Primary Clinical Evaluation of the Joint Replacement for the Treatment of the First Metatarsophalangeal Arthritis

Chin Med Sci J March 2011

Vol. 26, No. 1 P. 14-19

CHINESE MEDICAL SCIENCES JOURNAL ORIGINAL ARTICLE

Primary Clinical Evaluation of the Joint Replacement for the Treatment of the First Metatarsophalangeal Arthritis Qi-yi Li, Jin Jin*, Xi-sheng Weng, Jin Lin, Yi-dan Zhang, and Gui-xing Qiu Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China

Key words: joint replacement; arthritis; implant Objective To retrospectively assess the primary clinical results of a cohort of the first metatarsophalangeal joint replacement with double-stemmed hinge silicone implant. Methods A total of 12 patients (15 feet) received the joint replacement with double-stemmed hinge silicone implant. There were 2 males and 10 females with a mean age of 61.4 (range, 56-75) years old. Of them, 9 cases (11 feet) were hallux valgus with osteoarthritis; 1 case (2 feet) was rheumatic arthritis; 2 cases (2 feet) were traumatic arthritis. The subjective and objective results were evaluated during follow-up. Results All of the patients were followed up regularly with an average of 24.7 months, ranging from 12 to 38 months. Ten patients were completely satisfied with the operation; 1 patient showed partial satisfaction, and 1 patient was not satisfied because of the first matatarsophalangeal joint pain due to severe hyperosteogeny surrounding the cut bone surface 3 years after the operation. Osteolysis around the implant occurred in 2 cases without clinical symptoms, and no special treatment was given. Conclusion The joint replacement is a preferable method in alleviating pain and improving walking function with proper indication.

Chin Med Sci J 2011; 26(1):14-19

A

RTHRITIS of the first metatarsophalangeal joint

with prosthesis has been used more and more widely. Though

is a common and painful condition, with trea-

satisfactory clinical results have been reported,6-9 surgical te-

tment being determined by the disease severity,

chnique, implant design, materials, and patient selection re-

the extent of any associated deformity, the

main areas of heated debate and ongoing research. This retr-

patient's age and activity  level.1 Surgical treatments for

ospective study was therefore performed to evaluate the pri-

severe disease include arthrodesis,2 osteotomies,3 resec-

mary clinical outcomes of joint replacement with double-stem

4

tion arthroplasty, and joint replacement.

5, 6

With the de-

silicone implant for the first metatarsophalangeal arthritis.

velopment of joint replacement technique, arthroplasty

PATIENTS AND METHODS Received for publication December 8, 2010. *Corresponding author Tel: 86-10-65296081, E-mail: Jinjin9010@ 126.net

Patients From July 2001 to December 2003, a total of 12 patients

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(15 feet) were treated in our department. There were 2

metatarsal was excised distal to the metaphyseal flare with

males and 10 females. The average age was 61.4 years old

a 10 degree valgus angle maintaining. A portion of the base

(range, 56-75). Nine cases (11 feet) were hallux valgus

of the proximal phalanx was removed to provide a wider

with senile osteoarthritis; 1 case (2 feet) rheumatic ar-

joint space. The intramedullary canals were shaped in a

thritis; 2 cases (2 feet) post traumatic arthritis.

rectangular fashion to accept the implant stem. Bone edges

The inclusion criteria in our study were: (1) severe

were carefully smoothened. A preliminary reduction with a

senile osteoarthritis with hallux valgus of the first meta-

trial implant was done to check the proper size of the im-

tarsophalangeal joint; (2) severe rheumatic or rheumatoid

plant, the effectiveness of the realignment, the balance of

arthritic hallux valgus of the first metatarsophalangeal joint,

soft tissue and the motion of the toe. Then the implant was

in which X-ray showed joint-space narrowing or signs of

carefully placed in the canals. With the toe held in proper

bone erosion or bone cyst formation; (3) degenerative or

alignment including rotation and maintained the medial

traumatic arthritis of the first metatarsophalangeal joint;

and lateral soft tissue balance, the medial fascial-capsular

(4) pain with motion of the first metatarsophalangeal joint;

flap was firmly sutured. Then we must check the tension

(5) adequate bone density to accept stems and stresses of

and balance of the soft tissue around the joint. After the

an implant device; (6) age over 50 years old with less

cutaneous incision was closed, a sterile dressing held the

postoperative activity demand; (7) no infective process,

toe in the correct position for 3 to 4 weeks. Early exercise

and no allergy to implant material.

started mandatory on the 3rd postoperative day, while

All of the patients suffered severe pain caused by the first metatarsophalangeal arthritis. The other symptoms

weight-bearing exercise was mandatory 3 weeks after the operation.

and signs include swelling, callus, degeneration, malformation, and walking-distance limitation with need for

