- Email: [email protected]
Minimally-invasive hallux arthrodesis with endomedullary and a crossed screw fixation
G Model FAS 1369 No. of Pages 6
Foot and Ankle Surgery xxx (2019) xxx–xxx
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Minimally-invasive hallux arthrodesis with endomedullary and a crossed screw fixation Sofia Carlucci* , Ana C. Parise, Maria G. Santini-Araujo, Leonardo A. Conti, Daniel S. Villena, Carlos M. Dozo, Nelly M. Carrasco, Pablo Sotelano Hospital Italiano de Buenos Aires, Potosi 4247, C1199ABB, Buenos Aires, Argentina
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 June 2019 Received in revised form 24 August 2019 Accepted 19 September 2019 Available online xxx
Background: Minimally invasive surgery has several advantages: minor pain, smaller incisions and less tissue damage than traditional open surgery. Hallux arthrodesis with an endomedullary screw fixation provides compression and axial stability. The aim of this study was to describe the procedure and evaluate our first results of the minimally invasive first metatarsophalangeal arthrodesis with an endomedullary screw combined with a crossed screw fixation. Methods: We retrospectively studied 15 ft, with a minimum 1 year follow-up. Patients were evaluated with full-load radiographs and AOFAS score preoperatively and at last follow-up. Results: Consolidation rate was 93.3%, radiological consolidation time was 18 weeks (14–60). Radiographic alignment was achieved with satisfactory results. The preoperative AOFAS score improved from a mean 49 to 90 (p = 0.001). There was one postoperative superficial site infection, which healed and a patient developed a pseudarthrosis but it was asymptomatic. Conclusions: The minimally invasive metatarsophalangeal arthrodesis with an intramedullary screw is a secure procedure with comparable results to open techniques. Level of Clinical Evidence: 4. Case series. © 2019 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Arthritis Endomedullar screw Hallux disorders Hallux rigidus Mini-Invasive Percutaneous
1. Introduction The metatarsophalangeal hallux arthrodesis is a common procedure in forefoot surgery. It is indicated in advanced articular degeneration, in pathologies such as hallux rigidus, severe hallux valgus, inflammatory diseases or as salvage of previous interventions [1]. The main objective of the surgery is to obtain a plantigrade and stable hallux, eliminating pain [2]. Many techniques are described for hallux arthrodesis, differing in the approaches and internal fixation methods (e.g. crossed or parallel screws, Kirschner pins, staples, locked plates, endomedullar screw) [3]. Some biomechanical studies suggest that the
* Corresponding author. E-mail addresses: sofi[email protected] (S. Carlucci), [email protected] (A.C. Parise), [email protected] (M.G. Santini-Araujo), [email protected] (L.A. Conti), [email protected] (D.S. Villena), [email protected] (C.M. Dozo), [email protected] (N.M. Carrasco), [email protected] (P. Sotelano).
utilization of a dorsal locked plate combined with a cross compression screw, could be the more mechanically stable fixation [4], although it is not defined which is the gold standard. The use of an endomedullary screw provides compression and axial stability. This method was first described by Groulier el al. [5] and later by Hansen [6] and Castro [7]. The biomechanical study performed by Molloy [8] in fresh cadaver feet, compares the strength between two crossed screws and an endomedullary screw and demonstrates that the last one is significantly stiffer and provides 50% more strength. In 2013 Migues et al. [9] published them series using a 6.5 mm endomedullary screw, performing arthrodesis by medial open approach. They obtained 95% of articular fusion, with minimal complications. Even though this fixation does not provide rotational stability, they did not have complications in this topic. With the growing field in minimally invasive techniques, many procedures could be developed in forefoot surgery by small incisions, which reduces postoperative pain and soft tissue damage [10]. In spite of it, there are few publications about percutaneous hallux arthrodesis. We combined in our group a percutaneous hallux arthrodesis technique, with the endomedullary fixation described before,
https://doi.org/10.1016/j.fas.2019.09.005 1268-7731/© 2019 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: S. Carlucci, et al., Minimally-invasive hallux arthrodesis with endomedullary and a crossed screw fixation, Foot Ankle Surg (2019), https://doi.org/10.1016/j.fas.2019.09.005
G Model FAS 1369 No. of Pages 6
2
S. Carlucci et al. / Foot and Ankle Surgery xxx (2019) xxx–xxx
adding a crossed screw for rotational control. Our primary objective was to present the technique and, and our secondary aim was to present our first series with this minimally invasive approach. 2. Materials and methods We performed a retrospective analysis of patients who underwent hallux arthrodesis surgery through a percutaneous approach, fixed with an endomedullary screw and adding another crossed screw. Surgery was indicated in patients with advanced articular degeneration, and in those who presented severe pain, functional limitations or deformity; without response to conservative treatment. After study approval from our site’s institutional medical ethical review board, we have included 15 ft in 13 adult patients, who were operated on between March 2016 and March 2018. Patients who had had a history of previous surgery on the hallux, less than a year of follow-up or incomplete records were excluded. The information was obtained from the hospital database. All surgeries were performed by the same senior surgeon, specialized in foot and ankle surgery, with experience in minimally invasive surgery. The patients were evaluated with full-load radiographs at the preoperative time, at immediate postoperative time and 3 months, 6 months, and final follow up. Hallux metatarsophalangeal angle (HVA) was measured in preoperative and final follow up in anteroposterior and lateral radiographs. We also assessed the angle formed between the proximal hallux phalanx and the floor. The bone healing time was evaluated, defining as consolidation the presence of bone bridges at the arthrodesis site on radiographs, and absence of pain when loading on the foot [11,12]. The American Orthopaedic Foot & Ankle Society (AOFAS) score was registered in the preoperatory and at final follow-up, considering the maximum score 90, by annulling metatarsophalangeal movement.
