ray, which could increase the risk of metatarsalgia.9
Could First MPJ Arthrodesis Have An Impact For Other Joint Disorders?
First MPJ arthrodesis is reportedly effective in treating many joint disorders and may also be useful in cases of revision and salvage. These conditions include joint destructive rheumatologic disorders, neuromuscular-associated hallux abducto valgus deformities, hallux abducto valgus deformity associated with osteoarthritis or severe hallux abducto valgus deformities.31,33 Other conditions are loss of both sesamoids, failed implant arthroplasty, failed hallux abducto valgus surgery, hallux varus or failed Keller arthroplasty. Finally, additional conditions include avascular necrosis, osteopenia and osteomyelitis in which significant bone loss and consistency become factors.
The techniques in these cases often involve interpositional bone grafting and are more technically challenging concerning fixation, position and post-op recovery. The following case studies will serve to demonstrate examples of these techniques when performing arthrodesis.
Case Study One: Addressing A Failed Silastic Implant
A 57-year-old female got a referral to the office for a painful right first MPJ. She had received an implant arthroplasty 15 years prior. She noticed deviation of the hallux medially along with increasing pain at the MPJ and the ball of her right foot.
Medications included alprazolam (Xanax, Pfizer), buspirone (BuSpar, Bristol-Myers Squibb), gabapentin (Neurontin, Pfizer), tiotropium bromide (Spiriva, Pfizer) and trazodone (Oleptro, Angelini Labopharm), which she took for anxiety, emphysema and joint pain respectively. She was also tobacco dependent.
Clinically, there was deviation of the first to third digits medially but the second and third were reducible. Radiographs showed an implant of a Silastic nature without grommets. The implant appeared to have depressed into the first metatarsal head medially.
Her surgery consisted of removal of the failed Silastic implant and intercalary bone graft arthrodesis of the right first MPJ after thorough debridement. We used a dorsal locking plate with 2.7 mm locking screws.
We allowed heel touch weightbearing in a controlled ankle motion (CAM) boot with the use of crutches for the first four weeks. At the one month follow-up visit, we noted that the right second and third digits began to overlap so we performed capsulotomy and tenotomy. Full weightbearing occurred after four weeks. The X-rays showed consolidation and good alignment of the arthrodesis site at the eight-week follow-up visit. At the 10-week post-op fusion visit, the patient was ambulating well without decreased function and radiographic evidence of fusion at the first MPJ. No complications had occurred despite early weightbearing and a history of smoking.
Case Study Two: When A Patient Has An Ulcer Of Three Years’ Duration Under The First Metatarsal Head
A 57-year-old female received a referral to the office with a three-year history of ulceration below the left first metatarsal head. We performed tibial sesamoid excision in an attempt to heal the ulceration. This lead to a transfer ulceration under the fibular sesamoid. Following fibular sesamoid excision, the ulceration moved under the first metatarsal head. A Keller arthroplasty led to hallux malleus and continued ulceration.
The X-rays as well as a Ceretec bone scan were positive for osteomyelitis at the base of the proximal phalanx. We performed local wound care and ensured adequate offloading. Cultures revealed methicillin resistant Staphylococcus aureus (MRSA) and Pseudomonas. Consequently, we started the patient on oral antibiotics.
Her past medical history was significant for type 2 diabetes, cancer and heart disease with stent placement. She was taking atorvastatin (Lipitor, Pfizer), ticagrelor (Brilinta, AstraZeneca), glimepiride (Amaryl, Sanofi-Aventis), insulin glargine (Lantus, Sanofi-Aventis), metoprolol (Lopressor, Novartis) and doxycycline (Vibramycin, Pfizer). She denies ever smoking.
Once the ulceration was stable with no clinical signs of soft tissue infection, we scheduled a first MPJ arthrodesis. After scrubbing, prepping and draping, we covered the ulcer with Tegaderm (3M) to limit contamination of the clean surgical site. Next, resection of the osteomyelitic portion of the proximal phalanx occurred with use of a bone saw. The hallux length was acceptable so there was no bone grafting. Next, we placed a 4.0 bone screw across the joint surface to stabilize the opposing debrided bone surfaces. A four-hole locking plate and 3.5 mm locking screws further secured the reduction. We then flushed the ulceration and incision site with power irrigation mixed with bacitracin followed by primary closure.
We allowed the patient heel touch weightbearing in a CAM boot with the use of crutches for the first four weeks and subsequently progressed to full weightbearing in the CAM boot. In the postoperative course, the wound quickly improved and had healed five weeks after surgery. At eight weeks, X-rays revealed a healed fusion site with good alignment and fixation intact. At the final follow-up visit six months later, the patient was very pleased with her function, pain level and healed ulceration.
The first MPJ arthrodesis has become a reliable procedure with high patient satisfaction and predictable results. The advent of modern osteosynthesis techniques has allowed for early or immediate weightbearing, and high union rates. While implant arthroplasty is continuing to evolve with fourth-generation metatarsal head resurfacing implants, surgeons have not obtained consistent results and complication rates still remain higher than those of arthrodesis.
Dr. Visser is the Director of the Mineral Area Regional Medical Center Residency Program in Farmington, Mo. and the Director of SSM DePaul Residency Program in St. Louis.
Dr. Day is a second-year resident at Mineral Area Regional Medical Center Residency program in Farmington, Mo.
Dr. Sills-Powell is a third-year resident at SSM DePaul residency program in St. Louis.
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