PURPOSE OF THE STUDY: Hallux rigidus is a frequent disease of the first metatarsophalangeal (MTP) joint. It is a painful condition markedly reducing joint motion. For grade-3 and grade-4 disease, as classified by Coughlin, first MTP joint replacement is another option of surgical treatment, in addition to resection arthroplasty or arthrodesis. MATERIAL AND METHODS: In a group of 27 patients with symptomatic hallux rigidus, 28 MTP joint replacements using a TOEFIT-PLUS implant were carried out in the 2005-2009 period. There were 24 women and three men, with an average age of 56.3 years. The average follow-up was 24 months (range, 4 to 48). Indication for surgery included hallux rigidus in 20, conditions following Keller's arthroplasty in five, necrosis of the first metatarsus head in two cases and a condition after the Austin procedure in one patient. Pain, assessed by the Kitaoka score, and the range of joint motion; were evaluated before the surgery and at the final follow-up visit this also included the radiographic assessment of implant position and its integration. RESULTS: Of the 28 implants used, nine were hemiprosthetic and 19 total joint replacements. The average time between surgery and full weight-bearing was 6.6 weeks (range, 5 to 8) in both groups. The post-operative Kitaoka score was 87.1 (68-100) as compared with the preoperative value of 36.3 (24-52), and this difference was statistically significant.The range of motion at the first MTP improved from 14.7 degrees pre-operatively to 38.5 degrees post-operatively. There was no statistically significant difference in joint function, as assessed by the Kitaoka score and range of motion, between the two groups (hemiprosthetic vs. total joint replacements). The complications included prolonged skin healing with minor dehiscence in four cases. Revision surgery was required in three cases because of restricted joint motion associated with pain. In three cases of the total joint replacement group, there was radiographic evidence of asymptomatic osteolysis around both the phalangeal and the metatarsal component. In the hemiarthroplasty group, no osteolysis was recorded. DISCUSSION: Up to now several types of implants have been developed to alleviate pain and restore and maintain the first MTP motion in patients with hallux rigidus.The TOEFIT-PLUS implant belongs to the most recent ones. Our results are in agreement with those of other currently used replacements in terms of clinical and functional evaluation. The complications recorded in our study are also similar to those reported in the literature, which include aseptic loosening, dislocation and mechanical failure of the implant. There is no consistent approach to their treatment. Arthrodesis with tricortical graft seems to be an option, but it carries a considerable risk of failure. Since in our patients aseptic loosening was recorded only in the total joint replacement group, hemiarthroplasty has recently been preferred, because it has clinical and functional outcomes as good as total joint replacement. CONCLUSIONS: Our results with the use of TOEFIT-PLUS replacement show that this implant is effective in the treatment of hallux rigidus advanced stages and has good clinical outcomes, i.e., maintenance of motion at the MTP joint of the big toe, pain alleviation and early weight bearing. Since hemiarthroplasty is associated with fewer complications whose potential treatment is easier, this approach seems to have a better prospect than total joint replacement.
