577953

research-article2015

FAIXXX10.1177/1071100715577953Foot & Ankle InternationalKlein et al

Article

First Metatarsophalangeal Joint Arthrodesis Technique With Interposition Allograft Bone Block

Foot & Ankle International® 1­–8 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100715577953 fai.sagepub.com

Pamela C. Luk, MD1,2, Jeffrey E. Johnson, MD1, Jeremy J. McCormick, MD1, and Sandra E. Klein, MD1

Abstract Background: We present a technique of first metatarsophalangeal joint arthrodesis utilizing an interposition allograft bone block with a bipolar reaming technique that creates congruent fusion surfaces on both ends of the graft-host bone interface. In addition, we examined the union rates, fusion position, patient satisfaction, and functional outcome of this technique. Methods: Fifteen patients underwent first metatarsophalangeal joint arthrodesis with an interposition allograft bone block between September 2004 and October 2013. Charts and radiographs were reviewed. Six measures were compared on preoperative and postoperative radiographs. Clinical outcomes were measured using a telephone questionnaire, pre- and postoperative visual analog scale pain scale, and Foot and Ankle Ability Measure. Average follow-up was 46 weeks (range, 19 to 97). Results: Thirteen of 15 (87%) patients achieved bony union at an average of 21 weeks. One patient underwent revision arthrodesis for their nonunion. Symptomatic hardware was removed in 3 cases. Improvement was noted in visual analog scale pain scores (6 to 2) and functional scores as measured by the Foot and Ankle Ability Measure. There were no postoperative wound complications or infections. Average length of the first ray on anteroposterior radiograph increased from 10.7 to 11.3 cm and from 10.0 to 10.7 cm on the lateral radiograph. Thirteen of 14 patients were very satisfied or satisfied. One patient expressed dissatisfaction with the procedure. One patient was not available for clinical follow-up. Conclusion: First metatarsophalangeal joint allograft bone block arthrodesis using the bipolar reaming technique achieved high bony union rates and satisfactory radiographic and clinical outcomes. This procedure was an effective salvage option for managing bone loss on 1 or both sides of the joint. Level of Evidence: Level IV, retrospective case series. Keywords: hallux rigidus, first metatarsophalangeal joint, arthrodesis, arthroplasty Procedures on the hallux are commonly performed for arthritis and/or deformity, such as hallux valgus. In any hallux procedure, 1 concern involves shortening of the first ray causing alterations in the biomechanics of the forefoot and transfer metatarsalgia.3 This occurrence has been described with failure of hallux valgus correction, failure of implant arthroplasty, trauma, and arthrodesis procedures.2,5,22-24 If shortening is combined with severe arthritic changes in the first metatarsophalangeal (MTP) joint and loss of bone, a salvage procedure with arthrodesis is often required to manage pain and, if possible, restore length.2,5,23 One of the more common conditions leading to excessive shortening of the first ray requiring a salvage procedure is first MTP joint arthroplasty. Salvage of arthroplasty techniques is complicated when the implant fails, because deformity of the toe may exist in addition to shortening of the first ray. Restoration of hallux length and alignment

often cannot be achieved with an in situ fusion, and reconstruction with autograft or allograft bone is required. Several previous reports describe salvage of failed surgery for the hallux with first MTP joint fusion.2,9,23 The purpose of this study was to present a technique of first MTP joint arthrodesis with interposition allograft bone block using a spherical reaming method for salvage of a failed 1

Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, MO, USA 2 Congress Medical Associates, Arcadia, CA, USA Corresponding Author: Sandra E. Klein, MD, Associate Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8233, St Louis, MO 63110, USA. Email: [email protected]

2

Foot & Ankle International 

Table 1.  Patient Data, No. (%). Demographic dataa  Women   Average no. of previous surgeries   Tobacco use   Diabetes mellitus   Rheumatoid arthritis Causes of shortening   Failed implant   Failed hallux valgus procedure   Failed hallux rigidus procedure (other than implant)

  15 (100) 2.4 2 (13) 2 (13) 2 (13)   11  3  1

a

Average age, 57 years; range, 31 to 68 years.

implant arthroplasty or other procedures resulting in bone loss and excessive shortening of the hallux. We report the clinical and radiographic results of this technique.