Fig. 1. Kirschner pin is inserted retrogradely from the distal tip of the hallux towards the plantar side of the metatarsal head, crossing the first metatarsophalangeal articulation.
2.1. Surgical technique All procedures were ambulatory, under regional anesthesia, with an ankle block. The first step is to introduce the 5.5 mm cannulated screw’s Kirschner pin retrogradely from the distal tip of the hallux towards the plantar side of the metatarsal head, crossing the first metatarsophalangeal articulation (Fig. 1). The canal is made with the corresponding cannulated drill from proximal to distal, being careful not to cross the interphalangeal articulation (Fig. 2). The Kirschner wire is pulled back to the proximal phalanx. For the preparation of the articular surface, a medial incision is made with a Beaver blade. The capsule and soft tissues are carefully detached with a rasp. The debridement is performed with a low speed and high torque drill and a Shannon burr (Fig. 3). This step should be done under radioscopic guidance, ensuring correct alignment and proper osteophyte removal and articular cartilage. The pin is inserted again in the canal previously made (Fig. 4), and the cannulated screw is introduced from the metatarsal head to the phalanx, fixing the arthrodesis (Fig. 5). We preferred 5.5 or 6.5 mm cannulated screws, were possible fully threaded with stepped pitch. Last, a smaller diameter cannulated screw is placed percutaneously from medial to lateral crossing the arthrodesis site, to improve rotational control (Fig. 6). The patient is allowed to full bear walking, with a rigid sole post-operative shoe. Bandage is changed in the clinic every week,
Fig. 2. The canal is drilled from proximal to distal.
and it is removed at the third week. Normal shoe-wearing authorized after 1 month according to the clinical and radiological control. 2.2. Statistical analysis The data were tested for normality using the Shapiro–Wilk test. For normally distributed data, the mean, standard deviation. The
Please cite this article in press as: S. Carlucci, et al., Minimally-invasive hallux arthrodesis with endomedullary and a crossed screw fixation, Foot Ankle Surg (2019), https://doi.org/10.1016/j.fas.2019.09.005
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Fig. 3. Articular debridement is performed percutaneously.
Fig. 4. The pin is reinserted in the canal.
median and range are presented for not normal distribution data. The primary outcome was determined using t-Student test or Wilcoxon test as appropriate. Statistical significance was set at p < 0.05. The data were analyzed using STATA Software, version 13, for Windows (Statacorp LP College Station Texas). 3. Results Fifteen feet were evaluated who matched the inclusion criteria. The mean age was 71.4 7.8 years old; 10 were women, 5 men. Preoperatory diagnoses are shown in Table 1. The mean follow-up was 18 months (14–40). Consolidation was achieved in 14 ft (93.3%) in a median time of 18 weeks (IQR 12–18).
The metatarsophalangeal angle in the anteroposterior view in the last radiographs obtained an average angle of 14.10 ( 5.51 to 24.89). In the lateral incidence, the metatarsophalangeal angle was a median of 15.49 (8.65–22.11) of dorsiflexion. The angle between the proximal phalanx of the hallux and the ground was a median of 5.03 (2.07–7.64) (Table 2). The AOFAS score improved significantly, from a mean 43.6 to 84.8; with a mean difference of 41,2 points (SD 7.78; p < 0.001). Regarding the interphalangeal joint, we did not find degenerative changes on radiographs, nor did patients report pain at that site at the time of follow up. As complications we registered one skin burn because of the burr temperature, which resolved with oral antibiotics. There was
Please cite this article in press as: S. Carlucci, et al., Minimally-invasive hallux arthrodesis with endomedullary and a crossed screw fixation, Foot Ankle Surg (2019), https://doi.org/10.1016/j.fas.2019.09.005
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S. Carlucci et al. / Foot and Ankle Surgery xxx (2019) xxx–xxx Table 1 Preoperative diagnoses (N = 15 in 13 patients).
