- Email: [email protected]
Cheilectomy Combined With First Tarsometatarsal Joint Arthrodesis for Surgical Treatment of Midstage Hallux Rigidus Complicated by Medial Column Insufficiency: Prospective Evaluation of Outcomes
ARTICLE IN PRESS The Journal of Foot & Ankle Surgery 000 (2020) 1−6
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Cheilectomy Combined With First Tarsometatarsal Joint Arthrodesis for Surgical Treatment of Midstage Hallux Rigidus Complicated by Medial Column Insufficiency: Prospective Evaluation of Outcomes Troy J. Boffeli, DPM, FACFAS1, Rachel C. Collier, DPM, FACFAS2, Jonathan C. Thompson, DPM, MHA, FACFAS3, Samantha A. Luer, DPM4 1
Director, Foot & Ankle Surgery Residency Program, Regions Hospital/HealthPartners Institute for Education & Research, St. Paul, MN Attending, Foot & Ankle Surgery Residency Program, Regions Hospital/HealthPartners Institute for Education & Research, St. Paul, MN Foot & Ankle Surgeon, Orthopedic Center, Mayo Clinic Health System, Eau Claire, WI 4 Chief Resident, Foot & Ankle Surgery, Regions Hospital/HealthPartners Institute for Education and Research, St. Paul, MN 2 3
A R T I C L E
I N F O
Level of Clinical Evidence: 2 Keywords: first ray elevation hallux limitus metatarsus primus elevatus
A B S T R A C T
The role of metatarsus primus elevatus and first ray hypermobility is under scrutiny with regard to the pathoanatomy of hallux rigidus. Regardless of the underlying biomechanical cause, there is a subset of patients with hallux limitus present with concomitant insufficiency of the medial column identified on clinical exam and lateral imaging as dorsal divergence of the first compared with the second metatarsal. While cheilectomy and decompression metatarsal osteotomy are commonly used to mitigate retrograde forces at the first metatarsophalangeal joint (MPJ) level, traditional hallux limitus procedures do not address more proximal deformity of the medial column. Although the authors prefer to treat this complex condition with cheilectomy combined with tarsometatarsal joint arthrodesis, there is a paucity of literature on this approach. A prospective cohort study of consecutive patients was therefore performed to assess outcomes. Ten patients (3 males, 7 females) and 11 feet (8 right and 3 left) met the inclusion criteria. Mean follow-up was 21.9 months (range 12 to 52). Average age was 50.4 years (range 28 to 61). The average preoperative ACFAS score of 49.6 (range 29 to 61) improved to 78 (range 51 to 92) at 10 weeks postoperatively and 85.4 (range 60 to 100) at 1 year postoperatively. By 1 year postsurgery, 9 of 10 patients (90%) described their satisfaction level as very satisfied, and 1 (10%) was somewhat satisfied. © 2020 by the American College of Foot and Ankle Surgeons. All rights reserved.
Hallux rigidus (HR) is defined as degenerative arthrosis of the first metatarsophalangeal (MTP) joint (1). Although the exact etiology is not fully understood, findings such as an elevated first metatarsal, abnormally long hallux or first metatarsal, or flatfoot deformity have been implicated (1). Of these biomechanical findings, metatarsus primus elevatus (MPE) has been cited as “the most frequent cause of hallux rigidus” by Root et al (2) and numerous subsequent authors, although direct confirmation of this relationship with high-level research remains obscure. In a radiographic analysis of 120 feet, Meyer et al (3) did not find a significant difference in mean dorsal elevation between hallux valgus, HR, and control groups. Similarly, Horton et al (1) found no significant difference in first ray elevation between hallux valgus, HR, and Morton’s neuroma groups in a radiographic evaluation of 264 feet. However, they did find a higher amount of elevatus in more Financial Disclosure: None reported. Conflict of Interest: T.J.B., Consultant, Surgical Design Innovations. Address correspondence to: Troy Boffeli, DPM, FACFAS, 640 Jackson Street, Mailstop 11501G, St. Paul, MN 55101. E-mail address: [email protected] (T.J. Boffeli).
advanced stages of HR (1). In contrast to these studies, Roukis (4) analyzed 275 radiographs stratified into 4 groups based on pathological entity, revealing a statistically significantly greater level of elevatus in HR patients. Of note, the means of measuring elevatus varied between these studies. More recently, Bouaicha et al (5) developed a new method to measure elevatus in their radiographic analysis of 295 feet. Using this method, they found a significantly greater amount of MPE in patients with HR (+5.2 mm) compared with hallux valgus (+2.8 mm) and control groups (+2.6 mm) (5). Two measurements assessing the amount of divergence between the first metatarsal and lesser metatarsals are the Seiberg index (6) and sagittal intermetatarsal angle of Green (7). Certain HR procedures have focused on addressing MPE by realignment of the first ray. Metatarsal head decompression osteotomies are frequently used in the treatment of HR but have been shown to provide minimal correction in the sagittal plane (8,9), which is insufficient in situations of severe elevatus. Furthermore, metatarsal base or medial cuneiform osteotomies have been used to reduce elevatus (10,11) but do not address the medial column instability that is often present in HR with severe elevatus. First tarsometatarsal joint realignment arthrodesis
1067-2516/$ - see front matter © 2020 by the American College of Foot and Ankle Surgeons. All rights reserved. https://doi.org/10.1053/j.jfas.2019.04.019
ARTICLE IN PRESS 2
T.J. Boffeli et al. / The Journal of Foot & Ankle Surgery 00 (2020) 1−6
with cheilectomy has the unique ability to address intrinsic first ray deformity as well as medial column instability when present while also serving to decompress the first MTP joint when excessive first metatarsal length is present. The authors understand that the role of metatarsus primus elevates and first ray hypermobility is under scrutiny with regard to the pathoanatomy of hallux rigidus. Regardless of the underlying biomechanical cause, a subset of patients with hallux limitus present with concomitant insufficiency of the medial column identified on clinical exam and lateral imaging as dorsal divergence of the first compared with the second metatarsal. The goal of this study is to determine the viability of combined first tarsometatarsal joint realignment arthrodesis with cheilectomy in managing midstage HR with severe MPE. Methods After institutional review board approval, a prospective nonrandomized cohort study was performed of consecutive patients with HR and concomitant severe MPE treated with first tarsometatarsal joint realignment arthrodesis and cheilectomy beginning in December 2013 to February 2017. Eligible patients were prospectively enrolled in the study after completing written consent. A standard preoperative clinical and radiographic examination was performed, and patients completed the American College of Foot and Ankle Surgery (ACFAS) First MPJ and First Ray assessment preoperatively. Enrolled patients underwent first tarsometatarsal joint realignment arthrodesis with cheilectomy performed by 1 of 2 board-certified foot and ankle surgeons (TJB or RCC). Patients were evaluated at 2 weeks, 6 weeks, 10 weeks, and 1 year postoperatively, with routine clinical exam and radiographic analysis performed at each visit. A postoperative questionnaire was completed at the 10-week and 1-year follow-up visits and included the ACFAS First MPJ and First Ray Score assessment as well as additional questions pertaining to subjective percentage improvement in activity level, whether the patient would recommend the procedure to a friend with similar symptoms, and subjective level of satisfaction. Analysis of data was performed by institutional statisticians. A 2-tailed t test was used to determine whether statistical significance was achieved between scores, with a p value ≤ .05. A 2-tailed t test was also used to determine statistical significance when comparing preoperative and postoperative pain levels. Continuous variables were described in terms of the mean and minimum−maximum range. Categorical variables were described in terms of frequency counts and percentages. Lastly, postoperative questionnaire items that were not assessed preoperatively were described using tables or frequency counts and percentages, as no comparisons of outcomes could be made.