Methods Institutional Review Board approval was obtained for this study through our Human Research Protection Office. A retrospective review of patients undergoing first MTP joint arthrodesis by 3 surgeons between September 2004 and October 2013 was performed using the procedural code for arthrodesis. A total of 481 patients were identified. Chart review was performed to identify patients in which the procedure included the use of an interposition allograft. Fifteen patients underwent first MTP joint arthrodesis with a spherical reaming technique and interposition allograft during the time frame studied. All patients were women. The mean patient age was 57 years (range, 31 to 68) at the time of surgery. Eleven patients had failed implant arthroplasties for hallux rigidus or hallux valgus. One of these 11 patients presented with a nonunion after attempted MTP joint arthrodesis as a salvage procedure for failed arthroplasty. Three patients had failure of a hallux valgus surgery. In all 3 cases, excessive proximal phalanx or metatarsal shortening was present secondary to osteotomies for bunion correction. One of these 3 patients had additional complications of failed nonunion repair and subsequent wound infection. The final patient underwent a dorsal cheilectomy for hallux rigidus and progressed to advanced MTP joint arthritis with erosion of the proximal phalanx base (Table 1). The average number of surgeries performed prior to MTP joint arthrodesis with interposition allograft was 2.4 (range, 1 to 6). Two of 15 patients were actively smoking tobacco at the time of surgery. Two patients had a diagnosis of diabetes mellitus, and 2 other patients had rheumatoid arthritis. One patient with diabetes also had ulcerative colitis on routine prednisone (Table 1). Patients returned for postoperative clinical and radiographic evaluation with an

average length of follow-up of 46 weeks (range, 19 to 97 weeks). Patients who met the inclusion criteria were contacted by phone and invited to participate. Each patient answered a phone questionnaire regarding surgery satisfaction since the arthrodesis and the need for assistive devices, specialized shoe wear, or medication after the surgery. Surgery satisfaction was scored on a 10-point scale, and responses were categorized as very satisfied (8 to 10), satisfied (5 to 7), and dissatisfied (less than 5). Consenting patients were also mailed a visual analog scale (VAS) to evaluate their pain level on a scale of 0 to 10 (10 being the worst possible pain) over the last 30 days and the Foot and Ankle Ability Measure (FAAM) to document their postoperative functional levels. Preoperative VAS scores were available for 9 patients. The FAAM is a self-reported instrument devised to assess the physical function of individuals with musculoskeletal disorders of the leg, ankle, and foot19 and is composed of a 21-item activities-of-daily-living (ADL) subscale and an 8-item sports subscale. Preoperative FAAM ADL subscale scores were available and valid in 9 patients. In the remaining 6 patients the ADL subscale questions were either incomplete or not available. Preoperative FAAM sports subscale scores were available and valid in 7 patients. In 8 cases, the sports subscale was either incomplete or not available. Anteroposterior and lateral radiographs were obtained at 6 weeks postoperatively and at each clinic visit thereafter. Weightbearing radiographs were reviewed to assess hallux position preoperatively and at the most recent postoperative visit. Preoperative radiographs were not available for 2 patients, and hallux position changes could not be determined for these 2 cases. Hallux position was based on 6 criteria: (1) hallux valgus angle, (2) 1-2 intermetatarsal angle, (3) dorsiflexion angle of the first toe relative to the first metatarsal, (4) dorsiflexion angle of the first toe relative to the floor, (5) length of the first ray on anteroposterior radiographs, and (6) length of the first ray on lateral radiographs (Figure 1). Hallux valgus angle was determined on the anteroposterior radiograph by the angle subtended by lines along the longitudinal axis of the first metatarsal and proximal phalanx, and intermetatarsal angle was determined by the angle between lines bisecting the shafts of the first and second metatarsals on the anteroposterior view.2 The dorsiflexion angle relative to the first metatarsal was determined by measuring the angle subtended by the longitudinal axis of the first metatarsal and proximal phalanx on the lateral radiograph.2 The dorsiflexion angle relative to the floor was similarly measured as the angle between the longitudinal axis of the proximal phalanx and the axis of the floor on the lateral radiograph. Modifying a measurement described by Myerson et al,23 we evaluated the length of the first ray on both