Fig. 5. The screw is placed from the metatarsal approach.
one pseudarthrosis, but the patient was asymptomatic and did not accept a reintervention. 4. Discussion Metatarsophalangeal hallux arthrodesis is the treatment of choice in severe articular diseases or big deformities. Although implants have been developed for partial and total joint replacement, arthrodesis is still the recommended treatment for hallux rigidus grades III and IV [13] and other degenerative articular conditions. And while it is a frequent indication in everyday practice forefoot surgery, it has not yet been determined which are the most effective approaches and means of fixation.
Diagnosis
N = 15
Hallux rigidus Rheumatoid arthritis Severe hallux valgus Hallux varus
6 3 4 2
Currently, numerous studies had compared fixation methods, and blocked dorsal plates and screws combined with a compression screw is the method of choice at present [14–18]. However, no study has yet been developed to compare the stability of the fixation with an intramedullary screw. The placement of a plate and screws requires a wide approach to achieve the proper position of the implant, which may increase the risk of infection of the surgical site or damage of vascular or nervous structures and also may extend postoperative pain and swelling [19,20]. By a percutaneous technique and endomedullary fixation we have obtained comparable results, avoiding complications related to the approach. Also, less capsular and ligamentous debridement would help provide greater stability. Smaller incisions reduce immediate postoperative pain, allowing the patient to full-bear walk. Regarding the position of the arthrodesis, we obtained a mean metatarsophalangeal dorsiflexion angle of 15 , an acceptable value with respect to what is recommended in the literature, which varies widely between 15 and 40 [13,21–24]. There is not yet strong evidence on the correlation between the angle of radiographic extension and the clinical outcome [25]. Hallux valgus angle in the anteroposterior view also obtained an adequate value, being described as the desired one between 5 and 20 [13,22]. Although there were some patients whose values were not within these ranges, this did not affect any of them clinically. Percutaneous arthrodesis in the literature was only described by two authors. In Bauers study [26] described articular surfaces debridement in a flat shape by a percutaneous medial approach and it is fixed with 2 crossed percutaneous screws. It presents 36 cases with significant improvement in the AOFAS score from a mean 36/100 preoperatively to a mean 80/100 postoperatively (p = 0.02) and good alignment. Sott [27] reports 26 cases of percutaneous arthrodesis with 2 crossed screws but, unlike Bauer, performs the joint preparation preserving the congruence of the surfaces to maintain stability. It also obtained good clinical and radiographic results, with a
Fig. 6. A smaller crossed screw is placed percutaneously to improve rotational control.
Please cite this article in press as: S. Carlucci, et al., Minimally-invasive hallux arthrodesis with endomedullary and a crossed screw fixation, Foot Ankle Surg (2019), https://doi.org/10.1016/j.fas.2019.09.005
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Table 2 Preoperative and post operatory radiographical angles in AP and lateral views.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Median
MTP Angle AP Pre-OP
MTP Angle AP P-O
MTP Angle Lat Pre-OP
MTP Angle Lat P-O
Hallux-ground angle P-O
13.03 17.89 17.74 10.54 18.46 47.8 19.73 31.6 43.48 25.06 31.18 12.68 23.6 22.19 33.85 18.46
6.74 16.06 14.51 13.51 24.08 24.89 16.85 19.17 5.51 11.73 4.33 14.1 9.11 10.9 16.54 14.10
9.36 15.67 12.38 10.56 15.91 8.13 4.53 8.46 7.31 11.17 11.2 12.46 12.01 16.48 8.01 11.17
14.72 22.11 16.42 12.24 19.79 16.16 8.65 12.01 10.51 15.49 14.21 21.51 13.42 21.18 16.01 15.49
4.23 4.92 5.49 7.64 4.45 5.78 2.07 2.62 5.24 5.03 7.21 3.91 9.5 4.79 6.22 5.03
MTP: metatarsophalangeal, PRE-OP: preoperatory, P-O: post operatory; AP: anteroposterior, Lat: lateral.
