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.