Klein et al

3

Figure 1.  Radiographic measurements on anteroposterior (A) and lateral (B) views. A, 1-2 intermetatarsal angle; B, hallux valgus angle; C, length of first ray from metatarsal base to distal phalangeal tip; D, dorsiflexion angle relative to first metatarsal; E, dorsiflexion angle relative to the floor; F, length of first ray from metatarsal base to distal phalangeal tip.

anteroposterior and lateral radiographs as the distance from the distal aspect of the hallux distal phalanx to the midpoint of the first metatarsal base (Figure 1). Fusion was determined by the presence of bridging bony trabeculae across the arthrodesis sites and disappearance of the graft-phalanx or the graft-metatarsal interface.

Operative Technique All procedures were performed by 1 of 2 attending surgeons (J.E.J. and S.E.K.) using the same technique. The patient was placed in a supine position on the operating table. A thigh tourniquet or ankle Esmarch tourniquet was used. An incision was made dorsally or dorsal medially over the first MTP joint, often using the prior incision. Z-lengthening of the extensor hallucis longus was performed in one case. Implants, if present, were removed from the joint space. Fibrous tissue and inflamed synovium in the joint space and bony defects including cystic lesions were debrided (Figure 2). A 0.062-in Kirschner wire was inserted in the center of the distal metatarsal and placed proximally into the medullary canal of the shaft. The position of the guidewire was checked on fluoroscopic images before a cannulated hemispherical power reamer was placed over the Kirschner wire and used to remove remaining cartilage, sclerotic bone, and the subchondral plate while shaping the distal metatarsal (Figure 3A). Reamer diameter was based on the best fit over the distal metatarsal. If the metatarsal head structure was

Figure 2.  Initial joint preparation includes removal of fibrous tissue, debridement of cystic lesions, and removal of surrounding osteophytes.

4

Foot & Ankle International 

Figure 3.  The metatarsal head (A) and the base of the phalanx (B) are prepared with reamers.

preserved, the cup-shaped reamer was used and resulted in a convex distal metatarsal. If the distal metatarsal was flattened or significantly eroded, the opposite reamer was used to create a concave hemispherical depression in the distal metatarsal. The Kirschner wire was removed from the metatarsal, and a second wire was inserted into the center of the proximal phalanx base and directed distally into the diaphysis of the remaining phalanx. The position of this K-wire was checked on fluoroscopic imaging. Joint preparation was started with a smaller-diameter spherical reamer and finished with the maximum diameter reamer that still preserved a circumferential rim of cortical bone. The base of the proximal phalanx was always prepared to produce a concave hemispherical depression, given the natural concavity of the surface (Figure 3B). The reamer diameters used on the 2 joint surfaces were often the same, but this is not required in this technique. The joint was irrigated to clear the wound of reamer debris. A small drill bit was used to make multiple perforations at the base of the proximal phalanx as well as the distal metatarsal to increase surface area for fusion and stimulate bleeding. The toe was then held in gentle traction, and the gap was measured between the bony ends of the metatarsal and proximal phalanx. This gave an estimated size for the interposition allograft bone block. A tricortical iliac crest allograft was shaped in all cases using the cannulated power reamer system over a guidewire placed down the length of the graft (Figure 4). The graft was prepared using a reamer of equivalent diameter so that a convex end would complement a concave joint surface or vice versa. Two bone graft and reaming configurations were used (Figure 5). The middle portion of the graft was left rectangular with the tricortical shell intact. The graft was trialed in the MTP joint while