consolidation rate of 93%, as in our series and comparable to the results of the literature in other techniques. In both studies, the importance of the experience in percutaneous surgery of the surgeon is mentioned, in order to prevent excessive or asymmetric bone resection of the surfaces, which may generate malalignment of the arthrodesis or hallux shortening. We agree on this point, as this is the step that can present difficulties in the procedure. The use of an intramedullary screw provides a more stable and more rigid fixation than those used by Sott and Bauer [8]. Furthermore, inserting a screw into the metatarsal from the plant, would avoid the discomfort caused by the hardware and therefore the need to remove it later [7]. With the advance in materials and osteosynthesis design, we have chosen conical screws with complete and stepped thread, which increase compression in the arthrodesis and provide greater rigidity and strength to the construct [28]. The placement of a larger diameter screw gives more stability and rotational control; this is demonstrated in Migues’ study [9], where no complications are reported at this point. Anyhow, we also added a smaller diameter cross screw for greater control, since its placement does not increase the difficulty of the technique or the surgical time, although it does increase the costs. Biomechanical studies are needed to justify this, since this was not evaluated in the present study. Percutaneous surgery reduces the need for large incisions, and with it pain and complications related to the wound [10]. Although in this work we show the results in various pathologies with different angles, our sample is low to determine which is the appropriate indication for a mini-invasive or an open approach. We take into account that our study is retrospective and has a low number of patients, with a diversity of etiologies. It should be noted that with the new surgical procedures to maintain the metatarsophalangeal joint, arthrodesis is less indicated and in older patients. In addition, we are showing our early experience with this new technique. But we highlight that this is a novel procedure, with good final results, low number of complications, and adds a new indication to the field of percutaneous forefoot surgery. 5. Conclusions The minimally-invasive metatarsophalangeal arthrodesis of the hallux with an intramedullary screw is a secure procedure, with comparable results to open techniques. It can be considered among the options, although the experience in percutaneous surgery is essential. Our results may trigger new prospective studies in this field.
Conflict of interest None. References [1] Rammelt S, Panzner I, Mittlmeier T. Metatarsophalangeal joint fusion: why and how? Foot Ankle Clin 2015;20:465–77, doi:http://dx.doi.org/10.1016/j. fcl.2015.04.008. [2] Coughlin MJ. Arthrodesis of the first metatarsophalangeal joint. Orthop Rev 1990;19:177–86. [3] Moon JL, McGlamry MC. First metatarsophalangeal joint arthrodesis: current fixation options. Clin Podiatr Med Surg 2011;28:405–19, doi:http://dx.doi.org/ 10.1016/j.cpm.2011.02.002 ix. [4] Politi J, John H, Njus G, Bennett GL, Kay DB. First metatarsal-phalangeal joint arthrodesis: a biomechanical assessment of stability. Foot Ankle Int 2003; 24:332–7, doi:http://dx.doi.org/10.1177/107110070302400405. [5] Curvale G, Croisille H, Tracol P, Groulier P. [Metatarsophalangeal arthrodesis of the big toe]. Rev Chir Orthop Reparatrice Appar Mot 1987;73(Suppl. 2):258–61. [6] Hansen ST. The dysfunctional forefoot. In: Hansen ST, editor. Functional reconstruction of the foot and ankle. Philadelphia, PA: Lippincott Williams & Wilkins; 2000. p. 283–356. [7] Castro MD, Klaue K. Revisiting an alternative method of fixation for first MTP joint arthrodesis. Foot Ankle Int 2001;22:687–8, doi:http://dx.doi.org/10.1177/ 107110070102200813. [8] Molloy S, Burkhart BG, Jasper LE, Solan MC, Campbell JT, Belkoff SM. Biomechanical comparison of two fixation methods for first metatarsophalangeal joint arthrodesis. Foot Ankle Int 2003;24:169–71, doi:http://dx.doi. org/10.1177/107110070302400212. [9] Migues A, Calvi J, Sotelano P, Carrasco M, Slullitel G, Conti L. Endomedullary