PURPOSE OF THE STUDY In this study, we retrospectively reviewed a consecutive case series of first metatarsophalangeal (MTP) joint arthroscopies performed in our department over a span of six years. This study aimed to evaluate the efficacy and safety of arthroscopic treatment for various first MTP joint pathologies. MATERIAL AND METHODS A total of 36 patients that underwent first MTP joint arthroscopy between January 2014 and December 2019 were reviewed. The mean age at the time of surgery was 38.3 years (range, 14-65), with no gender predominance (19 males). All arthroscopies were performed by a single surgeon using a 2.7 mm arthroscope with a 30° viewing angle as well as other standard instruments with a diameter equal to or smaller than 3.5 mm. Postoperative results were assessed by a satisfaction questionnaire obtained during the telephone interview. For patients with sesamoid bone pathology ability to return to sports activities was also evaluated. RESULTS The far most common indication, in even twenty-nine patients, was hallux rigidus, five patients were treated for nonunion of sesamoid bone fracture, one patient had an osteochondral defect of the first metatarsal head and one was treated due to the development of arthrofibrosis following the open corrective procedure of hallux valgus. The mean follow-up was 31.2 months. Thirty-four patients responded to the satisfaction questionnaire. Thirty patients (88.2%) were either satisfied or very satisfied with the procedure and thirty-one (91.2%) of them stated that they would undergo the same procedure again. The satisfaction rate for patients with early stages of hallux rigidus (grade 1 and 2) was 90.4%. Only one patient in this group (2.8%) required open revision surgery due to recurrence of pain and joint stiffness. All patients with nonunion of sesamoid bone fracture were very satisfied with the procedure, and three out of four patients (75%) who were also competitive athletes resumed their sports activity at the same or improved level after the arthroscopy. Regarding arthroscopy-related complications we observed four cases (11.1%) of iatrogenic injury to dorsal sensory nerves of the great toe, resulting in only one permanent sensory impairment. DISCUSSION Considering the high satisfaction rate and low rate of complications in our study, as well as those published in the literature, we can suggest that arthroscopy of the first MTP joint is a safe and effective procedure. CONCLUSIONS Arthroscopy of the first MTP joint certainly has a place in the treatment of some pathological conditions of the first MTP joint, and in our opinion, it should be first-line surgical therapy for the initial stages of hallux rigidus and sesamoid bone pathology. Key words: arthroscopy, metatarsophalangeal joint, great toe, hallux rigidus, cheilectomy, sesamoid bone, sesamoidectomy.
This work concerns a biomechanical study aiming to ascertain the optimal type of joint resection when performing a joint arthrodesis. A 3-dimensional digital model of the first metatarsophalangeal joint including the entire first metatarsal bone and proximal phalanx using CT scans of the forefoot was created. Using this computer model, 4 types of resections; ball-and-socket, flat-on-flat, wedge 90°, and wedge 100° were simulated. Parameters measured using this model were the force necessary to separate the 2 fused surfaces, the surface area of the resected surfaces and the shortening of the first ray. By measuring the reactive force necessary to separate the phalanx from the first metatarsal, the 90° wedge resection was found to be the most stable, with comparable results in the case of the 100° wedge resection. Wedge resections are also more favorable when comparing the shortening of the first ray. Wedge resections, though being more technically difficult to perform prove to be the most stable for metatarsophalangeal joint-1 arthrodesis using this model.