Figure 4.  The allograft bone is prepared with reamers matching the sizes used for the metatarsal head and base of the phalanx.

minor adjustments were made with a saw until the fit was acceptable. Prior to final placement of the allograft bone block, morselized bone graft was packed into the medullary canal and bony defects within the metatarsal and proximal phalanx. This morselized bone graft consisted of iliac crest bone autograft in 6 patients, distal tibial autograft in 2 patients, and allograft bone in 7 patients. Iliac crest bone marrow aspirate was obtained in 4 patients for augmentation, and the allograft bone block was soaked in the aspirate. The allograft bone block was placed in the joint space, and the toe was positioned in slight valgus, slight dorsiflexion, and neutral rotation (Figure 6). The toe position was temporarily held with a 0.062 K-wire and examined for

5

Klein et al

appropriate position clinically, radiographically, and with a flat surface applied to the plantar aspect of the foot. Fourteen grafts were definitively fixed with a dorsal plate. One patient was fixed only with multiple longitudinally placed Steinmann pins, as the soft tissue tension did not allow for the placement of internal hardware. Additional fixation supplemented the dorsal plate in 5 patients (a Steinmann pin in 1, a cannulated oblique screw in 2, K-wire plus cannulated oblique screw in 1, and 2 crossing cannulated oblique screws in 1). Bone morphogenic protein (BMP) was placed alongside the graft in 7 patients. The tourniquet was then deflated to evaluate for adequate perfusion of the toe before wound closure. Additional procedures for associated foot problems were done along with the interposition graft arthrodesis in 9 patients. Six patients had concurrent shortening procedures of 1 or more lesser metatarsals. Two patients underwent lesser metatarsal head resection as part of this procedure. One patient had an interdigital neuroma excision.

Postoperative Protocol

Figure 5.  The metatarsal head was reamed according to the amount of bone loss, resulting in 2 possible grafting configurations. Artist: Jenny R. Plassmeyer.

Patients were immobilized in a nonweightbearing, bulky compression dressing splint for 2 weeks. Wounds were examined and sutures removed at 2 weeks, and a nonweightbearing short-leg cast was applied for the next 4 weeks. Weightbearing cast immobilization was continued for an additional 4 weeks. A removable boot was used in the transitioning phase from cast to regular shoe. Pins and wires, if present, were removed at 6 weeks postoperative.

Results

Figure 6.  The bone graft is placed in the defect and held with a K-wire before final fixation.

Average time to final radiographs was 46 weeks. Radiographic union was confirmed in 14 of the 15 patients at an average of 21 weeks (range, 9 to 40 weeks). The remaining patient had a fibrous nonunion between the metatarsal and the allograft, which had not healed at final follow-up (33 weeks). In 1 of the 14 patients determined to be united on radiographs, a nonunion between the proximal phalanx and the bone graft was discovered at the time of hardware removal. The patient with the fibrous nonunion between the metatarsal and allograft was the single patient who was fixed with Steinmann pins alone. Successful fusion of the first MTP joint at both the metatarsal-allograft and phalanx-allograft surfaces occurred in 13 of 15 patients (87%). Fourteen of 15 patients responded to the questionnaires (1 could not be contacted). Seventy-nine percent (11 of 14) of the patients were very satisfied with the surgery; 2 patients were satisfied; and 1 patient was dissatisfied. Four patients additionally noted that they would have had the surgery done earlier if the option had been presented to them. The dissatisfied patient was unhappy primarily because of the