- Publication type
- Meeting Abstract MeSH
Úvod: Ve střednědobé retrospektivní studii prezentujeme naše klinické výsledky s implantací totální endoprotézy ToeFit-Plus při léčbě degenerativních změn 1. MTP kloubu. Metoda a materiál: Od března 2006 do listopadu 2010 jsme implantovali 23 totálních náhrad ToeFit-Plus. Zkontrolovali jsme 22 pacientů, 19 žen a 3 muže. Průměrný věk byl 55 let (39–72). Počtem 13 ku 9 převažovalo levé chodidlo. Průměrná doba sledování byla 54 měsíců (24–72). Indikací byl hallux rigidus těžkého stupně III., IV. dle Coughlina po neúspěšné konzervativní nebo předešlé operační terapii. Klinické výsledky jsme hodnotili na základě dotazníků VAS a Kitaoka skóre. Postavení komponent jsme zkontrolovali rentgenologickým vyšetřením. Sledovali jsme období před operací, dále první kontrolní období v průměru 2,3 roku a druhé kontrolní období v průměru 4,6 roku po operaci. Výsledky: Průměrná hodnota Kitaoka skóre před operací byla 45 bodů (rozmezí 27–63), v prvním kontrolním období 76 bodů (47–95), v druhém kontrolním období 66 bodů (39–90). V dotazníku VAS jsme zaznamenali bodovou hodnotu 7 (6–9) před operací, v prvním kontrolním období 2 (1–6) a v druhém kontrolním období 4 (2–9). Průměrný rozsah pohybu (dorziflexe–plantiflexe) v 1. MTP skloubení byl před operací 20° (5–25), v prvním kontrolním období 46° (30–50) a v druhém kontrolním období 35° (10–45). Nejčastější komplikací byl osteolytický lem kolem falangeální komponenty 44 %, ztuhlost kloubu 36 %, progrese bolesti 22,7 %, reoperaci pro mechanické selhání implantátu podstoupilo 18 % pacientů. Diskuze: V krátkodobém období jsme dosáhli povzbudivých výsledků, zlepšení rozsahu pohybu, úlevu od bolesti, zachování opěrné funkce palce při chůzi. V celkovém hodnocení byla alarmující vysoká míra komplikací a 40 % nespokojených pacientů. Podobné zkušenosti ve svých pracích udávají Lange, Gibson, Fuhrman. Závěr: V současné době jsme od indikace totální náhrady při řešení pokročilého stadia hallux rigidus ustoupili.
Introduction: In our mid-term retrospective study we present clinical results of implantation of the Toefit-Plus total endoprosthesis as a treatment of severe degenerative changes of the first MTP joint. Material and methods: During the period between March 2006 to November 2010, we implanted a total of 23 Toefit-Plus endoprostheses. We followed up 22 patients, 19 women and 3 men, with an average age of 55 years (range, 39-72). The mean duration of follow-up was 54 months (range, 24-72). The indication for surgery was hallux rigidus, grade III and IV according to Coughlin. Clinical outcomes were evaluated by the VAS questionnaire and Kitaoka score. The implant position was assessed by X-ray images. We performed the examinations before surgery, then during the first follow-up period of, on average, 2,3 years post surgery, and finally during the second follow-up period, on average 4,6 years post surgery. Results: The mean pre-operative Kitaoka score was 45 (range, 27-63), the mean score in the first follow-up period was 76 (range, 47-95), and the mean score in the second follow-up period was 66 (range, 39-90). The mean value of the VAS questionnaire was 7 points (6-9) before surgery, 2 points (1-6) in the first follow-up period and 4 points (2-9) in the second follow-up period. Average range of motion at the first MTP joint was 20° (5-25) before surgery, 46° (30-50) in the first follow-up period, and 35° (10-45) in the second follow-up period. The most frequent complications included radiographic evidence of asymptomatic osteolysis around the phalangeal component (44%), stiffness of the first MTP joint (36,4%), and progression of pain (22,7%). Revision surgery was required in 18,2% of the patients due to mechanical failure of the implant Discussion: We achieved encouraging short-term outcomes with the use of Toefit-Plus implant – alleviation of pain, restoration of movement and support function of the big toe during gait. However, in the final assessment there was an alarmingly high rate of complications and 40% of unsatisfied patients. Lange, Gibson, and Fuhrman report similar experience. Conclusion: At the present time we have discontinued indicating total endoprosthesis of the first MTP joint in the treatment of grade III and IV hallus rigidus.