MPE was assessed with the technique described by Bouaicha et al (5) (Fig. 1). While standard radiographs and clinical exam provides insight into the degree of joint osteoarthritis, a lateral hallux stress dorsiflexion (DF) radiograph of the first MTP joint was also obtained to further aid in determining the stage of HR preoperatively (14). An example of a preoperative lateral stress dorsiflexion view is demonstrated in Fig. 2. This view provides a better appreciation of joint space at the upper one-third of the first MTP joint as well as maximum functional first MTP joint dorsiflexion. Metatarsal divergence was included in the criteria because if little to no divergence is seen on lateral radiograph, then there is potential for a falsely elevated first ray based on poor foot positioning, usually an inverted foot. Dorsal divergence is also associated with severe MPE. Severe MPE was defined as ≥7 mm despite clear definitions of MPE severity in the literature secondary to the Bouaicha et al (5) findings that MPE >5 mm seemed to be predictive of HR and our clinical findings that first to second metatarsal dorsal divergence occurs at ≥7 mm. Again, it is important to note that MPE was determined radiographically and not clinically. Exclusion criteria consisted of grade 1 or grade 4 HR, previous first ray surgical correction, current or prior foot and ankle trauma, infection, and other foot pathology. Patients with comorbidities consisting of diabetes mellitus, rheumatoid arthritis, peripheral vascular disease, autoimmune disease, and peripheral neuropathy were also excluded.
Surgical Technique Enrolled patients consented to cheilectomy with midfoot fusion versus first MTP joint fusion. Final procedure selection was based on intraoperative inspection of the first MTP joint. The initial incision was limited to the first MTP joint. First MTP joint cheilectomy was performed followed by critical evaluation of the cartilage integrity plus quality and extent of first MTP joint range of motion. Findings consistent with advanced first MTP joint degeneration would suggest that a joint-destructive MTP joint arthrodesis was indicated, and tarsometatarsal arthrodesis with cheilectomy was abandoned. Direct inspection of the first MTP joint that confirmed viable articular cartilage was deemed amenable to first tarsometatarsal arthrodesis with cheilectomy. If tarsometatarsal arthrodesis was indicated, the incision was extended proximally to expose the first tarsometatarsal joint. Care was taken to confine periosteal dissection to the joint areas to avoid excessive periosteal stripping (Fig. 3). Depending on first metatarsal length, elevatus was then corrected with planar cuts using a dorsally oriented apex wedge versus curettage and aggressive plantar burring during joint preparation. The fixation construct typically consisted of 3.5mm crossing cortical compression screws and variably a medial locking plate. The locking plate was used as augmentation to standard fixation when dictated by physiologic or social factors. The postoperative protocol consisted of non-weightbearing for 6 weeks in a below-knee boot followed by 4 weeks of protected weightbearing before transitioning back to normal shoe wear. Fig. 4 demonstrates a case example of preoperative and postoperative radiographs and clinical appearance.
Patient Selection
Results
Patients who were considered eligible for inclusion in the study met the following radiographic criteria: 1) severe MPE defined as ≥7 mm (5), 2) dorsal divergence of the first metatarsal in relation to the lesser metatarsals, and 3) stage II to early stage III HR determined by the staging criteria defined by Drago et al (12,13). Radiographically, the
Between December 2013 and February 2017, 98 patients had midstage HR who failed conservative treatment requiring operative management. 10 of 98 patients (10.2%) met the inclusion criteria (3 males, 7
Fig. 1. An example of our preoperative analysis of radiographs demonstrating severe metatarsus primus elevatus (MPE) in midstage hallux limitus for Patient 1 of the study. The preoperative anteroposterior and lateral radiographs exhibit a ridged first metatarsal head with minimal joint space narrowing and 9.7 mm of divergent elevatus. MPE, measured in red, is defined as the distance between the dorsal cortices of the first and second metatarsals at the intersection of the articular surface circle (5). The sagittal intermetatarsal angle of green, measured in yellow, is defined as the angle between the dorsal cortices of the first and second metatarsals and indicates the level of divergence (7).
ARTICLE IN PRESS T.J. Boffeli et al. / The Journal of Foot & Ankle Surgery 00 (2020) 1−6
3
Fig. 3. Limited dissection is important when performing combined first tarsometatarsal arthrodesis with cheilectomy. Care is taken to achieve adequate exposure at both joints yet avoid unnecessary periosteal stripping along the central portion of the first metatarsal shaft.
Fig. 2. A preoperative lateral hallux stress dorsiflexion (DF) view is useful to evaluate maximum functional hallux DF as well as the condition of the cartilage integrity at the dorsal one-third of the first metatarsophalangeal joint (MPJ) (14). (A) Preoperative lateral hallux stress DF view of Patient 7. Note the intact dorsal joint space with maximum functional DF, consistent with midstage hallux rigidus (HR). (B) Improved maximum functional DF 1 year after first tarsometatarsal joint arthrodesis with cheilectomy.
females), and the remainder of the 88 patients without concomitant severe MPE underwent cheilectomy alone (89.8%). Of those who met inclusion criteria, 1 patient (1 foot) was excluded because of an intraoperative decision to proceed with first MTP joint fusion rather than first tarsometatarsal joint arthrodesis with cheilectomy. All patients who met inclusion criteria underwent combined first tarsometatarsal arthrodesis with cheilectomy for management of midstage HR with severe MPE. The average age was 50.4 years (range 28 to 61). Mean follow-up was 21.9 months (range 12 to 52). Lower extremity laterality included 7 right (70%) and 3 left (30%). Patient comorbidities included vitamin D deficiency in 2 patients and hypothyroidism in 1 patient. See Table 1 for a list of patient characteristics. All patients included in the study had first to second metatarsal dorsal divergence preoperatively, and 10 of 10 feet had no divergence
at 10 weeks and 1 year postoperatively. Preoperative mean MPE was 8.85 mm (range 7.5 to 11.1 mm), which improved to 5.25 mm (range 3.7 to 6.8 mm) at 1 year postoperatively, a statistically significant difference (p < .05). Meary’s angle or lateral talo-first metatarsal angle was measured preoperatively as well as at 1 year postoperatively. Preoperative mean Meary’s angle was 6.6° (range 4° to 9°), which improved to 0.9° (range 0° to 4°) at 1 year postoperatively, a statistically significant difference (p < .05). All 9 patients (10 feet) filled out a preoperative subjective questionnaire. Table 2 is a summary of preoperative and postoperative questionnaire results, including ACFAS First MPJ and First Ray scores and pain levels. Preoperative mean level of pain on a typical day was 5.1 (range 2 to 7). Preoperative mean level of pain on the worst day was 7.8 (range 4 to 10). Preoperative ACFAS First MPJ and First Ray assessment mean was 49.6 (range 29 to 61). At 10 weeks postoperatively, all but 1 patient filled out the subjective questionnaire. 10-week postoperative mean pain level on a typical day was 0.67 (range 0 to 3), which was significantly decreased from preoperative levels, a statistically significant difference (p < .0001). The 10-week postoperative mean pain on the worst day was 3.2 (range 0 to 8); when compared with the preoperative pain on the worst day, this was a difference that was statistically significant (p = .0004). The 10-week postoperative ACFAS First MPJ and First Ray assessment mean was 78 (range 51 to 92), which was a statistically significant increase from preoperative scores (p < .0001). At 1 year postoperatively, all patients completed a subjective questionnaire. The 1-year postoperative mean pain level on a typical day was 0.7 (range 0 to 2), which compared with the preoperative pain level on a typical day was
ARTICLE IN PRESS 4
T.J. Boffeli et al. / The Journal of Foot & Ankle Surgery 00 (2020) 1−6
Table 1 Patient characteristics (9 patients, 10 feet) Characteristic Sex Male Female Age (yr) Laterality Right Left Follow-up (mo) Comorbidities Vitamin D deficiency Hypothyroidism
Value
2 (22.2) 7 (77.8) 50.4 (28 to 61) 7 (70) 3 (30) 21.9 (12 to 52) 2 1
Data are n (%), mean (range), or n. One patient (1 foot) was excluded because of intraoperative decision for first metatarsophalangeal joint fusion.