Definition of evaluation criteria

larger shoes. No patients suffered from primary talipes

We evaluated both the subjective and the objective results

adductus, flat foot or talipes cavus. Preoperative X-ray

according to the forefoot surgery evaluation criteria.10

indicated that 9 patients (11 feet) of hallux valgus and 1

Subjective evaluation included pain, walking ability and

patient (2 feet) of rheumatoid arthritis had notable mal-

phalangeal function, with a total score of 10 points. The

formation, different degrees of subluxation, degeneration

higher the score was, the better the effectiveness of the

and medial osteophyte formation of the first metatarso-

operation was. Patient satisfaction was classified into

phalangeal joint. Patients of traumatic arthritis mainly

complete satisfaction partial satisfaction, and dissatisfac-

represented with the narrowing and proliferative sclerosis

tion. Objective evaluation included hallux valgus angle and

of the joint space. All the patients in the group were senile

change of flexion and extension angle of the metatarso-

and had moderate to severe hallux valgus with degenera-

phalangeal joint. We also monitored the appearance of the

tion of the joint and with less postoperative activity de-

foot, the position of implant and the change of bone mass

mand. Patients with larger first-second intermetatarsal

around the implant by radiographic evaluations.

angle, or patients with higher postoperative activity demand were excluded in the study.

Statistical analysis The results were presented as x r s . Our data were an-

Operative technique

alyzed with SAS. P value less than 0.01 was considered

All patients underwent the first metatarsophalangeal joint

statistically significant.

replacement using the double-stemmed Swanson hinge silicone implant (Wright Medical Technology Inc., TX, USA). The size of the implant was properly selected according to

RESULTS

the preoperative radiographic images and prosthesis

All of the patients were followed up regularly with an

templates. The incision was slightly curved, longitudinal

average of 24.7 months, ranging from 12 to 38 months

over the dorsomedial aspect of the first metatarsopha-

(Table 1). No early postoperative complications were found.

langeal joint. Care must be taken to avoid injury to the

The symptoms including pain, walking ability and pha-

small dorsal sensory nerves and veins in the area. The

langeal function were all improved significantly (P<0.01).

fascia and medial capsule of the joint were exposed and

Ten patients (13 feet) were completely satisfied (Fig. 1); 1

incised medial to the extensor hallucis longus tendon to

patient (1 foot) partially satisfied; and 1 patient (1 foot)

prepare a capsuloligamentous flap for later closure and

unsatisfied with the result. The partially satisfied one was a

correction of the deviation deformity. The head of the first

senile arthritic patient with hallux valgus who underwent

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CHINESE MEDICAL SCIENCES JOURNAL

bilateral replacements of the feet. He felt weakness in one

March 2011

formed or planned.

foot while walking after the operation. The unsatisfied one

Postoperative radiography follow-up showed 2 patients

was a traumatic arthritic patient of the first metatarso-

(2 feet) had hyperostosis on the osteotomy surface of the

phalangeal joint. He still had pain in the joint when

metatarsophalangeal joint. One was quite slight and was

weight-bearing and could not walk long distance. The ra-

asymptomatic, the other one was severe with painful hy-

diography of 3 years postoperation showed severe hy-

perostosis and osteolysis around the prosthesis. And there

perostosis around the osteotomy surface of the metatar-

was another 1 patient (1 foot) with osteolysis around the

sophalangeal joint, accompanied by osteolysis around the

silicon rubber implant but without symptom. No loosening,

implant (Fig. 2). No revision surgery has so far been per-

dislocation, or fracture of the implant was noted.

Table 1. Preoperative and follow-up results of 15 feet of 12 patients undergoing the first metatarsophalangeal joint replacement with double-stemmed hinge silicone implant§ (n=15) Time Preoperation Follow-up

Pain

Walking ability

Phalangeal function

Hallux valgus angle

Flexion angle

(points)

(points)

(points)

(°)

(°)

2.8±0.6

4.1±0.9

4.3±0.5

28.9±11.8

118.0±3.4

17.4±3.7

29.2±6.4

11.9±4.6

19.2±2.4

31.1±6.3

*

7.1±1.7

7.4±1.9

*

7.1±1.8

*

7.2±3.3

*

Extension angle Range of joint (°)

motion (°)

§: Plus-minus values are means±SD. Pain, walking ability, and phalangeal function utilize 10 points scoring method. The lower the score is, the severer the symptom is. *

P<0.01 compared with preoperation.

A

B

C

Figure 1. Radiographs of a 68-year-old female with hallux valgus of left foot. A. Preoperative radiograph shows 29° hallux valgus angle with appearance of osteoarthritis. B. Postoperative radiograph shows correction of the hallux valgus after Swanson implant replacement. C. Radiograph shows satisfactory result after 30 months of follow-up.

A

B

Figure 2. Radiographs of a 61-year-old male with traumatic arthritis of the left first metatarsophalangeal joint. A. Preoperative radiograph shows narrowing of the joint space. B. Radiograph one month after the Swanson implant replacement. C. Hyperostosis and osteolysis occur around the implant after 37 months of follow-up.