screw fixation for first metatarsophalangeal arthrodesis. Foot Ankle Int 2013; 34:1152–7, doi:http://dx.doi.org/10.1177/1071100713483113. [10] Maffulli N, Longo UG, Marinozzi A, Denaro V. Hallux valgus: effectiveness and safety of minimally invasive surgery. A systematic review. Br Med Bull 2011; 97:149–67, doi:http://dx.doi.org/10.1093/bmb/ldq027. [11] Corrales LA, Morshed S, Bhandari M, Miclau 3rd T. Variability in the assessment of fracture-healing in orthopaedic trauma studies. J Bone Jt Surg Am 2008;90:1862–8, doi:http://dx.doi.org/10.2106/JBJS.G.01580. [12] Dijkman BG, Sprague S, Schemitsch EH, Bhandari M. When is a fracture healed? Radiographic and clinical criteria revisited. J Orthop Trauma 2010;24 (Suppl 1):S76–80, doi:http://dx.doi.org/10.1097/BOT.0b013e3181ca3f97. [13] Coughlin MJ, Shurnas PS. Hallux rigidus. Grading and long-term results of operative treatment. J Bone Jt Surg Am 2003;85-A:2072–88. [14] Claassen L, Plaass C, Pastor M-F, Ettinger S, Wellmann M, Stukenborg-Colsman C, et al. First metatarsophalangeal joint arthrodesis: a retrospective comparison of crossed-screws, locking and non-locking plate fixation with lag screw. Arch Bone Jt Surg 2017;5:221–5. [15] Doty J, Coughlin M, Hirose C, Kemp T. Hallux metatarsophalangeal joint arthrodesis with a hybrid locking plate and a plantar neutralization screw: a prospective study. Foot Ankle Int 2013;34:1535–40, doi:http://dx.doi.org/ 10.1177/1071100713494779. [16] Cone B, Staggers JR, Naranje S, Hudson P, Ingram J, Shah A. First metatarsophalangeal joint arthrodesis: does the addition of a lag screw to a dorsal locking plate influence union rate and/or final alignment after fusion. J Foot Ankle Surg 2018; 57:259–63, doi:http://dx.doi.org/10.1053/j.jfas.2017.09.003. [17] Latif A, Dhinsa BS, Lau B, Abbasian A. First metatarsophalangeal fusion using joint specific dorsal plate with interfragmentary screw augmentation: clinical
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and radiological outcomes. Foot Ankle Surg 2019;25:132–6, doi:http://dx.doi. org/10.1016/j.fas.2017.09.005. Foote KM, Teasdall RD, Tanaka ML, Scott AT. First metatarsophalangeal arthrodesis: a biomechanical comparison of three fixation constructs. J Surg Orthop Adv 2012;21:223–31. Kelikian AS. Technical considerations in hallux metatarsalphalangeal arthrodesis. Foot Ankle Clin 2005;10:167–90, doi:http://dx.doi.org/10.1016/j.fcl.2004.11.002. Womack JW, Ishikawa SN. First metatarsophalangeal arthrodesis. Foot Ankle Clin 2009;14:43–50, doi:http://dx.doi.org/10.1016/j.fcl.2008.11.008. Lewis JT, Hanselman AE, Lalli TAJ, Daigre JL, Santrock RD. Effect of dorsal plate positioning on dorsiflexion angle in arthrodesis of the first metatarsophalangeal joint: a cadaveric study. Foot Ankle Int 2014;35:802–8, doi:http://dx. doi.org/10.1177/1071100714534419. Mann RA, Coughlin MJ, DuVries HL. Hallux rigidus: a review of the literature and a method of treatment. Clin Orthop Relat Res 1979;57–63. DeOrio JK. Technique tip: arthrodesis of the first metatarsophalangeal joint — prevention of excessive dorsiflexion. Foot Ankle Int 2007;28:746–7, doi:http:// dx.doi.org/10.3113/FAI.2007.0746.
[24] Mckeever DC. Arthrodesis of the first metatarsophalangeal joint for hallux valgus, hallux rigidus, and metatarsus primus varus. J Bone Jt Surg Am 1952;129–34, doi:http://dx.doi.org/10.2106/00004623-195234010-00013. [25] Aas M, Johnsen TM, Finsen V. Arthrodesis of the first metatarsophalangeal joint for hallux rigidus—optimal position of fusion. Foot 2008;131–5, doi: http://dx.doi.org/10.1016/j.foot.2008.03.002. [26] Bauer T, Lortat-Jacob A, Hardy P. First metatarsophalangeal joint percutaneous arthrodesis. Orthop Traumatol Surg Res 2010;96:567–73, doi:http://dx.doi. org/10.1016/j.otsr.2010.01.011. [27] Fanous RN, Ridgers S, Sott AH. Minimally invasive arthrodesis of the first metatarsophalangeal joint for hallux rigidus. Foot Ankle Surg 2014;20:170–3, doi:http://dx.doi.org/10.1016/j.fas.2014.03.004. [28] Downey MW, Kosmopoulos V, Carpenter BB. Fully threaded versus partially threaded screws: determining shear in cancellous bone fixation. J Foot Ankle Surg 2015;54:1021–4, doi:http://dx.doi.org/10.1053/ j.jfas.2015.04.017.