6 outcome of the concomitant lesser toe surgeries. Only 1 patient stated that she would not undergo the surgery again if given the same circumstances. Postoperatively, none of the patients required the use of an assistive device (wheelchair, walker, crutches, cane) or specialized footwear for ADL. One patient had custom orthotics for snowboarding shoes. Three patients wore over-the-counter orthotics. One patient took anti-inflammatory medication on a daily basis for persistent great toe pain. The average preoperative VAS pain score in the 9 patients for whom scores were available was 6 (range, 2 to 8.5). The average postoperative VAS pain score in the 14 patients contacted was 2 (range, 0 to 6). Four patients were pain-free after surgery (VAS pain score, 0). Regarding postoperative VAS scores in only the patients with preoperative scores, the average was 2 (range, 0 to 6). Postoperative FAAM ADL subscale scores were valid (sufficient number of questions answered) in 13 of the 14 patients available for follow-up. These 13 patients included the 9 patients with preoperative ADL scores. The average FAAM ADL score was 63.9 (range, 45 to 86) preoperatively and 83.5 (range, 43 to 100) postoperatively, given all scores that were available (9 preoperative and 13 postoperative). When the subset of 9 patients with both scores is considered, the average preoperative FAAM ADL score was 63.9 (range, 45 to 86), and the postoperative score was 81.5 (range, 43 to 100). Patients most consistently reported difficulty with squatting and rising up on the toes. The majority of patients had no difficulty with walking or performing ADL. Postoperative FAAM sports subscale scores were available for 7 of the 14 patients contacted. The remaining 7 had insufficient responses for calculating a score. Only 4 patients had complete data to calculate pre- and postoperative sports scores. The average FAAM sports subscale score was 37.1 (range, 19 to 50) preoperatively in the 7 patients with available scores and 50.1 (range, 9 to 88) postoperatively in the 7 patients with available scores. Regarding only the patients with complete pre- and postoperative data, the preoperative average sports subscale score was 35.5 (range, 19 to 47), and the postoperative average score was 35.3 (range, 9 to 69). Pre- and postoperative radiographic measures are reported in Table 2 for the 13 patients with preoperative radiographs available. A wide range of deformity existed preoperatively, and the range of measures was noted to improve after surgery. Length of the first ray was maintained, but significant increases in length were not seen. Bone graft size was available in 11 of 13 patients with preand postoperative radiographs. The average bone graft inserted was 18 mm (range, 10 to 25 mm). Three patients experienced complications. One asymptomatic pseudoarthrosis occurred but required no further treatment. A second patient was found to have a nonunion at the time of symptomatic hardware removal surgery and was

Foot & Ankle International  Table 2.  Radiographic Measurements: 13 Patients With Preand Postoperative Radiographs. Average (Range) Radiographic Parameter

Preoperative

Postoperative

Hallux valgus angle, degrees Intermetatarsal angle, degrees Dorsiflexion first metatarsal, degrees Dorsiflexion floor, degrees Anteroposterior length, cm Lateral length, cm

12.2 (–28 to 30)a

12.7 (4 to 22)

10.5 (4 to 17)

10.2 (4 to 15)

33.9 (15 to 71)

25.6 (16 to 40)

15.8 (1 to 53)

8.7 (2 to 19)

10.7 (9.2 to 11.7)

11.1 (9.3 to 12.1)

10.0 (8.8 to 11.1)

10.6 (9 to 12.7)

a

Negative value indicate a varus deformity.

treated with revision arthrodesis. The third patient developed a stress fracture at the interface of the proximal phalanx and bone graft several months after symptomatic hardware removal. A computed tomography scan prior to hardware removal had confirmed fusion. Revision surgery was discussed, but the patient elected to continue with conservative management. Symptomatic hardware was removed in a total of 3 patients. There were no cases of wound complications or deep infections. There were no complications associated with harvesting distal tibia bone graft, iliac crest bone graft, or iliac crest bone marrow aspirate.

Discussion We present a technique for salvage of a failed first MTP joint arthroplasty or procedures causing bone loss and deformity of the hallux with a high rate of successful fusion (87%). Various techniques for first MTP joint surface preparation have been described and include excision of cartilage, flat cuts, tongue and trough, and peg or cone and socket.13,17,21 McKeever published the earliest description of preparing complementary joint surfaces in a cup-and-cone fashion for first MTP joint arthrodesis in 1952.20 Marin presented a technique using Marin reamers, conically shaped manual instruments that fashioned the metatarsal head into a pointed cone that could be placed into a similarly sized hole in the base of the proximal phalanx.18 Because of the significant bony stability, Marin reported a series of successful fusions with minimal fixation and immediate weightbearing. Technologic advancements have since made way for powerdriven small joint reamers.4 Curtis et al6 demonstrated in a biomechanical cadaveric model that conically reamed surfaces fixed with an interfragmentary screw had greater rigidity and stability as compared with planar excision of joint