- Keywords
- Kitaoka skóre, ToeFit-Plus,
- MeSH
- Arthroplasty, Replacement * methods statistics & numerical data MeSH
- Time Factors MeSH
- Adult MeSH
- Hallux Rigidus * surgery radiography MeSH
- Middle Aged MeSH
- Humans MeSH
- Pain Measurement statistics & numerical data MeSH
- Metatarsophalangeal Joint * surgery radiography MeSH
- Young Adult MeSH
- Postoperative Complications MeSH
- Prosthesis Design MeSH
- Joint Prosthesis MeSH
- Reoperation statistics & numerical data MeSH
- Retrospective Studies MeSH
- Range of Motion, Articular MeSH
- Prosthesis Failure MeSH
- Aged MeSH
- Patient Satisfaction MeSH
- Visual Analog Scale MeSH
- Treatment Outcome MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Young Adult MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
In a retrospective study, to evaluate the results of surgical treatment of hallux rigidus on the basis of clinical rating, radiographic findings and visual analogue scale (VAS). MATERIAL: The group included 68 patients, 38 women and 30 men, treated at the orthopaedic ward of the Hospital Ceské Budejovice in the period from April 2004 to June 2007. The average age of the patients was 58.6 years (range, 34 to 79). Right and left feet were affected in 42 and 26 patients, respectively. Follow-up ranged from 3 to 30 months. METHODS: Surgery was undertaken only after all means of conservative treatment had been used. Indications for each type of operation were based on the severity of disorder of the first metatarsophalangeal joint (MTPJ), patient's age, toe's motion restriction and physical stress on the patient's big toe. In patients with moderate degenerative MTPJ disease, in 25 feet, a Moberg dorsal wedge osteotomy of the first proximal phalanx was carried out when plantar flexion was preserved; in 12 feet, a Youngswick sagittal V osteotomy was indicated when both flexion and extension were limited and the first metatarsus was long enough; in 14 cases cheilectomy alone was used. In patients with severe arthritis, the TOEFIT-PLUS modular joint replacement of th first MTPJ was used in seven, the Brandes-Keller resection arthroplasty was carried out in six and arthrodesis of the first MTPJ was performed in four. All patients were examined at 2 and 6 weeks after surgery. Those undergoing osteotomy, arthrodesis or joint replacement were X-rayed after surgery and then at 6 weeks of follow-up. RESULTS: The outcome of treatment was evaluated at 3 to 30 months after surgery by clinical and X-ray examination and using the VAS. The average range of MTPJ motion improved from 5 degrees to 22 degrees in dorsiflexion and from 17.5 degrees to 27 degrees in plantar flexion. Osteotomy or arthrodesis in all patients healed in correct alignment, without loosening or migration of prosthetic components. Based on the VAS (100-point scale), pain assessment was 34 preoperatively and 78 post-operatively; joint motion increased from 51 before to 82 after surgery; and ability for daily activities from 50 to 84. The overall VAS score was 42 before surgery and improved to 83 after surgery. Five patients were dissatisfied; two of them underwent repeat surgery (arthrodesis) with marked improvement and one achieved improvement by shoe modification. The rest of the group reported good or very good outcomes. DISCUSSION: Resection arthroplasty, widely used before, is now performed only in patients exerting minimal physical activity and with severe arthritic disease, because it results in loss of the big toe's supporting function. Osteotomies by Moberg or Youngswick procedures involve the use of screws (Barouk). Stable osteosynthesis allows for early post-operative rehabilitation and weight bearing in appropriate modified shoes. Dorsal wedge osteotomy is the method most frequently used in our department to the full satisfaction of our patients.TOEFIT joint replacement is indicated in elderly patients with severe degenerative disease who wish to maintain toe motion and have adequate weight bearing of the treated foot. Emphasis is placed on good post-operative rehabilitation of the joint and on co-operation with the patient. CONCLUSIONS: The hallux rigidus diagnosis covers several grades of degenerative disease of the first MTPJ and therefore its surgical treatment must necessarily involve more than one operative procedure. Even when an appropriate technique is used, the problems may not resolve completely. When the technique to be used is considered, good communication with the patient is necessary, because they should know the principle of treatment and an anticipated outcome of it. Our results show that the surgical treatment of hallux rigidus has good outcome if it is correctly indicated and technically well performed and completed with good post-operative care.