Please cite this article in press as: S. Carlucci, et al., Minimally-invasive hallux arthrodesis with endomedullary and a crossed screw fixation, Foot Ankle Surg (2019), https://doi.org/10.1016/j.fas.2019.09.005
Foot and Ankle Surgery xxx (2019) xxx–xxx
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Minimally-invasive hallux arthrodesis with endomedullary and a crossed screw fixation Sofia Carlucci* , Ana C. Parise, Maria G. Santini-Araujo, Leonardo A. Conti, Daniel S. Villena, Carlos M. Dozo, Nelly M. Carrasco, Pablo Sotelano Hospital Italiano de Buenos Aires, Potosi 4247, C1199ABB, Buenos Aires, Argentina
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 June 2019 Received in revised form 24 August 2019 Accepted 19 September 2019 Available online xxx
Background: Minimally invasive surgery has several advantages: minor pain, smaller incisions and less tissue damage than traditional open surgery. Hallux arthrodesis with an endomedullary screw fixation provides compression and axial stability. The aim of this study was to describe the procedure and evaluate our first results of the minimally invasive first metatarsophalangeal arthrodesis with an endomedullary screw combined with a crossed screw fixation. Methods: We retrospectively studied 15 ft, with a minimum 1 year follow-up. Patients were evaluated with full-load radiographs and AOFAS score preoperatively and at last follow-up. Results: Consolidation rate was 93.3%, radiological consolidation time was 18 weeks (14–60). Radiographic alignment was achieved with satisfactory results. The preoperative AOFAS score improved from a mean 49 to 90 (p = 0.001). There was one postoperative superficial site infection, which healed and a patient developed a pseudarthrosis but it was asymptomatic. Conclusions: The minimally invasive metatarsophalangeal arthrodesis with an intramedullary screw is a secure procedure with comparable results to open techniques. Level of Clinical Evidence: 4. Case series. © 2019 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Arthritis Endomedullar screw Hallux disorders Hallux rigidus Mini-Invasive Percutaneous
1. Introduction The metatarsophalangeal hallux arthrodesis is a common procedure in forefoot surgery. It is indicated in advanced articular degeneration, in pathologies such as hallux rigidus, severe hallux valgus, inflammatory diseases or as salvage of previous interventions [1]. The main objective of the surgery is to obtain a plantigrade and stable hallux, eliminating pain [2]. Many techniques are described for hallux arthrodesis, differing in the approaches and internal fixation methods (e.g. crossed or parallel screws, Kirschner pins, staples, locked plates, endomedullar screw) [3]. Some biomechanical studies suggest that the
* Corresponding author. E-mail addresses: sofi[email protected] (S. Carlucci), [email protected] (A.C. Parise), [email protected] (M.G. Santini-Araujo), [email protected] (L.A. Conti), [email protected] (D.S. Villena), [email protected] (C.M. Dozo), [email protected] (N.M. Carrasco), [email protected] (P. Sotelano).
utilization of a dorsal locked plate combined with a cross compression screw, could be the more mechanically stable fixation [4], although it is not defined which is the gold standard. The use of an endomedullary screw provides compression and axial stability. This method was first described by Groulier el al. [5] and later by Hansen [6] and Castro [7]. The biomechanical study performed by Molloy [8] in fresh cadaver feet, compares the strength between two crossed screws and an endomedullary screw and demonstrates that the last one is significantly stiffer and provides 50% more strength. In 2013 Migues et al. [9] published them series using a 6.5 mm endomedullary screw, performing arthrodesis by medial open approach. They obtained 95% of articular fusion, with minimal complications. Even though this fixation does not provide rotational stability, they did not have complications in this topic. With the growing field in minimally invasive techniques, many procedures could be developed in forefoot surgery by small incisions, which reduces postoperative pain and soft tissue damage [10]. In spite of it, there are few publications about percutaneous hallux arthrodesis. We combined in our group a percutaneous hallux arthrodesis technique, with the endomedullary fixation described before,
https://doi.org/10.1016/j.fas.2019.09.005 1268-7731/© 2019 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: S. Carlucci, et al., Minimally-invasive hallux arthrodesis with endomedullary and a crossed screw fixation, Foot Ankle Surg (2019), https://doi.org/10.1016/j.fas.2019.09.005
G Model FAS 1369 No. of Pages 6
2
S. Carlucci et al. / Foot and Ankle Surgery xxx (2019) xxx–xxx
adding a crossed screw for rotational control. Our primary objective was to present the technique and, and our secondary aim was to present our first series with this minimally invasive approach. 2. Materials and methods We performed a retrospective analysis of patients who underwent hallux arthrodesis surgery through a percutaneous approach, fixed with an endomedullary screw and adding another crossed screw. Surgery was indicated in patients with advanced articular degeneration, and in those who presented severe pain, functional limitations or deformity; without response to conservative treatment. After study approval from our site’s institutional medical ethical review board, we have included 15 ft in 13 adult patients, who were operated on between March 2016 and March 2018. Patients who had had a history of previous surgery on the hallux, less than a year of follow-up or incomplete records were excluded. The information was obtained from the hospital database. All surgeries were performed by the same senior surgeon, specialized in foot and ankle surgery, with experience in minimally invasive surgery. The patients were evaluated with full-load radiographs at the preoperative time, at immediate postoperative time and 3 months, 6 months, and final follow up. Hallux metatarsophalangeal angle (HVA) was measured in preoperative and final follow up in anteroposterior and lateral radiographs. We also assessed the angle formed between the proximal hallux phalanx and the floor. The bone healing time was evaluated, defining as consolidation the presence of bone bridges at the arthrodesis site on radiographs, and absence of pain when loading on the foot [11,12]. The American Orthopaedic Foot & Ankle Society (AOFAS) score was registered in the preoperatory and at final follow-up, considering the maximum score 90, by annulling metatarsophalangeal movement.