Klein et al surfaces fixed with K-wires, dorsal plate, or interfragmentary screw. Dome-shaped joint preparation with reamers has been favored because of ease of use and reproducibility of congruent joint surfaces to optimize fusion rates.10,25 This method further affords the ability to independently adjust valgus, dorsiflexion, and supination alignment of the great toe without making additional bony cuts. Our salvage interposition bone block technique incorporates these attributes of a successful primary arthrodesis, and we have found it technically easier and more reproducible than a flat cut technique. This technique maintains hallux length and restores alignment. A relatively short and unstable first ray leads to inadequate loading of the great toe and transfer metatarsalgia. This weightbearing imbalance translates into abnormal gait biomechanics of decreased walking velocity, longer stance phase, and shorter single-limb stance phase.2 Rebalancing the lengths of the first ray and the lesser metatarsals is possible with lesser metatarsal shortening osteotomies16 and/or first MTP joint arthrodesis with interposition bone block. In many cases, both procedures are necessary to regain balance. It is noteworthy that the increase in length of the first ray is less than the length of the bone graft used due to bone removal during joint preparation, which was also recognized by Myerson et al.23 Most radiographic measures improved with the insertion of a bone block, and both varus and cock-up toe deformities were corrected. Postoperative hallux valgus angles ranged from 4 to 22 degrees, and postoperative dorsiflexion angle relative to the first metatarsal ranged from 16 to 40 degrees, which falls within the recommended range of 5 to 30 degrees and 0 to 40 degrees, respectively.5 In this study, arthrodesis did not change the 1-2 intermetatarsal angle. We report a union rate of 87% using allograft interposition bone graft, which is comparable to other reports of salvage procedures. Hecht et al12 were the first to present a case series of arthrodesis for salvage after failed implant arthroplasty. They reported an 80% union rate using flat cuts and a tricortical iliac crest autograft. Brodsky et al2 reviewed a series of 12 patients who underwent salvage first MTP arthrodesis with tricortical iliac crest bone autograft. Joint surfaces were prepared in situ. The union rate was 92% (11 of 12 patients). There were 2 cases of skin necrosis, ultimately requiring a radial forearm flap for soft tissue coverage. Bhosale et al1 reported a union rate of 90% in their cases series of 10 feet presenting with failed joint arthroplasty or Keller resection arthroplasty and treated with flat cuts, iliac crest tricortical autograft, and dorsal plating. These similarities to our union rate suggest that allograft is a reasonable alternative to autograft bone. Myerson et al23 treated 24 patients with first MTP joint arthrodesis and interposition bone graft with a union rate of 79%. There was a combination of autograft and allograft bone blocks used, but the latter was favored as the study

