Hemiarthroplasty for Hallux Rigidus: Mid-Term Results

Hemiarthroplasty for Hallux Rigidus: Mid-Term Results

The Journal of Foot & Ankle Surgery xxx (2015) 1–3 Contents lists available at ScienceDirect The Journal of Foot & Ankle Surgery journal homepage: w...

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The Journal of Foot & Ankle Surgery xxx (2015) 1–3

Contents lists available at ScienceDirect

The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org

Original Research

Hemiarthroplasty for Hallux Rigidus: Mid-Term Results Daniel Gheorghiu, MBChB, MRCS(Ed), FRCS(Orth) 1, Claire Coles, MBChB 2, Jordi Ballester, FRCS(TrþOrth) 1 1 2

Trauma and Orthopaedic Surgeon, Whiston Hospital, Liverpool, England Surgical Trainee, Whiston Hospital, Liverpool, England

a r t i c l e i n f o

a b s t r a c t

Level of Clinical Evidence: 4

Hallux rigidus is a progressive osteoarthritic condition affecting the first metatarsophalangeal joint that causes pain and stiffness, with a marked reduction in dorsiflexion. Joint arthrodesis has previously been the standard treatment of hallux rigidus; however, new surgical techniques have evolved and first metatarsophalangeal joint hemiarthroplasty is now a viable option. The present retrospective study reviewed the data from the 11 patients (12 feet) who had undergone first metatarsophalangeal joint hemiarthroplasty with the HemiCAPÒ prosthesis. Postoperatively, all feet were clinically and radiologically assessed and scored using the hallux metatarsophalangeal-interphalangeal scale developed by the American Orthopaedic Foot and Ankle Society and the Foot and Ankle Disability Index score. Follow-up examinations were performed at a mean of 47 (range 36 to 48) months and showed a mean postoperative American Orthopaedic Foot and Ankle Society score of 66.5 (range 22 to 92) and mean Foot and Ankle Disability Index score of 63.7 (range 26.9 to 98.1). Of the 12 feet, 5 (41.7%) were reported to be pain free at the follow-up examination, 3 (25%) had mild pain, 2 (16.7%) had moderate, and 2 (16.7%) severe pain. Furthermore, 5 feet (42%) displayed no evidence of radiologic subsidence and 7 feet (58%) displayed a mean subsidence of 2.71 (range 1 to 6) mm. Hemiarthroplasty is designed to maintain the joint range of movement and allow easy conversion to arthrodesis, if required. In the present study, most patients continued to have a limited range of movement with only reasonable levels of satisfaction. Most patients continued to experience some level of pain postoperatively. The HemiCAPÒ prosthesis has recently been adapted to include a dorsal flange. This might improve the range of dorsiflexion not seen with the traditional model. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.

Keywords: American Orthopaedic Foot and Ankle Society AOFAS arthrodesis arthrosurface first metatarsophalangeal joint HemiCAPÒ prosthesis

Hallux rigidus is a progressive osteoarthritic condition affecting the first metatarsophalangeal joint (MTPJ). Degenerative changes in this joint are characterized by the loss of cartilage and decreased osteophyte formation. These, in turn, cause irregularities in the joint surfaces and inflammation of the joint, resulting in pain and stiffness (1,2). In hallux rigidus, the total arc of motion will be decreased. Plantar flexion is generally maintained, with a marked reduction in dorsiflexion. This usually results from the development of an osteophyte providing a mechanical block. Many grading and classification systems are available to score hallux rigidus. The most widely used scoring system is the radiographic grading system by Hattrup and Johnson (3): Grade 1: Well-preserved joint space with mild to moderate osteophytes

Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Claire Coles, MBChB, 15 Terrace Road, Swansea, SA1 6HN Wales. E-mail address: [email protected] (C. Coles).