Fig. 1. Kirschner pin is inserted retrogradely from the distal tip of the hallux towards the plantar side of the metatarsal head, crossing the first metatarsophalangeal articulation.
2.1. Surgical technique All procedures were ambulatory, under regional anesthesia, with an ankle block. The first step is to introduce the 5.5 mm cannulated screw’s Kirschner pin retrogradely from the distal tip of the hallux towards the plantar side of the metatarsal head, crossing the first metatarsophalangeal articulation (Fig. 1). The canal is made with the corresponding cannulated drill from proximal to distal, being careful not to cross the interphalangeal articulation (Fig. 2). The Kirschner wire is pulled back to the proximal phalanx. For the preparation of the articular surface, a medial incision is made with a Beaver blade. The capsule and soft tissues are carefully detached with a rasp. The debridement is performed with a low speed and high torque drill and a Shannon burr (Fig. 3). This step should be done under radioscopic guidance, ensuring correct alignment and proper osteophyte removal and articular cartilage. The pin is inserted again in the canal previously made (Fig. 4), and the cannulated screw is introduced from the metatarsal head to the phalanx, fixing the arthrodesis (Fig. 5). We preferred 5.5 or 6.5 mm cannulated screws, were possible fully threaded with stepped pitch. Last, a smaller diameter cannulated screw is placed percutaneously from medial to lateral crossing the arthrodesis site, to improve rotational control (Fig. 6). The patient is allowed to full bear walking, with a rigid sole post-operative shoe. Bandage is changed in the clinic every week,
Fig. 2. The canal is drilled from proximal to distal.
and it is removed at the third week. Normal shoe-wearing authorized after 1 month according to the clinical and radiological control. 2.2. Statistical analysis The data were tested for normality using the Shapiro–Wilk test. For normally distributed data, the mean, standard deviation. The
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Fig. 3. Articular debridement is performed percutaneously.
Fig. 4. The pin is reinserted in the canal.
median and range are presented for not normal distribution data. The primary outcome was determined using t-Student test or Wilcoxon test as appropriate. Statistical significance was set at p < 0.05. The data were analyzed using STATA Software, version 13, for Windows (Statacorp LP College Station Texas). 3. Results Fifteen feet were evaluated who matched the inclusion criteria. The mean age was 71.4 7.8 years old; 10 were women, 5 men. Preoperatory diagnoses are shown in Table 1. The mean follow-up was 18 months (14–40). Consolidation was achieved in 14 ft (93.3%) in a median time of 18 weeks (IQR 12–18).
The metatarsophalangeal angle in the anteroposterior view in the last radiographs obtained an average angle of 14.10 ( 5.51 to 24.89). In the lateral incidence, the metatarsophalangeal angle was a median of 15.49 (8.65–22.11) of dorsiflexion. The angle between the proximal phalanx of the hallux and the ground was a median of 5.03 (2.07–7.64) (Table 2). The AOFAS score improved significantly, from a mean 43.6 to 84.8; with a mean difference of 41,2 points (SD 7.78; p < 0.001). Regarding the interphalangeal joint, we did not find degenerative changes on radiographs, nor did patients report pain at that site at the time of follow up. As complications we registered one skin burn because of the burr temperature, which resolved with oral antibiotics. There was
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S. Carlucci et al. / Foot and Ankle Surgery xxx (2019) xxx–xxx Table 1 Preoperative diagnoses (N = 15 in 13 patients).
Fig. 5. The screw is placed from the metatarsal approach.
one pseudarthrosis, but the patient was asymptomatic and did not accept a reintervention. 4. Discussion Metatarsophalangeal hallux arthrodesis is the treatment of choice in severe articular diseases or big deformities. Although implants have been developed for partial and total joint replacement, arthrodesis is still the recommended treatment for hallux rigidus grades III and IV [13] and other degenerative articular conditions. And while it is a frequent indication in everyday practice forefoot surgery, it has not yet been determined which are the most effective approaches and means of fixation.