C

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plant provided high levels of patient satisfaction in lower activity demand patients.1 There were significant im-

DISCUSSION

provements in scores for pain, ambulation, function and

The first metatarsophalangeal joint replacement was

shoe wear (P<0.0001). The mean hallux valgus angle

first developed in the 1950s as an alternative solution for

decreased from 37.9° to 24.1° (P<0.0001). In Granberry’s

patients in whom the arthrodesis, metatarsal osteotomy,

study,17 a series of 90 consecutive total joint replacements

or excisional arthroplasty was not the ideal choice.11 Over

of the first metatarsophalangeal joint with a flexible hinged

time, it had become clearer that certain implant designs,

prosthesis were reviewed. Subjective responses showed

implant materials, and patient characteristics were asso-

favorable over-all ratings were associated with relief of

Since 1974, Swanson

pain (P<0.05) and with the ability to wear cosmetically

recommended the use of double-stem hinged implant in

acceptable shoes (P<0.05). Although the average range

patients with severe hallux valgus with arthritic destruction

of motion was from 26° of extension to 13° of flexion, 22

on both sides of the joint, as in some patients with

feet of the 73 feet (30%) had flexion of less than 15°. The

12

ciated with poorer outcomes.

One advantage of

range of motion of the toe did not change markedly with

the Swanson system design is the compatibility between

the duration of implantation of the prosthesis and did not

the flexible implant and the grommet, so will the survival

correlate with the severity of postoperative pain or the

rate of the prostheses be longer. This system has been

distance that the patient was able to walk.

13

rheumatoid arthritis and in the elderly.

widely used in the treatment of rheumatoid arthritis, degenerative or post traumatic arthritis nowadays.14

In our study, the overall satisfaction rate was 83.3% (10 in 12 patients). All of the patients could wear any shoes

The double-stemmed Swanson hinge silicone implant

as wished. The postoperative radiographs showed that the

is a kind of constrained implant composed of two parts: the

hallux valgus angle and the malformations of the meta-

flexible implant and the titanium grommet. The implant is

tarsophalangeal joints were well corrected. The postop-

made of silicone elastomer with two stems fit into the in-

erative average extension and flexion angles were 19.2°

tramedullary canal of the metatarsal and phalanx. The

and 11.9° respectively. And the postoperative range of

flexural concavity or open portion of the hinge is placed

joint motion was 31.1°, which had no significant difference

superiorly or dorsally to allow greater range of extension of

from the preoperative range of motion (P>0.05). The

the toe. The proximal and distal stems have a rectangular

results might be caused by the bias of etiological distribu-

cross section to help provide rotational stability in the in-

tion in which senile osteoarthritis accounted for a dominant

tramedullary canals. The titanium shield grommet is de-

portion of our cases. In this way, patients who had high

signed for use in patients where cutting or abrasion of the

expectation on postoperative activity were not recom-

flexible implant from contact with thin, sharp bone edges

mended to undergo this kind of replacement according to

can occur, or in patients who have high activity demands.

our study.

The grommet can protect the implant from sharp bone

The key points and goals of the surgery are to realign

ends in areas where abrasion, wear, and cutting are most

the joint and balance the soft tissue function. The operation

likely to occur due to forces exerted on the implant during

technique was very important for good results since most

flexion and extension. In a meta-analysis of the first

of the patients were hallux valgus with osteoarthritis. We

metatarsophalangeal joint replacement, the constrained

should not place too much emphasis on radiographic

total silicone implant showed best estimated effect of

measurements and miss the finer points of clinical soft

89.7%.

15

tissue examination since the stability of the artificial joint

Smetana et al16 reported that the subjective satisfac-

relied on it. Preoperative and intraoperative evaluation of

tion rate of the patients who had undergone this kind of

the capsule, tendons and soft tissue around the joint will

operation was 79%. The average extension and flexion

ultimately determine the long-term results of the surgery.

angles were 19° and 10° respectively. And the total range

In our study, the medial capsule of the first metatarso-

of joint motion was 29°. Postoperative radiographs showed

phalangeal joint was incised in a V-shaped fashion, leaving

that 17.5% of feet had osteolysis at the bone head; 15.5%

a distally based flap on the proximal phalanx for later

of the feet had calcification around the implant; osteophyte

closure and correction of the valgus deformity.

was formed in 67% of the feet at the proximal end of the

Although a meta-analysis of 47 studies showed that

phalanx and the distal end of the metatarsal bone.

this kind of total silicone implant had the best estimated

Bankes’s cohort study of 45 consecutive patients with a

effect among the implants made of all kinds of materials,15

minimum 5-year follow-up showed that the Swanson im-

all long follow-up studies reported an increased number of

18

CHINESE MEDICAL SCIENCES JOURNAL

implant failures and complications.18-20 The complications

6.

March 2011

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7.

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6, 17, 18, 21

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In our group of patients, hy-

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Shankar NS, Asaad SS, Craxford AD. Hinged silastic im-

Clin Orthop 1990; 255:268-72. 9.

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vision as the end point, the patients of our group had 100%

208-18.

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We thought that the

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worked as a spacer to maintain the range of motion of the

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been conducted domestically,

23-25

most of which showed

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