Grade 2: Reduced joint space with moderate osteophytes, sclerosis, and cysts Grade 3: Complete loss of joint space, marked osteophytes, and subchondral cysts within the metatarsal head Coughlin and Shurnas (4) introduced a 5-level grading system that incorporated the original workings of Hattrup and Johnson’s radiographic classification and a clinical element. The grading system begins at 0 and details the degree of dorsiflexion producible in the joint, joint space preservation, osteophytes, and pain experienced. Nonsurgical and surgical treatments are available for the treatment of hallux rigidus; however, the choice of surgical treatment typically depends on the disease stage and will also be influenced by the patient’s activity level. A number of surgical procedures currently exist for its treatment, including cheilectomy, excisional arthroplasty (Keller procedure), and MTPJ arthrodesis, the current reference standard (5–7). However, MTPJ arthrodesis can be associated with complications such as malunion and nonunion and has been associated with footwear difficulties (8). MTPJ hemiarthroplasty was introduced in 1952; however, since then, few studies have documented the mid- and long-term outcomes

1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.11.001

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Fig. 1. Preoperative lateral weightbearing radiograph of patient A’s right foot.

of patients undergoing this procedure (6,9). Thus, the aim of the present study was to determine whether first MTPJ hemiarthroplasty with the HemiCAPÒ prosthesis (ArthrosurfaceÒ, Franklin, MA) provides satisfactory outcomes in the treatment of hallux rigidus. Patients and Methods In the present retrospective study, the data from 12 feet (6 right, 6 left) in 11 consecutive patients who had undergone first MTPJ hemiarthroplasty using the HemiCAPÒ prosthesis from March 2007 to March 2008 were reviewed. Patients were identified retrospectively from the surgeon’s (J.B.) logbook and recruited consecutively. All patients consented to involvement within the study. Surgery was solely completed by 1 coauthor (J.B.). All other aspects of the data retrieval, analysis, and write-up of the data was performed among all 3 co-authors equally. Follow-up examinations were performed after a mean of 47 (range 36 to 48) months. Of the 11 patients, 4 (36%) were male and 7 (64%) were female. Preoperatively, all patients had grade II hallux rigidus using the Coughlin and Shurnas classification. The patients were evaluated using the hallux metatarsophalangeal-interphalangeal scale developed by the American Orthopaedic Foot and Ankle Society (AOFAS) and the Foot and Ankle Disability Index (FADI) score. The clinical and radiologic assessment evaluated the range of movement within the joint and the amount of pain experienced and determined any level of subsidence within the joint. The range of movement within the joint was measured using a goniometer, and the degree of dorsiflexion obtained was recorded. Patients were also invited to leave comments regarding their experience with the procedure. The implant used in the present study was the HemiCAPÒ prosthesis, which includes an articular resurfacing component with a Morse taper screw interlock on its underside. This can be seen in Figs. 1 to 4, which show the pre- and postoperative radiographs of 1 of our patients in the present study. Fig. 3. Preoperative weightbearing radiograph, frontal view, of patient A’s right foot.

Results At the follow-up examination, the mean AOFAS score was 66.5 (range 22 to 92), and the mean FADI score was 63.7 (range 26.9 to 98.1). Using the AOFAS scale, the results for 2 feet (16.7%) were good, 8 feet (66.7%) were moderate, and 2 feet (16.7%) were poor. Of the 12 feet, 5 (41.7%) were pain free at the follow-up examination, 3 (25%) had mild pain, 2 (16.7%) moderate, and 2 (16.7%) severe pain. The range of motion was measured, and all patients were found to have

ongoing severe restrictions in the movement of the joint, in accordance with the AOFAS score. The immediate postoperative plain radiographs of all the patients were compared with the radiographs taken 6 months postoperatively to assess any degree of subsidence. The picture archiving and communication system was used to review the radiographs, including using the calibrated ruling system to measure the distance from the base of the first metatarsal to the base plate of the prosthesis. Of the 12 feet, 5 (42%) displayed no evidence of radiologic subsidence. However, 7 feet (58%) displayed evidence of subsidence ranging from only 1 mm to up to 6 mm, with a mean subsidence of 2.71 mm. Of the 11 patients, 5 (45%) commented that they would not undergo the same operation again, and another requested revision to MTPJ fusion. However, 1 patient noted that she had been able to successfully return to dancing after the joint replacement. Discussion

Fig. 2. Postoperative lateral weightbearing radiograph of patient A’s right foot with HemiCAPÒ prosthesis in situ.