with the preoperative pain level on the worst day was statistically significant (p < .0001). Lastly, the 1-year ACFAS First MPJ and First Ray assessment mean score was 85.4 (range 60 to 100), and compared with preoperative ACFAS scores, there was a statistically significant improvement (p < .0001). Graphs that summarize the ACFAS assessment score improvements as well as the average pain scale improvements are demonstrated in Table 3 and Table 4. At 10 weeks postoperatively, 2 of 9 patients (22%) described their satisfaction level as neutral, and 7 of 9 (78%) described their satisfaction level as very satisfied. By 1 year postoperatively, 9 of 10 patients (90%) described their satisfaction level as very satisfied, and 1 patient, who encountered a postoperative complication listed below, was somewhat satisfied. The mean subjective percent improvement at 1 year postoperatively was 96.5% (range 75% to 100%). Nine of ten patients (90%) at 1 year postoperatively would recommend a similar procedure to a family member or friend. One patient (10%) had a partial nonunion of the first tarsometatarsal joint (Fig. 5). This patient had a preoperative vitamin D deficiency but no other comorbidities. Revision first tarsometatarsal arthrodesis with trephine and autologous bone graft from the heel was performed at 15 months postoperatively. The MTP joint was not addressed during revision. The patient was followed for 7 months after revision surgery, and at that time, radiographs demonstrated complete osseous union, without any acute concerns. No other patients required subsequent surgery or encountered postoperative complications. Discussion
Fig. 4. Case example including preoperative and postoperative radiographs as well as clinical photos for Patient 8. (A) Preoperative anteroposterior (AP) radiograph. (B) Fixation and bony fusion demonstrated at 12 months postoperatively. (C) Clinical photo demonstrating rectus alignment and well-healed surgical scar. (D) Preoperative lateral radiograph demonstrating significant metatarsus primus elevatus (MPE) with midstage hallux rigidus (HR). (E) 12-month postoperative radiograph with fixation and correction of MPE noted. (F) Clinical photo at 12 months postoperatively demonstrating adequate dorsiflexion of the metatarsophalangeal (MTP) joint.
statistically significant (p < .0001). At 1 year postoperatively, the mean pain level on the worst day was 2.2 (range 0 to 6), which compared
Mild MPE has traditionally been addressed with either cheilectomy or distal metatarsal osteotomy; however, severe MPE presents a surgical dilemma, as traditional HR procedures fail to adequately address severe deformity. Although there is controversy about the role of MPE in HR, it seems intuitive from a biomechanical standpoint that severe MPE is directly causative of HR. Elevation of the first metatarsal creates a maligned first MTP joint, which leads to uneven cartilage wear and potential for degenerative changes. Dorsal impingement is also accentuated with severe MPE contributing to arthritis. To obtain adequate correction of severe MPE deformity in patients with midstage HR, we believe that first tarsometatarsal realignment arthrodesis with cheilectomy is a viable option for this select group. A variety of other procedures have been discussed in the literature for management of severe MPE with HR but are suboptimal for various reasons. Isolated aggressive cheilectomy of the first MTP fails to address MPE and generally does not provide sufficient resection to minimize impingement in severe MPE with medial column instability. To refute this, a recent study included 27 feet who underwent first MTP arthroplasty with measurement of preoperative as well as postoperative MPE using multiple radiographic angles (15). They found that MPE self-
ARTICLE IN PRESS T.J. Boffeli et al. / The Journal of Foot & Ankle Surgery 00 (2020) 1−6
5
Table 2 Pre- and postoperative questionnaire results Preoperative
10 Weeks
Patient
Side
Pain, Typical Day
Pain, Worst Day
ACFAS Score
1 1 2 3 4 5 6 7 8 9 Average
L R R L L R R R L R
4 2 5 4 6 8 7 4 6 5 5.1
5 4 10 8 8 8 8 8 10 9 7.8
52 41 58 52 53 54 52 61 29 44 49.6
Pain, Typical Day
Pain, Worst Day
0 0 0 3 3 0
0 0 4 8 4 2
0 0 0 0.67*
3 7 1 3.2*
1 Year ACFAS Score
Pain, Typical Day
Pain, Worst Day
ACFAS Score
89 92 92 59 75 79
0 0 1 1 1 1 2 0 1 0 0.7*
1 1 4 3 2 2 6 0 2 1 2.2*
100 97 92 93 74 89 60 83 74 92 85.4*
82 51 83 78*
Abbreviation: ACFAS, American College of Foot and Ankle Surgery. * Statistically significant, p ≤ .05 compared with preoperative value.
Table 3 American College of Foot and Ankle Surgery (ACFAS) First Metatarsophalangeal Joint (MPJ) and First Ray assessment showed serial improvement throughout the postoperative course
Both the 10-week and 12-month postoperative assessments demonstrated a statistically significant difference (p < .001 and p < .001) compared with the preoperative assessments.
Table 4 Subjective pain level evaluated preoperatively and at 10 weeks and 12 months postoperatively
Pain level on a typical day as well as pain level on the worst day both improved postoperatively. Compared with preoperative scores, both postoperative scores demonstrated statistical significance (p < .001 and p < .001).