Úvod: V naší práci přinášíme zhodnocení výsledků Akinovy klínovité osteotomie základního článku palce nohy. Srovnáváme dvě metody fixace - cerkláží a skobkou. Soubor pacientů a metodika: Soubor představuje celkem 66 osteotomií u 58 pacientů provedených v letech 2003-2010. Ve 20 případech byla fixace provedena metodou tahové cerkláže a 46 fixací skobkou. K operaci byli indikováni pacienti s hallux valgus deformitou předonoží s hallux valgus angle (HVA) minimálně 15°. Primární výkon byl vždy kombinován s osteotomií I. metatarzu a eventuálně dalšími výkony na předonoží. Byla provedena klínovitá osteotomie typu close-wedge základního článku palce, 4 mm distálně od kloubní štěrbiny I. metatarzofalangeálního kloubu. Fixace byla provedena tahovou cerkláží nebo fixační skobkou. Výsledky: Bylo provedeno 20 Akin osteotomií s fixací cerkláží u 18 pacientů. V 18 případech byla operace provedena v jedné době spolu s dalšími výkony - scarf osteotomie 8x, scarf osteotomie + Weil osteotomie 8x, Lapidus 2x, odloženě byly provedeny 2 osteotomie následně po izolované scarf osteotomii 1x, po scarf osteotomii + Weil osteotomii 1x. Peroperační komplikace: trascize šlachy m. flexor hallucis longus 1x, větší krvácení s nutností revize rány 1x, pooperační komplikace: 5x výrazný otok nohy, z toho 1x infekce, 1x roztržení cerkláže, 1x selhání cerkláže. HVA z 32° se zlepšil na 9°, výsledný úhel varizace základního článku palce Cobb byl 16°, AOFAS skóre se zlepšilo ze 48 na 84. Kostní zhojení bylo zjištěno u všech 20 Akin osteotomií do třetího pooperačního měsíce. Bylo provedeno 46 Akin osteotomií s fixací skobkou u 40 pacientů. Ve 44 případech byla operace provedena v jedné době s dalšími výkony - scarf osteotomie 20x, scarf osteotomie + Weil osteotomie 21x, Lapidus + Weil osteotomie 3x, odloženě byly provedeny 2 osteotomie následně po scarf + Weil osteotomii. Peroperační komplikace: nestabilita fragmentů bez možnosti komprese 2x, pooperační komplikace: 10x větší otok nohy, z toho 1x infekce. HVA ze 42° se zlepšil na 19°, výsledný úhel varizace Cobb byl 13°, AOFAS skóre se zlepšilo ze 44 na 86. Kostní zhojení bylo zjištěno u všech 46 Akin osteotomií do třetího pooperačního měsíce. Diskuze: Akinova bazální osteotomie zažívá svou renesanci jako doplňkový výkon k osteotomiím metatarzů. Jsou diskutovány různé jiné typy fixace. Námi použité dvě metody mají podobné výsledky s odstupem jednoho roku. Skobku je možno použít u deformit s větším HVA úhlem před operací. Akinova osteotomie výrazně zlepšuje úhel valgozity palce. Vyžaduje však jemnou operační techniku a zkušenosti s operativou nohy při řešení případných komplikací.
Introduction: In this article, we bring an evaluation of the results of Akin medial closing wedge osteotomy of the proximal phalanx of the great toe. We are comparing 2 fixation methods - tension-band wiring technique and staple technique. The sample of patients and methods: the sample includes 66 osteotomies made during 2003-2010 in 58 patients. In 20 cases the fixation was performed using the band wiring method and 46 fixations using the staple method. We indicated patients suffering from hallux valgus deformity of forefoot with hallux valgus angle (HVA) of at least 15° for the surgery. The primary intervention was always combined with osteotomy of the I. metatarsal bone and, alternatively with other interventions performed in the forefoot. We performed a wedge osteotomy of proximal phalanx of the great toe, in the distance of 4 mm from the joint gap of the I. metatarsophalangeal joint. The fixation was performed with tension-band wiring or with the staple. Results: In 18 patients, we performed 20 Akin osteotomies, with tension-band wiring fixation. In 18 cases the operation was performed concurrently with another surgical intervention - Scarf osteotomy 8x, Scarf osteotomy + Weil osteotomy 8x, Lapidus 2x. In