Some patients will not be enthusiastic about the idea of joint arthrodesis because they wish to retain an active lifestyle, which is not always possible with a first MTPJ fusion a first MTPJ fusion is not always compatible. Arthrodesis can limit activities and affect normal gait (6,10,11).

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for those patients with surviving hemiarthroplasty (at a mean of 30 months). Although patient satisfaction was reasonable, a number of patients commented that they would not undergo the procedure again. Most patients continued to have a poor range of movement in the joint. The outcomes of the operation with regard to postoperative range of movement were similar to outcomes of arthrodesis, thus little difference was seen between the 2 operations when comparing this endpoint. The results from that retrospective study showed moderate success when assessing the patients’ AOFAS and FADI scores but poor results when observing the range of motion and incidence of postoperative pain (13). Hasselman and Shields (1) also used the Arthrosurface HemiCAPÒ prosthesis in their study and reported a mean AOFAS score of 82.1 at an average follow-up of 20 months. In another study, Aslan et al (14) assessed the outcomes after MTPJ hemiarthroplasty with the HemiCAPÒ prosthesis. The mean follow-up examination at 37 months showed a mean postoperative AOFAS score of 85.1 and an increase of 40 in postoperative movement within the joint. One limitation of the present study was the absence of patient preoperative scores. Although the postoperative AOFAS scores were modest, the preoperative scores would have allowed us to assess the extent of any changes in the scores after surgery. Our study was further limited by the small study size and the lack of a control group, which did not allow for randomization. In conclusion, in assessing the mid-term results after MTPJ hemiarthroplasty for hallux rigidus, we found not only a marked decrease in patient satisfaction scores but also a significant decrease in the range of movement. Although most patients had a moderate outcome according to the AOFAS score and remained pain free at the follow-up examination, the range of movement was severely restricted in all patients. ArthrosurfaceÒ, who presented the first HemiCAPÒ prosthesis >10 years ago, have recently changed the design, introducing a dorsal flange intended to improve roll-off during dorsiflexion and prevent osteophyte regrowth. The new design might help improve the range of dorsiflexion not seen with the traditional model (15). References Fig. 4. Postoperative weightbearing radiograph, frontal view, of patient A’s right foot with HemiCAPÒ prosthesis in situ.

MTPJ hemiarthroplasty leaves open the possibility for additional treatment options, including arthrodesis. If the operation is successful, it will theoretically maintain the range of movement within the joint, an important advantage for hemiarthroplasty. Replacement of only 1 surface ensures the maintenance of toe length and generally requires minimal bone resection, allowing easy conversion to arthrodesis, if necessary (6). Only a few studies of the mid-term results of first MTPJ hemiarthroplasty have been published; however, the mid- and long-term operative success rate after joint arthrodesis has always remained high (range 92% to 100%) (12). Raikin and Ahmad (13) performed a retrospective study that compared the outcomes of hemiarthroplasty versus arthrodesis. The results were favorable for arthrodesis, alleviating the patients’ symptoms and restoring function, with 87% of patients having satisfactory outcomes after arthrodesis compared with only 60% of patients after hemiarthroplasty. For the patients who had undergone hemiarthroplasty, the treatment failed in 24%, but all fusions were successful. Of the patients with failed hemiarthroplasty, 1 required revision and another 4 underwent fusion. The mean pain score was markedly better for the patients undergoing arthrodesis. At the final follow-up examination, the mean AOFAS score was 83.8 for the patients after arthrodesis (at a mean of 79.4 months) and only 71.8

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