7 progressed, as its use in other procedures demonstrated excellent healing. A 5-mm bone burr was used to prepare the metatarsal and proximal phalanx joint surfaces, but it was stated that they were not contoured to fit the bone graft. Interestingly, none of the nonunions occurred in cases treated with structural allograft. Gross et al11 identified 12 cases of first MTP joint fusion after failure of an implant arthroplasty. A variety of interpositional material was used, including iliac crest autograft (5 of 12), iliac crest allograft (1 of 12), calcaneal autograft and bone putty (1 of 12), bone graft from morselized metatarsal heads (4 of 12), and 1 without any supplementation. The authors report 2 nonunions (16.7%) and 41.7% delayed union. One patient had a wound complication requiring a rotational flap. Historically, the rate of union for primary first MTP joint fusions has been 71% to 98%.5 Our union rate is comparable to those of interposition arthrodesis with autograft and even primary arthrodesis. In cases of failed surgery of the hallux, treatment options include conservative management, removal of hardware, synovectomy, and arthrodesis.8 Removal of hardware and synovectomy can be a successful salvage procedure in toes without significant malalignment, as pain can be reduced and clinical outcomes improved; however, patients are still not functionally normal. Gait studies have demonstrated first metatarsal head avoidance of loading, greater pressures under the lesser metatarsal heads, lower walking velocity, and greater time spent in stance phase.14 In situ first MTP arthrodesis has been discussed as a salvage procedure for another situation of a shortened hallux with deformity: the failed Keller resection arthroplasty.5,16 Most patients have good to excellent satisfaction scores, improvement in pain scores,5 and improvement in AOFAS scores, from a mean of 42 to 76 as reported by Machacek et al.16 In situ arthrodesis patients fared much better than patients treated with a repeat Keller procedure. These patients had a high rate of fair and poor satisfaction, recurrent cock-up or valgus deformity, and subjectively noted loss of push-off strength, transfer metatarsalgia, and shoewear problems in the same study.16 Our patient satisfaction scores, pain improvement, and functional outcomes mirror the findings in patients who have undergone interposition arthrodesis with autograft.1,2 However, good and excellent satisfaction scores after primary first MTP arthrodesis are slightly higher, ranging from 89% to 100%.7,11,15 There are several limitations to this study. This was a retrospective case series with a small number of patients. Although the technique and type of interpositional graft used was uniform across all cases, a variety of augments were used (bone morphogenic protein, morselized autograft vs allograft). Preoperative and postoperative FAAM scores were not available on all patients. Compliance rate with the questionnaires may have been increased if the patients had completed questionnaires in the clinic setting rather than

8 through the mail. Plain radiographs were used to determine fusion rather than computed tomography, which may have generated less accurate times to union. Additionally, the postoperative radiographs were not obtained at routine intervals. Ideally, radiographs would be obtained on a weekly basis to evaluate time to union most accurately. In conclusion, prior studies cite interpositional arthrodesis as more difficult and associated with higher nonunion rates and higher wound complication rates than other salvage options. In this study, we report a technique based on the principles of using concentric hemispheric surfaces as used in a primary arthrodesis. This technique was relatively easy to perform and allowed correction of deformity with a union rate comparable to previous reports for primary arthrodesis. There was a high level of satisfaction postoperatively with pain and functional improvement. Arthrodesis with an interpositional allograft bone block was an effective salvage procedure for failed first MTP joint implant arthroplasty or other causes of a shortened hallux with deformity. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

References 1. Bhosale A, Munoruth A, Blundell C, et al. Complex primary arthrodesis of the first metatarsophalangeal joint after bone loss. Foot Ankle Int. 2011;32(10):968-972. 2. Brodsky JW, Ptaszek AJ, Morris SG. Salvage first MTP arthrodesis utilizing ICBG: clinical evaluation and outcome. Foot Ankle Int. 2000;21(4):290-296. 3. Cancilleri F, Marinozzi A, Martinelli N, et al. Comparison of plantar pressure, clinical, and radiographic changes of the forefoot after biplanar Austin osteotomy and triplanar Boc osteotomy in patients with mild hallux valgus. Foot Ankle Int. 2008;29(8):817-824. 4. Coughlin MJ, Abdo RV. Arthrodesis of the first metatarsophalangeal joint with Vitallium plate fixation. Foot Ankle Int. 1994;15(1):18-28. 5. Coughlin MJ, Mann RA. Arthrodesis of the first metatarsophalangeal joint as salvage for the failed Keller procedure. J Bone Joint Surg Am. 1987;69(1):68-75. 6. Curtis MJ, Myerson M, Jinnah RH, Cox QG, Alexander I. Arthrodesis of the first metatarsophalangeal joint: a biomechanical study of internal fixation techniques. Foot Ankle. 1993;14(7):395-399. 7. Doty J, Coughlin M, Hirose C, Kemp T. Hallux metatarsophalangeal joint arthrodesis with a hybrid locking plate and a plantar neutralization screw: a prospective study. Foot Ankle Int. 2013;34(11):1535-1540.