two cases we carried a secondary Akin osteotomy after carried isolated Scarf osteotomy 1x and Scarf osteotomy + Weil osteotomy 1x. Preoperative complications: Cut of tendon m. flexor hallucis longus 1x, intensive bleeding which forced to revision of wound 1x. Postoperative complications: 5x swollen foot, 1x infection, 1x cerclage damage, 1x cerclage failure. HVA has on average improved from 32° to 9°, the final Cobb varisation angle of the proximal phalanx of the great toe was 16°, AOFAS score improved from 48 to 84. By the end of the third postoperative month, the bone seemed to be healed at all 20 Akin osteotomies. In 40 patients, 46 Akin osteotomies with staple fixation were performed as well. In 44 cases the operation was performed concurrently with other surgical interventions - scarf osteotomy 20x, scarf osteotomy + Weil osteotomy 21x, Lapidus + Weil osteotomies 3x. In two cases we carried secondary Akin osteotomy after Scarf osteotomy + Weil osteotomy. Perioperative complications: instability of the fragments without possibility of compression 2x, postoperative complications: 10x swollen foot, one of which with infection. HVA improved from 42° to 19°, the final Cobb varisation angle was 13°, AOFAS score improved from 44 to 86. The bone was found to be healed in all 46 Akin osteotomies by the third postoperative month. Discussion: the Akin osteotomy is going through its rebirth as a supplementary intervention of metatarsal osteotomies. Several types of fixation have been discussed. Both methods, used by us, demonstrate similar results within 1 year. A staple might be used in case of deformities with a larger HVA angle. Akin osteotomy significantly improves the valgosity angle of proximal phalanx of the great toe. However, it requires a well-mastered operative technique as well as substantial experience in solving potential complications that might arise during the foot surgeries.
- Klíčová slova
- tahová cerkláž, varizační skobka,
- MeSH
- chirurgické staplery MeSH
- dospělí MeSH
- hallux valgus * chirurgie radiografie MeSH
- kostní dráty MeSH
- kostní šrouby MeSH
- lidé středního věku MeSH
- lidé MeSH
- metatarzální kosti chirurgie radiografie MeSH
- mladiství MeSH
- osteotomie * metody MeSH
- palec nohy chirurgie radiografie MeSH
- pooperační komplikace MeSH
- protézy a implantáty * MeSH
- retrospektivní studie MeSH
- senioři MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- srovnávací studie MeSH
The important part of hallux valgus deformity operations, especially in the case of an incongruent joint, is the release of the soft tissue on the lateral side of the first metatarsophalangeal joint. The purpose of the present anatomic study was, with preparation of the lateral structures of the joint and lateral conjoined tendon, to provide a background for a surgical tip of the release of the joint for an additional metatarsal osteotomy. For the present study, we used 30 specimens (15 left and 15 right) from 19 cadavers at the Institute of Anatomy, First Faculty of Medicine, Charles Faculty (Prague, Czech Republic). Only specimens that met the criteria of hallux valgus were included in the present study. The technique was based on the incision of the lateral sesamoid ligament and partial tenotomy of the lateral conjoined tendon from the first interdigital web space. The release was done gradually with supination and abduction of the big toe to achieve the smallest size of the tenotomy. The median of the tenotomy size of the conjoined tendon was 6.5 (range 5 to 14) mm. The median size of the conjoined tendon in the frontal plane just ventral to the sesamoid bone was 10.6 (range 8 to 14) mm. The technique of the release, in which the big toe was abducted and supinated, can minimize the size of the lateral conjoined tendon release and can minimize the possibility of a postoperative deformity.