corrected after first MTP arthroplasty alone and was statistically significant. Preoperative mean first to second metatarsal elevation was 10.57 mm, 2-week postoperative mean was 7.86 mm, and 10-week postoperative mean was 6.87 mm. The decrease in MPE occurred rapidly and was maintained at 10 weeks postoperatively. The authors of that study suggested that additional procedures may be unnecessary as MPE corrected spontaneously with cheilectomy alone. However, this suggestion is likely premature because of the short-term follow-up of 10 weeks, continued significant MPE, and no mention of preoperative evaluation for the presence or absence of medial column instability. Also, while this may be more relevant with less extensive MPE, it remains to be seen whether it would hold true in solely extensive MPE, which is what we are studying here. An aggressive cheilectomy would also require substantial bone resection, not leaving adequate surface area for subsequent first MTP joint arthrodesis in the future if necessary. Another procedure, the Cotton plantarflexory wedge osteotomy, is indicated for MPE in the absence of degenerative joint disease or medial column instability. An inherent concern with performing the Cotton osteotomy in this setting would be further impingement of the first MTP joint due to lengthening of the medial column. Distal first metatarsal decompression osteotomies remain an option to address MPE but provide a limited amount of plantarflexion, and thus would not typically be sufficient in cases of severe MPE. First metatarsal base plantarflexory decompression osteotomies fail to address medial column instability and do not provide correction at the axis of the deformity. First tarsometatarsal joint realignment arthrodesis with cheilectomy has many advantages when managing HR with severe MPE. Tarsometatarsal joint arthrodesis achieves sufficient plantarflexion and decompression of the first ray. Decompression is achieved through shortening of the first ray during joint preparation. Arthrodesis fundamentally stabilizes and addresses any concomitant medial column instability. Tarsometatarsal joint arthrodesis also addresses the deformity at the center of rotational angulation (CORA). CORA is commonly used to define the axis of deformity in determining the ideal location for intervention to optimize the position of articular surfaces. This has traditionally been described in the setting of long bone deformity (16) but has also been applied to such deformities as hallux valgus as a means of restoring anatomic alignment rather than creating a surgical deformity of the metatarsal (17). In the setting of HR with severe MPE, the same approach should be considered to correct elevatus at the CORA, generally considered to be at the level of the first tarsometatarsal joint, without potentially creating an additional deformity via alternate osteotomies in the metatarsal or medial cuneiform. In theory, by creating near-anatomic alignment of the first ray, it is now better aligned if subsequent first MTP arthrodesis or joint replacement is needed in the
ARTICLE IN PRESS 6
T.J. Boffeli et al. / The Journal of Foot & Ankle Surgery 00 (2020) 1−6
joint is a well-documented complication in the literature, with a reported incidence from 2% to 10% (18). One of ten patients in this study did develop a partial nonunion that was revised. In conclusion, a variety of procedures have been advocated to address the surgical dilemma of HR with MPE; however, few truly address severe elevatus deformity. First tarsometatarsal realignment arthrodesis with cheilectomy corrects the deformity and stabilizes the medial column at a level not achieved by extra-articular procedures. This prospective study with intermediate term follow-up demonstrates high patient satisfaction and statistically significant improvement in ACFAS First MPJ and First Ray scores, as well as level of pain, at 1 year postoperatively. Limitations of this study include the relatively small number of patients in the study, intermediate-term follow-up, and the noncomparative nature. The low number of patients enrolled over a 4year period demonstrates that few patients fit into this protocol with concomitant severe MPE, HR, and medial column instability. Regarding the intermediate-term follow-up, HR is progressive over time, and a longer-term follow-up would provide information on whether this procedure offers more time until eventual MTP arthrodesis or prevents the need for one altogether. A comparative, randomized study with isolated cheilectomy was not performed, as the authors felt it was not possible given the drawbacks of isolated cheilectomy in severe MPE. These preliminary intermediate-term outcomes appear promising for patients with the appropriate indications; however, continued studies with a larger sample size and long-term follow-up are necessary to ultimately provide better understanding of the biomechanical contribution of the first ray to HR deformity.
References
Fig. 5. One patient had symptomatic partial nonunion of the first tarsometatarsal joint without loss of correction (n = 1 of 10 feet). Preoperative vitamin D deficiency was demonstrated. Revision first tarsometatarsal joint arthrodesis with trephine autologous bone graft from heel performed at 15 months postoperatively. (A) Preoperative anteroposterior (AP) radiograph. (B) Partial nonunion. (C) 7-month status after revision, demonstrating complete fusion. (D) Preoperative lateral radiograph. (E) Partial nonunion. (F) 7-month status after revision, demonstrating complete fusion.
future. Furthermore, improved first ray alignment may decrease the risk of transfer metatarsalgia in the event that subsequent first MTP joint fusion becomes necessary. As with any procedure, there are risks and disadvantages of first tarsometatarsal joint realignment arthrodesis with cheilectomy. First, this is a joint-destructive procedure. However, tarsometatarsal fusion with cheilectomy spares fusion of the first MTP joint. Second, if subsequent first MTP fusion becomes necessary, there is ultimately the potential that 2 adjacent joints may need to be fused. Although this can present a relative dilemma, arthrodesis of both joints is not an absolute contraindication, and outcomes in this setting have not been fully delineated. Furthermore, there remains the option of performing subsequent first MTP joint implant arthroplasty as an alternate joint-destructive procedure should this become necessary, and the first ray would be optimally aligned for the procedure. Lastly, nonunion of the first tarsometatarsal
1. Horton G, Park Y, Myerson M. Role of metatarsus primus elevatus in the pathogenesis of hallux rigidus. Foot Ankle Int 1999;20:777–780. 2. Root ML, Orien WP, Weed JH. Motion of the joints of the foot: the first ray. In: Root SA, ed. Clinical Biomechanics. Volume II: Normal and Abnormal Function of the Foot, Los Angeles: Clinical Biomechanics, 1977. 46−51, 350−354. 3. Meyer JO, Nishon LR, Weiss L, Docks G. Metatarsus primus elevatus and the etiology of hallux rigidus. J Foot Surg 1987;26:237–241. 4. Roukis TS. Metatarsus primus elevatus in hallux rigidus: fact or fiction? J Am Podiatr Med Assoc 2005;95:221–228. 5. Bouaicha S, Ehrmann C, Moor BK, Maquieira GJ, Espinosa N. Radiographic analysis of metatarsus primus elevatus and hallux rigidus. Foot Ankle Int 2010;31:807–813. 6. Green DR. Radiology and biomechanical foot types. In: Miller SJ, Mahan KT, Yu GU, Camasta CA, eds. Reconstructive Surgery of the Foot and Leg, Update ’98, Tucker, GA: The Podiatry Institute, 1998292–315. 7. Camasta CA. Radiographic evaluation and classification of metatarsus primus elevatus. In: Camasta CA, ed. Reconstructive Surgery of the Foot and Leg, Update ’94, Tucker, GA: The Podiatry Institute, 1994122–127. 8. Dickerson JB, Green R, Green DR. Long-term follow-up of the Green-Watermann osteotomy for hallux limitus. J Am Podiatr Med Assoc 2002;92:543. 9. Laakmann G, Green RM, Green DR. The modified Watermann procedure: a preliminary retrospective study. In: Camasta CA, ed. Reconstructive Surgery of the Foot and Leg: Update ’95, Tucker, GA: The Podiatry Institute, 1995128. 10. Lambrinudi C. Metatarsus primus elevatus. Proc R Soc Med 1938;31:273. 11. Davies GF. Plantarflexory base wedge osteotomy in the treatment of functional and structural metatarsus primus elevatus. Clin Podiatr Med Surg 1989;6:93–102. 12. Vanore JV, Christensen JC, Kravitz SR, Schuberth JM, Thomas JL, Weil LS, Zlotoff HJ, Mendicino RW, Couture SD; Clinical Practice Guideline First Metatarasophalangeal Joint Disorders Panel of the American College of Foot and Ankle Surgeons. Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 2: hallux rigidus. J Foot Ankle Surg 2003;42:124–136. 13. Drago JJ, Oloff L, Jacobs AM. A comprehensive review of hallux limitus. J Foot Ankle Surg 1984;23:213–220. 14. Boffeli T, Collier RC. Lateral stress dorsiflexion view: a case series demonstrating clinical utility in midterm hallux limitus. J Foot Ankle Surg 2015;54:739–746. 15. Sanchez PJ, Grady JF, Lenz RC, Park SJ, Ruff JG. Metatarsus primus elevatus resolution after first metatarsophalangeal joint arthroplasty: eliminating elevatus without an osteotomy—a preliminary study. JAPMA 2018;108:200–204. 16. Lamm BM, Paley D. Deformity correction planning for hindfoot, ankle and lower limb. Clin Podiatr Med Surg 2004;21:305–326. 17. Smith WB, Dayton P, Santrock RD, Hatch DJ. Understanding frontal plane correction in hallux valgus repair. Clin Podiatr Med Surg 2018;35:27–36. 18. Mirmiran R, Wide B, Nielsen M. Retrospective analysis of the rate and interval to union for joint arthrodesis of the foot and ankle. J Foot Ankle Surg 2014;53:420–425.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Cheilectomy Combined With First Tarsometatarsal Joint Arthrodesis for Surgical Treatment of Midstage Hallux Rigidus Complicated by Medial Column Insufficiency: Prospective Evaluation of Outcomes Troy J. Boffeli, DPM, FACFAS1, Rachel C. Collier, DPM, FACFAS2, Jonathan C. Thompson, DPM, MHA, FACFAS3, Samantha A. Luer, DPM4 1