Diagnosis
N = 15
Hallux rigidus Rheumatoid arthritis Severe hallux valgus Hallux varus
6 3 4 2
Currently, numerous studies had compared fixation methods, and blocked dorsal plates and screws combined with a compression screw is the method of choice at present [14–18]. However, no study has yet been developed to compare the stability of the fixation with an intramedullary screw. The placement of a plate and screws requires a wide approach to achieve the proper position of the implant, which may increase the risk of infection of the surgical site or damage of vascular or nervous structures and also may extend postoperative pain and swelling [19,20]. By a percutaneous technique and endomedullary fixation we have obtained comparable results, avoiding complications related to the approach. Also, less capsular and ligamentous debridement would help provide greater stability. Smaller incisions reduce immediate postoperative pain, allowing the patient to full-bear walk. Regarding the position of the arthrodesis, we obtained a mean metatarsophalangeal dorsiflexion angle of 15 , an acceptable value with respect to what is recommended in the literature, which varies widely between 15 and 40 [13,21–24]. There is not yet strong evidence on the correlation between the angle of radiographic extension and the clinical outcome [25]. Hallux valgus angle in the anteroposterior view also obtained an adequate value, being described as the desired one between 5 and 20 [13,22]. Although there were some patients whose values were not within these ranges, this did not affect any of them clinically. Percutaneous arthrodesis in the literature was only described by two authors. In Bauers study [26] described articular surfaces debridement in a flat shape by a percutaneous medial approach and it is fixed with 2 crossed percutaneous screws. It presents 36 cases with significant improvement in the AOFAS score from a mean 36/100 preoperatively to a mean 80/100 postoperatively (p = 0.02) and good alignment. Sott [27] reports 26 cases of percutaneous arthrodesis with 2 crossed screws but, unlike Bauer, performs the joint preparation preserving the congruence of the surfaces to maintain stability. It also obtained good clinical and radiographic results, with a
Fig. 6. A smaller crossed screw is placed percutaneously to improve rotational control.
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Table 2 Preoperative and post operatory radiographical angles in AP and lateral views.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Median
MTP Angle AP Pre-OP
MTP Angle AP P-O
MTP Angle Lat Pre-OP
MTP Angle Lat P-O
Hallux-ground angle P-O
13.03 17.89 17.74 10.54 18.46 47.8 19.73 31.6 43.48 25.06 31.18 12.68 23.6 22.19 33.85 18.46
6.74 16.06 14.51 13.51 24.08 24.89 16.85 19.17 5.51 11.73 4.33 14.1 9.11 10.9 16.54 14.10
9.36 15.67 12.38 10.56 15.91 8.13 4.53 8.46 7.31 11.17 11.2 12.46 12.01 16.48 8.01 11.17
14.72 22.11 16.42 12.24 19.79 16.16 8.65 12.01 10.51 15.49 14.21 21.51 13.42 21.18 16.01 15.49
4.23 4.92 5.49 7.64 4.45 5.78 2.07 2.62 5.24 5.03 7.21 3.91 9.5 4.79 6.22 5.03
MTP: metatarsophalangeal, PRE-OP: preoperatory, P-O: post operatory; AP: anteroposterior, Lat: lateral.
consolidation rate of 93%, as in our series and comparable to the results of the literature in other techniques. In both studies, the importance of the experience in percutaneous surgery of the surgeon is mentioned, in order to prevent excessive or asymmetric bone resection of the surfaces, which may generate malalignment of the arthrodesis or hallux shortening. We agree on this point, as this is the step that can present difficulties in the procedure. The use of an intramedullary screw provides a more stable and more rigid fixation than those used by Sott and Bauer [8]. Furthermore, inserting a screw into the metatarsal from the plant, would avoid the discomfort caused by the hardware and therefore the need to remove it later [7]. With the advance in materials and osteosynthesis design, we have chosen conical screws with complete and stepped thread, which increase compression in the arthrodesis and provide greater rigidity and strength to the construct [28]. The placement of a larger diameter screw gives more stability and rotational control; this is demonstrated in Migues’ study [9], where no complications are reported at this point. Anyhow, we also added a smaller diameter cross screw for greater control, since its placement does not increase the difficulty of the technique or the surgical time, although it does increase the costs. Biomechanical studies are needed to justify this, since this was not evaluated in the present study. Percutaneous surgery reduces the need for large incisions, and with it pain and complications related to the wound [10]. Although in this work we show the results in various pathologies with different angles, our sample is low to determine which is the appropriate indication for a mini-invasive or an open approach. We take into account that our study is retrospective and has a low number of patients, with a diversity of etiologies. It should be noted that with the new surgical procedures to maintain the metatarsophalangeal joint, arthrodesis is less indicated and in older patients. In addition, we are showing our early experience with this new technique. But we highlight that this is a novel procedure, with good final results, low number of complications, and adds a new indication to the field of percutaneous forefoot surgery. 5. Conclusions The minimally-invasive metatarsophalangeal arthrodesis of the hallux with an intramedullary screw is a secure procedure, with comparable results to open techniques. It can be considered among the options, although the experience in percutaneous surgery is essential. Our results may trigger new prospective studies in this field.
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