PURPOSE OF THE STUDY Hemiarthoplasty or total replacement of the first metatarsophalangeal (MTP) joint has been used in orthopaedic surgery for the last 60 year, but good post-operative outcomes have been achieved only in the last ten years. Joint replacement is mainly used in stage 3 and stage 4 hallux rigidus conditions for which arthrodesis is not indicated. The operation on the first MTP joint has its place in the present-day orthopaedics. This study describes anatomical measurements and the development of the first Czech implant (MEDIN Orthopaedics) to replace this joint. MATERIAL AND METHODS Thirty cadaver specimens were used to develop basic shapes of phalangeal and metatarsal components. A standard technique was used for anatomical dissection of the first MTP joint. Fifteen specimens were cut in the sagittal plane and fifteen in the transverse plane in order to open the intramedullary cavity of the proximal phalanx of the great toe and the first metatarsal bone. The basic shapes of phalangeal and metatarseal components were designed based on the shape of cortical bone of their inner surfaces. Data for the shape, size and scale of articular components were obtained by measurement on 58 dry bone specimens of the first metatarsus and on 30 calibrated X-ray images. In order to adjust the scale and size of components, the final shape and the range of implant size were tested on 50 specimens of dissected lower extremities fixed in formaldehyde, acetone, ethyl-alcohol and glycerol. RESULTS The new type of a first MTP implant designed by us was based on cone-shaped anchor components coated with hydroxyapatite. The implants can be used in hemiarthroplasty or total joint replacement. The metatarsal insert was designed with a declination angle of 20 degrees to facilitate good dorsiflexion and with a flattening to ensure good function of the sesamoid bones, The phalangeal articular insert was made of either CoCr alloy or low-weight polyethylene for use in hemiarthroplasty and total joint replacement, respectively. DISCUSSION The new implants are designed for treatment of stage 3 or stage 4 hallux rigidus. We recommend to use hemiarthroplasty or total joint replacement only in the case of first metatarsal head destruction or severe joint destruction due to rheumatoid arthritis. CONSLUSIONS Our anatomical study of the first MTP joint, proximal phalanx of the great toe and first metatarsal bone was used to design the first Czech implant of this joint.
- MeSH
- artroplastika prstů metody přístrojové vybavení MeSH
- hallux limitus chirurgie MeSH
- hallux rigidus chirurgie MeSH
- lidé MeSH
- metatarzofalangeální kloub anatomie a histologie chirurgie patologie MeSH
- palec nohy chirurgie patologie MeSH
- protézy kloubů využití MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- klinické zkoušky MeSH
V posledních letech prodělává revmatochirurgie poměrně výrazný vývoj. Přes významné pokroky v oblasti farmakologické terapie zánětlivých revmatických onemocnění zatím význam chirurgické terapie neklesá. Posouvá se pouze načasování výkonů a jejich frekvence podle lokalizace. Moderní operační postupy V ortopedii se obráží i v revmatochirurgii. Zahrnují nejen nové materiály, ale i počítačovou navigaci a zejména artroskopii. Revmatochirurgické indikace se z velkých kloubů dolní končetiny rozšiřují i na končetinu horní a od kloubů kořenových na periferní. Technický pokrok přinesl i další náhrady kloubů, jako je zápěstí, drobné klouby ruky a prstů, náhrady trapezia a karpometakarpálního kloubu I. paprsku ruky, na dolní končetině náhrady hlezna a metatarzofalangeálního kloubu palce nohy. Endoprotézami výčet revmatochirurgických operací nekončí. Osteotomie a artrodézy, které jsou u velkých nosných kloubů jen východiskem z nouze, mohou na drobných periferních kloubech prinést nemocnému značný prospěch.
- MeSH
- artroplastiky kloubů metody MeSH
- artroskopie metody využití MeSH
- klouby nohy (od hlezna dolů) chirurgie patologie MeSH
- klouby ruky chirurgie patologie MeSH
- lidé MeSH
- ortopedické výkony klasifikace metody MeSH
- palec nohy chirurgie patologie MeSH
- revmatické nemoci chirurgie MeSH
- synovektomie MeSH
- synoviální membrána MeSH
- Check Tag
- lidé MeSH
- MeSH
- amputace metody využití MeSH
- diabetická noha chirurgie komplikace MeSH
- diabetické nefropatie komplikace terapie MeSH
- hlezenní kloub chirurgie MeSH
- lidé MeSH
- ortopedické výkony metody trendy využití MeSH
- pahýl po amputaci chirurgie MeSH
- palec nohy chirurgie MeSH
- syndrom kladívkového prstu chirurgie MeSH
- záchrana končetiny metody využití MeSH
- zákroky plastické chirurgie metody využití MeSH
- Check Tag
- lidé MeSH