Director, Foot & Ankle Surgery Residency Program, Regions Hospital/HealthPartners Institute for Education & Research, St. Paul, MN Attending, Foot & Ankle Surgery Residency Program, Regions Hospital/HealthPartners Institute for Education & Research, St. Paul, MN Foot & Ankle Surgeon, Orthopedic Center, Mayo Clinic Health System, Eau Claire, WI 4 Chief Resident, Foot & Ankle Surgery, Regions Hospital/HealthPartners Institute for Education and Research, St. Paul, MN 2 3
A R T I C L E
I N F O
Level of Clinical Evidence: 2 Keywords: first ray elevation hallux limitus metatarsus primus elevatus
A B S T R A C T
The role of metatarsus primus elevatus and first ray hypermobility is under scrutiny with regard to the pathoanatomy of hallux rigidus. Regardless of the underlying biomechanical cause, there is a subset of patients with hallux limitus present with concomitant insufficiency of the medial column identified on clinical exam and lateral imaging as dorsal divergence of the first compared with the second metatarsal. While cheilectomy and decompression metatarsal osteotomy are commonly used to mitigate retrograde forces at the first metatarsophalangeal joint (MPJ) level, traditional hallux limitus procedures do not address more proximal deformity of the medial column. Although the authors prefer to treat this complex condition with cheilectomy combined with tarsometatarsal joint arthrodesis, there is a paucity of literature on this approach. A prospective cohort study of consecutive patients was therefore performed to assess outcomes. Ten patients (3 males, 7 females) and 11 feet (8 right and 3 left) met the inclusion criteria. Mean follow-up was 21.9 months (range 12 to 52). Average age was 50.4 years (range 28 to 61). The average preoperative ACFAS score of 49.6 (range 29 to 61) improved to 78 (range 51 to 92) at 10 weeks postoperatively and 85.4 (range 60 to 100) at 1 year postoperatively. By 1 year postsurgery, 9 of 10 patients (90%) described their satisfaction level as very satisfied, and 1 (10%) was somewhat satisfied. © 2020 by the American College of Foot and Ankle Surgeons. All rights reserved.
Hallux rigidus (HR) is defined as degenerative arthrosis of the first metatarsophalangeal (MTP) joint (1). Although the exact etiology is not fully understood, findings such as an elevated first metatarsal, abnormally long hallux or first metatarsal, or flatfoot deformity have been implicated (1). Of these biomechanical findings, metatarsus primus elevatus (MPE) has been cited as “the most frequent cause of hallux rigidus” by Root et al (2) and numerous subsequent authors, although direct confirmation of this relationship with high-level research remains obscure. In a radiographic analysis of 120 feet, Meyer et al (3) did not find a significant difference in mean dorsal elevation between hallux valgus, HR, and control groups. Similarly, Horton et al (1) found no significant difference in first ray elevation between hallux valgus, HR, and Morton’s neuroma groups in a radiographic evaluation of 264 feet. However, they did find a higher amount of elevatus in more Financial Disclosure: None reported. Conflict of Interest: T.J.B., Consultant, Surgical Design Innovations. Address correspondence to: Troy Boffeli, DPM, FACFAS, 640 Jackson Street, Mailstop 11501G, St. Paul, MN 55101. E-mail address: [email protected] (T.J. Boffeli).
advanced stages of HR (1). In contrast to these studies, Roukis (4) analyzed 275 radiographs stratified into 4 groups based on pathological entity, revealing a statistically significantly greater level of elevatus in HR patients. Of note, the means of measuring elevatus varied between these studies. More recently, Bouaicha et al (5) developed a new method to measure elevatus in their radiographic analysis of 295 feet. Using this method, they found a significantly greater amount of MPE in patients with HR (+5.2 mm) compared with hallux valgus (+2.8 mm) and control groups (+2.6 mm) (5). Two measurements assessing the amount of divergence between the first metatarsal and lesser metatarsals are the Seiberg index (6) and sagittal intermetatarsal angle of Green (7). Certain HR procedures have focused on addressing MPE by realignment of the first ray. Metatarsal head decompression osteotomies are frequently used in the treatment of HR but have been shown to provide minimal correction in the sagittal plane (8,9), which is insufficient in situations of severe elevatus. Furthermore, metatarsal base or medial cuneiform osteotomies have been used to reduce elevatus (10,11) but do not address the medial column instability that is often present in HR with severe elevatus. First tarsometatarsal joint realignment arthrodesis
1067-2516/$ - see front matter © 2020 by the American College of Foot and Ankle Surgeons. All rights reserved. https://doi.org/10.1053/j.jfas.2019.04.019
ARTICLE IN PRESS 2
T.J. Boffeli et al. / The Journal of Foot & Ankle Surgery 00 (2020) 1−6
with cheilectomy has the unique ability to address intrinsic first ray deformity as well as medial column instability when present while also serving to decompress the first MTP joint when excessive first metatarsal length is present. The authors understand that the role of metatarsus primus elevates and first ray hypermobility is under scrutiny with regard to the pathoanatomy of hallux rigidus. Regardless of the underlying biomechanical cause, a subset of patients with hallux limitus present with concomitant insufficiency of the medial column identified on clinical exam and lateral imaging as dorsal divergence of the first compared with the second metatarsal. The goal of this study is to determine the viability of combined first tarsometatarsal joint realignment arthrodesis with cheilectomy in managing midstage HR with severe MPE. Methods After institutional review board approval, a prospective nonrandomized cohort study was performed of consecutive patients with HR and concomitant severe MPE treated with first tarsometatarsal joint realignment arthrodesis and cheilectomy beginning in December 2013 to February 2017. Eligible patients were prospectively enrolled in the study after completing written consent. A standard preoperative clinical and radiographic examination was performed, and patients completed the American College of Foot and Ankle Surgery (ACFAS) First MPJ and First Ray assessment preoperatively. Enrolled patients underwent first tarsometatarsal joint realignment arthrodesis with cheilectomy performed by 1 of 2 board-certified foot and ankle surgeons (TJB or RCC). Patients were evaluated at 2 weeks, 6 weeks, 10 weeks, and 1 year postoperatively, with routine clinical exam and radiographic analysis performed at each visit. A postoperative questionnaire was completed at the 10-week and 1-year follow-up visits and included the ACFAS First MPJ and First Ray Score assessment as well as additional questions pertaining to subjective percentage improvement in activity level, whether the patient would recommend the procedure to a friend with similar symptoms, and subjective level of satisfaction. Analysis of data was performed by institutional statisticians. A 2-tailed t test was used to determine whether statistical significance was achieved between scores, with a p value ≤ .05. A 2-tailed t test was also used to determine statistical significance when comparing preoperative and postoperative pain levels. Continuous variables were described in terms of the mean and minimum−maximum range. Categorical variables were described in terms of frequency counts and percentages. Lastly, postoperative questionnaire items that were not assessed preoperatively were described using tables or frequency counts and percentages, as no comparisons of outcomes could be made.
