27th Annual AOFAS Summer Meeting July 14, 2011
Alejandro E. Pino, MDElizabeth Young, BSLucas J. Bader, MDChloe Cheng, BS
Andrew J. Elliott, MD1
Matthew M. Roberts, MDDavid S. Levine, MD
Jonathan T. Deland, MD2
Martin O’Malley, MD
1)Financial relationship with Bacterin 2)Financial relationship with Zimmer, Arthrex and Tornier
Introduction
First Metatarsophalangeal Joint (MTPJ) Arthrodesis offers reliable pain relief
Many accepted techniques
Stigma due to perceived functional limitation
Introduction
Good functional outcomes described
One technique
Single surgeon
Homogeneous patient population
Our Study
Review functional outcomes after first MTPJ arthrodesis
Multiple surgeons
Different fixation techniques
Heterogeneous population
Hypothesis
Arthrodesis for the treatment of severe degeneration of the first MTPJ yields good functional outcomes regardless of fixation technique.
Principles of arthrodesis upheld
Methods
HSS Dept of Foot/Ankle Surgery patient database CPT code
2006-2009
Five different surgeons
Methods
Pre/Postoperative FAOS, SF-12/36, activity/shoe wear specific questionnaire Brodsky et al FAI 2005
Radiographic evaluation
Methods
Subgroup analysis
Arthrodesis technique Cross screws versus Plate/lag screw
Previous surgery
Concomitant procedure
Inclusion
Failed conservative treatment
Minimum 1-year follow-up
Exclusion
Concomitant lesser metatarsal head resections
Age less than 18
Demographics
51 patients (55 feet) Mean age 58.9 (42-74)
M:F 11:44
Average f/u 32 months (16-73)
67% Hallux Rigidus
Previous Procedures
Fixation Technique
Plate/lag screw 32 Patients
Cross screw 23 Patients
32 Patients (34 Feet) Isolated procedure
Concomitant Procedures
05101520253035
Results
Preop Postop p-value
SF score 69.9 (26.5-93)
79.5 (32.5-98.1)
0.0017
Sport* 58.2 (0-100) 77.6 (0-100) 0.0002
QOL* 38.2 (0-75) 75.2 (6.25-100)
<0.0001
Pain* 61.7 (25-100)
90.7 (55.6-100)
<0.0001
Symptoms*
61.6 (21.4-100)
86.6 (41.7-100)
<0.0001
Activity* 75.3 (25-100)
95.8 (79.4-100)
<0.0001
VAS (Pain) 5.5 (2-9) 2.5 (0-10)
*FAOS
Results
54% Denied shoe-wear limitations
89% Satisfied/highly satisfied
Functional Outcomes
Functional Outcomes
Radiographic Evaluation
82% Union rate
Plate/screw
Cross screw
p Value
Union 93% 62% 0.021
Satisfaction 85% 95%
ROH 14% 4%
Solitary Procedure
Equivalent outcome scores
Similar union rate
Prior Procedure
Equivalent outcome scores
Union rate 90% vs 68%
p=0.067
Limitations
Lack of standardization Postoperative protocol Technique
Concomitant procedures
Discussion
Good functional results
Rarely limits daily activities In-line athletics
Concomitant/Previous procedures
Discussion
Union rate Plate/screw vs Cross screw
Satisfaction rate
Shoe wear limitations
References
1. Baumhauer, JF; Nawoczenski, DA; DiGiovanni, BF; Wilding, GE: Reliability and validity of the American Orthopaedic Foot and Ankle Society Clinical Rating Scale: a pilot study for the hallux and lesser toes. Foot Ankle Int. 27:1014-1019, 2006.
2. Beertema, W; Draijer, WF; van Os, JJ; Pilot, P: A retrospective analysis of surgical treatment in patients with symptomatic hallux rigidus: long-term follow-up. J. Foot Ankle Surg. 45:244-251, 2006.
3. Bennett, GL; Sabetta, J: First metatarsalphalangeal joint arthrodesis: evaluation of plate and screw fixation. Foot Ankle Int. 30:752-757, 2009.
4. Bennett, GL; Kay, DB; Sabatta, J: First metatarsophalangeal joint arthrodesis: an evaluation of hardware failure. Foot Ankle Int. 26:593-596, 2005.
5. Brodsky, JW; Passmore, RN; Pollo, FE; Shabat, S: Functional outcome of arthrodesis of the first metatarsophalangeal joint using parallel screw fixation. Foot Ankle Int. 26:140-146, 2005.
6. Button, G; Pinney, S: A meta-analysis of outcome rating scales in foot and ankle surgery: is there a valid, reliable, and responsive system? Foot Ankle Int. 25:521-525, 2004.
7. Chen, L; Lyman, S; Do, H; Adam, S; Young, E; Deland, J; Ellis, S: Validation of the Foot and Ankle Outcome Score for Hallux Valgus. Hospital for Special Surgery Fellow Presentation, 2011.
8. Coughlin, MJ; Shurnas, PS: Hallux rigidus. J. Bone Joint Surg. Am. 86-A Suppl 1:119-130, 2004.
9. Coughlin, MJ; Shurnas, PS: Hallux rigidus. Grading and long-term results of operative treatment. J. Bone Joint Surg. Am. 85-A:2072-2088, 2003.
References
10. DeFrino, PF; Brodsky, JW; Pollo, FE; Crenshaw, SJ; Beischer, AD: First metatarsophalangeal arthrodesis: a clinical, pedobarographic and gait analysis study. Foot Ankle Int. 23:496-502, 2002.
11. Fuhrmann, RA: First metatarsophalangeal arthrodesis for hallux rigidus. Foot Ankle Clin. 16:1-12, 2011.
12. Goucher, NR; Coughlin, MJ: Hallux metatarsophalangeal joint arthrodesis using dome-shaped reamers and dorsal plate fixation: a prospective study. Foot Ankle Int. 27:869-876, 2006.
13. Hope, M; Savva, N; Whitehouse, S; Elliot, R; Saxby, TS: Is it necessary to re-fuse a non-union of a Hallux metatarsophalangeal joint arthrodesis? Foot Ankle Int. 31:662-669, 2010.
14. Kumar, S; Pradhan, R; Rosenfeld, PF: First metatarsophalangeal arthrodesis using a dorsal plate and a compression screw. Foot Ankle Int. 31:797-801, 2010.
15. Poggio, D; de Retana, PF; Borda, D; Hortua, P; Asuncion, J; Rios, J: Analysis of the clinical score progressions during the first year after first MTPJ fusion. Foot Ankle Int. 31:578-583, 2010.
16. Raikin, SM; Ahmad, J; Pour, AE; Abidi, N: Comparison of arthrodesis and metallic hemiarthroplasty of the hallux metatarsophalangeal joint. J. Bone Joint Surg. Am. 89:1979-1985, 2007.
17. User's Manual for the SF-36v2 Health Survey, Second Edition, Chapter 3: 29-37
18. van Doeselaar, DJ; Heesterbeek, PJ; Louwerens, JW; Swierstra, BA: Foot function after fusion of the first metatarsophalangeal joint. Foot Ankle Int. 31:670-675, 2010.
19. Womack, JW; Ishikawa, SN: First metatarsophalangeal arthrodesis. Foot Ankle Clin. 14:43-50, 2009.