Foot & Ankle International  8. Esway JE, Conti SF. Joint replacement in the hallux metatarsophalangeal joint. Foot Ankle Clin. 2005;10(1):97-115. 9. Garras DN, Durinka JB, Bercik M, Miller AG, Raikin SM. Conversion arthrodesis for failed first metatarsophalangeal joint hemiarthroplasty. Foot Ankle Int. 2013;34(9): 1227-1232. 10. Goucher NR, Coughlin MJ. Hallux metatarsophalangeal joint arthrodesis using dome-shaped reamers and dorsal plate fixation: a prospective study. Foot Ankle Int. 2006;27(11): 869-876. 11. Gross CE, Hsu AR, Lin J, Holmes GB, Lee S. Revision MTP arthrodesis for failed MTP arthroplasty. Foot Ankle Spec. 2013;6(6):471-478. 12. Hecht PJ, Gibbons MJ, Wapner KL, Cooke C, Hoisington SA. Arthrodesis of the first metatarsophalangeal joint to salvage failed silicone implant arthroplasty. Foot Ankle Int. 1997;18(7):383-390. 13. Humbert JL, Bourbonniere C, Laurin CA. Metatarsophalangeal fusion for hallux valgus: indications and effect on the first metatarsal ray. Can Med Assoc J. 1979;120(8):937-941, 956. 14. Kitaoka HB, Holiday AD Jr, Chao EY, Cahalan TD. Salvage of failed first metatarsophalangeal joint implant arthroplasty by implant removal and synovectomy: clinical and biomechanical evaluation. Foot Ankle. 1992;13(5):243-250. 15. Kumar S, Pradhan R, Rosenfeld PF. First metatarsophalangeal arthrodesis using a dorsal plate and a compression screw. Foot Ankle Int. 2010;31(9):797-801. 16. Machacek F, Jr., Easley ME, Gruber F, Ritschl P, Trnka HJ. Salvage of a failed Keller resection arthroplasty. J Bone Joint Surg Am. 2004;86(6):1131-1138. 17. Mann RA, Oates JC. Arthrodesis of the first metatarsophalangeal joint. Foot Ankle. 1980;1(3):159-166. 18. Marin GA. Arthrodesis of the metatarsophalangeal joint of the big toe for hallux valgus and hallux rigidus: a new method. Int Surg. 1968;50(2):175-180. 19. Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen JM. Evidence of validity for the Foot and Ankle Ability Measure (FAAM). Foot Ankle Int. 2005;26(11): 968-983. 20. McKeever DC. Arthrodesis of the first metatarsophalangeal joint for hallux valgus, hallux rigidus, and metatarsus primus varus. J Bone Joint Surg Am. 1952;34(1):129-134. 21. Moynihan FJ. Arthrodesis of the metatarso-phalangeal joint of the great toe. J Bone Joint Surg Br. 1967;49(3):544-551. 22. Myerson MS, Miller SD, Henderson MR, Saxby T. Staged arthrodesis for salvage of the septic hallux metatarsophalangeal joint. Clin Orthop Relat Res. 1994;(307):174-181. 23. Myerson MS, Schon LC, McGuigan FX, Oznur A. Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int. 2000;21(4): 297-306. 24. Singh B, Draeger R, Del Gaizo DJ, Parekh SG. Changes in length of the first ray with two different first MTP fusion techniques: a cadaveric study. Foot Ankle Int. 2008;29(7): 722-725. 25. Smith RW, Joanis TL, Maxwell PD. Great toe metatarsophalangeal joint arthrodesis: a user-friendly technique. Foot Ankle. 1992;13(7):367-377.

First Metatarsophalangeal Joint Arthrodesis Technique With Interposition Allograft Bone Block.

We present a technique of first metatarsophalangeal joint arthrodesis utilizing an interposition allograft bone block with a bipolar reaming technique...
577KB Sizes 0 Downloads 71 Views