MPE was assessed with the technique described by Bouaicha et al (5) (Fig. 1). While standard radiographs and clinical exam provides insight into the degree of joint osteoarthritis, a lateral hallux stress dorsiflexion (DF) radiograph of the first MTP joint was also obtained to further aid in determining the stage of HR preoperatively (14). An example of a preoperative lateral stress dorsiflexion view is demonstrated in Fig. 2. This view provides a better appreciation of joint space at the upper one-third of the first MTP joint as well as maximum functional first MTP joint dorsiflexion. Metatarsal divergence was included in the criteria because if little to no divergence is seen on lateral radiograph, then there is potential for a falsely elevated first ray based on poor foot positioning, usually an inverted foot. Dorsal divergence is also associated with severe MPE. Severe MPE was defined as ≥7 mm despite clear definitions of MPE severity in the literature secondary to the Bouaicha et al (5) findings that MPE >5 mm seemed to be predictive of HR and our clinical findings that first to second metatarsal dorsal divergence occurs at ≥7 mm. Again, it is important to note that MPE was determined radiographically and not clinically. Exclusion criteria consisted of grade 1 or grade 4 HR, previous first ray surgical correction, current or prior foot and ankle trauma, infection, and other foot pathology. Patients with comorbidities consisting of diabetes mellitus, rheumatoid arthritis, peripheral vascular disease, autoimmune disease, and peripheral neuropathy were also excluded.
Surgical Technique Enrolled patients consented to cheilectomy with midfoot fusion versus first MTP joint fusion. Final procedure selection was based on intraoperative inspection of the first MTP joint. The initial incision was limited to the first MTP joint. First MTP joint cheilectomy was performed followed by critical evaluation of the cartilage integrity plus quality and extent of first MTP joint range of motion. Findings consistent with advanced first MTP joint degeneration would suggest that a joint-destructive MTP joint arthrodesis was indicated, and tarsometatarsal arthrodesis with cheilectomy was abandoned. Direct inspection of the first MTP joint that confirmed viable articular cartilage was deemed amenable to first tarsometatarsal arthrodesis with cheilectomy. If tarsometatarsal arthrodesis was indicated, the incision was extended proximally to expose the first tarsometatarsal joint. Care was taken to confine periosteal dissection to the joint areas to avoid excessive periosteal stripping (Fig. 3). Depending on first metatarsal length, elevatus was then corrected with planar cuts using a dorsally oriented apex wedge versus curettage and aggressive plantar burring during joint preparation. The fixation construct typically consisted of 3.5mm crossing cortical compression screws and variably a medial locking plate. The locking plate was used as augmentation to standard fixation when dictated by physiologic or social factors. The postoperative protocol consisted of non-weightbearing for 6 weeks in a below-knee boot followed by 4 weeks of protected weightbearing before transitioning back to normal shoe wear. Fig. 4 demonstrates a case example of preoperative and postoperative radiographs and clinical appearance.
Patient Selection
Results
Patients who were considered eligible for inclusion in the study met the following radiographic criteria: 1) severe MPE defined as ≥7 mm (5), 2) dorsal divergence of the first metatarsal in relation to the lesser metatarsals, and 3) stage II to early stage III HR determined by the staging criteria defined by Drago et al (12,13). Radiographically, the
Between December 2013 and February 2017, 98 patients had midstage HR who failed conservative treatment requiring operative management. 10 of 98 patients (10.2%) met the inclusion criteria (3 males, 7
Fig. 1. An example of our preoperative analysis of radiographs demonstrating severe metatarsus primus elevatus (MPE) in midstage hallux limitus for Patient 1 of the study. The preoperative anteroposterior and lateral radiographs exhibit a ridged first metatarsal head with minimal joint space narrowing and 9.7 mm of divergent elevatus. MPE, measured in red, is defined as the distance between the dorsal cortices of the first and second metatarsals at the intersection of the articular surface circle (5). The sagittal intermetatarsal angle of green, measured in yellow, is defined as the angle between the dorsal cortices of the first and second metatarsals and indicates the level of divergence (7).
ARTICLE IN PRESS T.J. Boffeli et al. / The Journal of Foot & Ankle Surgery 00 (2020) 1−6
3
Fig. 3. Limited dissection is important when performing combined first tarsometatarsal arthrodesis with cheilectomy. Care is taken to achieve adequate exposure at both joints yet avoid unnecessary periosteal stripping along the central portion of the first metatarsal shaft.
Fig. 2. A preoperative lateral hallux stress dorsiflexion (DF) view is useful to evaluate maximum functional hallux DF as well as the condition of the cartilage integrity at the dorsal one-third of the first metatarsophalangeal joint (MPJ) (14). (A) Preoperative lateral hallux stress DF view of Patient 7. Note the intact dorsal joint space with maximum functional DF, consistent with midstage hallux rigidus (HR). (B) Improved maximum functional DF 1 year after first tarsometatarsal joint arthrodesis with cheilectomy.
females), and the remainder of the 88 patients without concomitant severe MPE underwent cheilectomy alone (89.8%). Of those who met inclusion criteria, 1 patient (1 foot) was excluded because of an intraoperative decision to proceed with first MTP joint fusion rather than first tarsometatarsal joint arthrodesis with cheilectomy. All patients who met inclusion criteria underwent combined first tarsometatarsal arthrodesis with cheilectomy for management of midstage HR with severe MPE. The average age was 50.4 years (range 28 to 61). Mean follow-up was 21.9 months (range 12 to 52). Lower extremity laterality included 7 right (70%) and 3 left (30%). Patient comorbidities included vitamin D deficiency in 2 patients and hypothyroidism in 1 patient. See Table 1 for a list of patient characteristics. All patients included in the study had first to second metatarsal dorsal divergence preoperatively, and 10 of 10 feet had no divergence
at 10 weeks and 1 year postoperatively. Preoperative mean MPE was 8.85 mm (range 7.5 to 11.1 mm), which improved to 5.25 mm (range 3.7 to 6.8 mm) at 1 year postoperatively, a statistically significant difference (p < .05). Meary’s angle or lateral talo-first metatarsal angle was measured preoperatively as well as at 1 year postoperatively. Preoperative mean Meary’s angle was 6.6° (range 4° to 9°), which improved to 0.9° (range 0° to 4°) at 1 year postoperatively, a statistically significant difference (p < .05). All 9 patients (10 feet) filled out a preoperative subjective questionnaire. Table 2 is a summary of preoperative and postoperative questionnaire results, including ACFAS First MPJ and First Ray scores and pain levels. Preoperative mean level of pain on a typical day was 5.1 (range 2 to 7). Preoperative mean level of pain on the worst day was 7.8 (range 4 to 10). Preoperative ACFAS First MPJ and First Ray assessment mean was 49.6 (range 29 to 61). At 10 weeks postoperatively, all but 1 patient filled out the subjective questionnaire. 10-week postoperative mean pain level on a typical day was 0.67 (range 0 to 3), which was significantly decreased from preoperative levels, a statistically significant difference (p < .0001). The 10-week postoperative mean pain on the worst day was 3.2 (range 0 to 8); when compared with the preoperative pain on the worst day, this was a difference that was statistically significant (p = .0004). The 10-week postoperative ACFAS First MPJ and First Ray assessment mean was 78 (range 51 to 92), which was a statistically significant increase from preoperative scores (p < .0001). At 1 year postoperatively, all patients completed a subjective questionnaire. The 1-year postoperative mean pain level on a typical day was 0.7 (range 0 to 2), which compared with the preoperative pain level on a typical day was
ARTICLE IN PRESS 4
T.J. Boffeli et al. / The Journal of Foot & Ankle Surgery 00 (2020) 1−6
Table 1 Patient characteristics (9 patients, 10 feet) Characteristic Sex Male Female Age (yr) Laterality Right Left Follow-up (mo) Comorbidities Vitamin D deficiency Hypothyroidism
Value
2 (22.2) 7 (77.8) 50.4 (28 to 61) 7 (70) 3 (30) 21.9 (12 to 52) 2 1
Data are n (%), mean (range), or n. One patient (1 foot) was excluded because of intraoperative decision for first metatarsophalangeal joint fusion.
with the preoperative pain level on the worst day was statistically significant (p < .0001). Lastly, the 1-year ACFAS First MPJ and First Ray assessment mean score was 85.4 (range 60 to 100), and compared with preoperative ACFAS scores, there was a statistically significant improvement (p < .0001). Graphs that summarize the ACFAS assessment score improvements as well as the average pain scale improvements are demonstrated in Table 3 and Table 4. At 10 weeks postoperatively, 2 of 9 patients (22%) described their satisfaction level as neutral, and 7 of 9 (78%) described their satisfaction level as very satisfied. By 1 year postoperatively, 9 of 10 patients (90%) described their satisfaction level as very satisfied, and 1 patient, who encountered a postoperative complication listed below, was somewhat satisfied. The mean subjective percent improvement at 1 year postoperatively was 96.5% (range 75% to 100%). Nine of ten patients (90%) at 1 year postoperatively would recommend a similar procedure to a family member or friend. One patient (10%) had a partial nonunion of the first tarsometatarsal joint (Fig. 5). This patient had a preoperative vitamin D deficiency but no other comorbidities. Revision first tarsometatarsal arthrodesis with trephine and autologous bone graft from the heel was performed at 15 months postoperatively. The MTP joint was not addressed during revision. The patient was followed for 7 months after revision surgery, and at that time, radiographs demonstrated complete osseous union, without any acute concerns. No other patients required subsequent surgery or encountered postoperative complications. Discussion
Fig. 4. Case example including preoperative and postoperative radiographs as well as clinical photos for Patient 8. (A) Preoperative anteroposterior (AP) radiograph. (B) Fixation and bony fusion demonstrated at 12 months postoperatively. (C) Clinical photo demonstrating rectus alignment and well-healed surgical scar. (D) Preoperative lateral radiograph demonstrating significant metatarsus primus elevatus (MPE) with midstage hallux rigidus (HR). (E) 12-month postoperative radiograph with fixation and correction of MPE noted. (F) Clinical photo at 12 months postoperatively demonstrating adequate dorsiflexion of the metatarsophalangeal (MTP) joint.
statistically significant (p < .0001). At 1 year postoperatively, the mean pain level on the worst day was 2.2 (range 0 to 6), which compared
Mild MPE has traditionally been addressed with either cheilectomy or distal metatarsal osteotomy; however, severe MPE presents a surgical dilemma, as traditional HR procedures fail to adequately address severe deformity. Although there is controversy about the role of MPE in HR, it seems intuitive from a biomechanical standpoint that severe MPE is directly causative of HR. Elevation of the first metatarsal creates a maligned first MTP joint, which leads to uneven cartilage wear and potential for degenerative changes. Dorsal impingement is also accentuated with severe MPE contributing to arthritis. To obtain adequate correction of severe MPE deformity in patients with midstage HR, we believe that first tarsometatarsal realignment arthrodesis with cheilectomy is a viable option for this select group. A variety of other procedures have been discussed in the literature for management of severe MPE with HR but are suboptimal for various reasons. Isolated aggressive cheilectomy of the first MTP fails to address MPE and generally does not provide sufficient resection to minimize impingement in severe MPE with medial column instability. To refute this, a recent study included 27 feet who underwent first MTP arthroplasty with measurement of preoperative as well as postoperative MPE using multiple radiographic angles (15). They found that MPE self-
ARTICLE IN PRESS T.J. Boffeli et al. / The Journal of Foot & Ankle Surgery 00 (2020) 1−6
5
Table 2 Pre- and postoperative questionnaire results Preoperative
10 Weeks
Patient
Side
Pain, Typical Day
Pain, Worst Day
ACFAS Score
1 1 2 3 4 5 6 7 8 9 Average
L R R L L R R R L R
4 2 5 4 6 8 7 4 6 5 5.1
5 4 10 8 8 8 8 8 10 9 7.8
52 41 58 52 53 54 52 61 29 44 49.6
Pain, Typical Day
Pain, Worst Day
0 0 0 3 3 0
0 0 4 8 4 2
0 0 0 0.67*
3 7 1 3.2*
1 Year ACFAS Score
Pain, Typical Day
Pain, Worst Day
ACFAS Score
89 92 92 59 75 79
0 0 1 1 1 1 2 0 1 0 0.7*
1 1 4 3 2 2 6 0 2 1 2.2*
100 97 92 93 74 89 60 83 74 92 85.4*
82 51 83 78*
Abbreviation: ACFAS, American College of Foot and Ankle Surgery. * Statistically significant, p ≤ .05 compared with preoperative value.
Table 3 American College of Foot and Ankle Surgery (ACFAS) First Metatarsophalangeal Joint (MPJ) and First Ray assessment showed serial improvement throughout the postoperative course
Both the 10-week and 12-month postoperative assessments demonstrated a statistically significant difference (p < .001 and p < .001) compared with the preoperative assessments.
Table 4 Subjective pain level evaluated preoperatively and at 10 weeks and 12 months postoperatively
Pain level on a typical day as well as pain level on the worst day both improved postoperatively. Compared with preoperative scores, both postoperative scores demonstrated statistical significance (p < .001 and p < .001).
corrected after first MTP arthroplasty alone and was statistically significant. Preoperative mean first to second metatarsal elevation was 10.57 mm, 2-week postoperative mean was 7.86 mm, and 10-week postoperative mean was 6.87 mm. The decrease in MPE occurred rapidly and was maintained at 10 weeks postoperatively. The authors of that study suggested that additional procedures may be unnecessary as MPE corrected spontaneously with cheilectomy alone. However, this suggestion is likely premature because of the short-term follow-up of 10 weeks, continued significant MPE, and no mention of preoperative evaluation for the presence or absence of medial column instability. Also, while this may be more relevant with less extensive MPE, it remains to be seen whether it would hold true in solely extensive MPE, which is what we are studying here. An aggressive cheilectomy would also require substantial bone resection, not leaving adequate surface area for subsequent first MTP joint arthrodesis in the future if necessary. Another procedure, the Cotton plantarflexory wedge osteotomy, is indicated for MPE in the absence of degenerative joint disease or medial column instability. An inherent concern with performing the Cotton osteotomy in this setting would be further impingement of the first MTP joint due to lengthening of the medial column. Distal first metatarsal decompression osteotomies remain an option to address MPE but provide a limited amount of plantarflexion, and thus would not typically be sufficient in cases of severe MPE. First metatarsal base plantarflexory decompression osteotomies fail to address medial column instability and do not provide correction at the axis of the deformity. First tarsometatarsal joint realignment arthrodesis with cheilectomy has many advantages when managing HR with severe MPE. Tarsometatarsal joint arthrodesis achieves sufficient plantarflexion and decompression of the first ray. Decompression is achieved through shortening of the first ray during joint preparation. Arthrodesis fundamentally stabilizes and addresses any concomitant medial column instability. Tarsometatarsal joint arthrodesis also addresses the deformity at the center of rotational angulation (CORA). CORA is commonly used to define the axis of deformity in determining the ideal location for intervention to optimize the position of articular surfaces. This has traditionally been described in the setting of long bone deformity (16) but has also been applied to such deformities as hallux valgus as a means of restoring anatomic alignment rather than creating a surgical deformity of the metatarsal (17). In the setting of HR with severe MPE, the same approach should be considered to correct elevatus at the CORA, generally considered to be at the level of the first tarsometatarsal joint, without potentially creating an additional deformity via alternate osteotomies in the metatarsal or medial cuneiform. In theory, by creating near-anatomic alignment of the first ray, it is now better aligned if subsequent first MTP arthrodesis or joint replacement is needed in the
ARTICLE IN PRESS 6
T.J. Boffeli et al. / The Journal of Foot & Ankle Surgery 00 (2020) 1−6
joint is a well-documented complication in the literature, with a reported incidence from 2% to 10% (18). One of ten patients in this study did develop a partial nonunion that was revised. In conclusion, a variety of procedures have been advocated to address the surgical dilemma of HR with MPE; however, few truly address severe elevatus deformity. First tarsometatarsal realignment arthrodesis with cheilectomy corrects the deformity and stabilizes the medial column at a level not achieved by extra-articular procedures. This prospective study with intermediate term follow-up demonstrates high patient satisfaction and statistically significant improvement in ACFAS First MPJ and First Ray scores, as well as level of pain, at 1 year postoperatively. Limitations of this study include the relatively small number of patients in the study, intermediate-term follow-up, and the noncomparative nature. The low number of patients enrolled over a 4year period demonstrates that few patients fit into this protocol with concomitant severe MPE, HR, and medial column instability. Regarding the intermediate-term follow-up, HR is progressive over time, and a longer-term follow-up would provide information on whether this procedure offers more time until eventual MTP arthrodesis or prevents the need for one altogether. A comparative, randomized study with isolated cheilectomy was not performed, as the authors felt it was not possible given the drawbacks of isolated cheilectomy in severe MPE. These preliminary intermediate-term outcomes appear promising for patients with the appropriate indications; however, continued studies with a larger sample size and long-term follow-up are necessary to ultimately provide better understanding of the biomechanical contribution of the first ray to HR deformity.
References
Fig. 5. One patient had symptomatic partial nonunion of the first tarsometatarsal joint without loss of correction (n = 1 of 10 feet). Preoperative vitamin D deficiency was demonstrated. Revision first tarsometatarsal joint arthrodesis with trephine autologous bone graft from heel performed at 15 months postoperatively. (A) Preoperative anteroposterior (AP) radiograph. (B) Partial nonunion. (C) 7-month status after revision, demonstrating complete fusion. (D) Preoperative lateral radiograph. (E) Partial nonunion. (F) 7-month status after revision, demonstrating complete fusion.
future. Furthermore, improved first ray alignment may decrease the risk of transfer metatarsalgia in the event that subsequent first MTP joint fusion becomes necessary. As with any procedure, there are risks and disadvantages of first tarsometatarsal joint realignment arthrodesis with cheilectomy. First, this is a joint-destructive procedure. However, tarsometatarsal fusion with cheilectomy spares fusion of the first MTP joint. Second, if subsequent first MTP fusion becomes necessary, there is ultimately the potential that 2 adjacent joints may need to be fused. Although this can present a relative dilemma, arthrodesis of both joints is not an absolute contraindication, and outcomes in this setting have not been fully delineated. Furthermore, there remains the option of performing subsequent first MTP joint implant arthroplasty as an alternate joint-destructive procedure should this become necessary, and the first ray would be optimally aligned for the procedure. Lastly, nonunion of the first tarsometatarsal
1. Horton G, Park Y, Myerson M. Role of metatarsus primus elevatus in the pathogenesis of hallux rigidus. Foot Ankle Int 1999;20:777–780. 2. Root ML, Orien WP, Weed JH. Motion of the joints of the foot: the first ray. In: Root SA, ed. Clinical Biomechanics. Volume II: Normal and Abnormal Function of the Foot, Los Angeles: Clinical Biomechanics, 1977. 46−51, 350−354. 3. Meyer JO, Nishon LR, Weiss L, Docks G. Metatarsus primus elevatus and the etiology of hallux rigidus. J Foot Surg 1987;26:237–241. 4. Roukis TS. Metatarsus primus elevatus in hallux rigidus: fact or fiction? J Am Podiatr Med Assoc 2005;95:221–228. 5. Bouaicha S, Ehrmann C, Moor BK, Maquieira GJ, Espinosa N. Radiographic analysis of metatarsus primus elevatus and hallux rigidus. Foot Ankle Int 2010;31:807–813. 6. Green DR. Radiology and biomechanical foot types. In: Miller SJ, Mahan KT, Yu GU, Camasta CA, eds. Reconstructive Surgery of the Foot and Leg, Update ’98, Tucker, GA: The Podiatry Institute, 1998292–315. 7. Camasta CA. Radiographic evaluation and classification of metatarsus primus elevatus. In: Camasta CA, ed. Reconstructive Surgery of the Foot and Leg, Update ’94, Tucker, GA: The Podiatry Institute, 1994122–127. 8. Dickerson JB, Green R, Green DR. Long-term follow-up of the Green-Watermann osteotomy for hallux limitus. J Am Podiatr Med Assoc 2002;92:543. 9. Laakmann G, Green RM, Green DR. The modified Watermann procedure: a preliminary retrospective study. In: Camasta CA, ed. Reconstructive Surgery of the Foot and Leg: Update ’95, Tucker, GA: The Podiatry Institute, 1995128. 10. Lambrinudi C. Metatarsus primus elevatus. Proc R Soc Med 1938;31:273. 11. Davies GF. Plantarflexory base wedge osteotomy in the treatment of functional and structural metatarsus primus elevatus. Clin Podiatr Med Surg 1989;6:93–102. 12. Vanore JV, Christensen JC, Kravitz SR, Schuberth JM, Thomas JL, Weil LS, Zlotoff HJ, Mendicino RW, Couture SD; Clinical Practice Guideline First Metatarasophalangeal Joint Disorders Panel of the American College of Foot and Ankle Surgeons. Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 2: hallux rigidus. J Foot Ankle Surg 2003;42:124–136. 13. Drago JJ, Oloff L, Jacobs AM. A comprehensive review of hallux limitus. J Foot Ankle Surg 1984;23:213–220. 14. Boffeli T, Collier RC. Lateral stress dorsiflexion view: a case series demonstrating clinical utility in midterm hallux limitus. J Foot Ankle Surg 2015;54:739–746. 15. Sanchez PJ, Grady JF, Lenz RC, Park SJ, Ruff JG. Metatarsus primus elevatus resolution after first metatarsophalangeal joint arthroplasty: eliminating elevatus without an osteotomy—a preliminary study. JAPMA 2018;108:200–204. 16. Lamm BM, Paley D. Deformity correction planning for hindfoot, ankle and lower limb. Clin Podiatr Med Surg 2004;21:305–326. 17. Smith WB, Dayton P, Santrock RD, Hatch DJ. Understanding frontal plane correction in hallux valgus repair. Clin Podiatr Med Surg 2018;35:27–36. 18. Mirmiran R, Wide B, Nielsen M. Retrospective analysis of the rate and interval to union for joint arthrodesis of the foot and ankle. J Foot Ankle Surg 2014;53:420–425.