R A Fuhrmann1, T Pillukat. 1. Klinik für Fuß- und Sprunggelenkschirurgie, Rhön-Klinikum, Bad Neustadt, Deutschland. info@fusschirurgie-bad-neustadt.de
Abstract
OBJECTIVE: Fusion of the first metatarsophalangeal joint and realignment of the great toe in patients with painful arthritis to achieve pain-free walking. INDICATIONS: Hallux rigidus grade 3/4, hallux valgus et rigidus, claw toe deformity of the great toe, salvage after endoprosthesis or cheilectomy, avascular necrosis of the first metatarsal head arthritis of the first metatarsophalangeal joint. CONTRAINDICATIONS: Infection, painful arthritis of the interphanageal joint (relative contraindication), and severe osteoporosis (relative contraindication). SURGICAL TECHNIQUE: Dorsal approach to the first metatarsophalangeal joint. Removal of all osteophytes and circumferential capsular release. Debridement of the sesamoids. Cartilage resection (flat cuts or "cup and cone" reaming) and multiple drilling of the subchondral layer. In case of osseous defects, interposition of a corticocancellous bone graft. Trial reduction and assessment of the toe alignment. Fixation with two screws, one lag screw and dorsal plating, or dorsal plating only. Wound closure in layers. POSTOPERATIVE MANAGEMENT: Full weight bearing in a postoperative shoe or partial weight bearing in a short cast for 4-6 weeks. If the X-ray reveals sufficient bone healing, patients are allowed to wear sneakers with a stiff sole for 3-6 months. Sport activities with impact loading are limited for at least 3 months. Final X-ray control after 6 months. RESULTS: A total of 70 feet with a fusion of the first metatarsophalangeal joint were followed up after 28 months. Postoperative complications (7.3%): 5 wound slough, 1 infection, and 6 painful delayed union. Modified AOFAS forefoot score (max. 85 points) was 43 (32-58) points preoperatively and 82 (71-85) points postoperatively. Great toe alignment was perfect in 57 feet. Nine toes showed a valgus (> 20°) and 4 toes a varus malalignment. Fifty-four attained full ground contact. Eight patients reached the ground by flexion of the interphalangeal joint and 8 patients presented with dorsiflexion of the great toe. X-ray showed consolidation of the arthrodesis in 64 feet (91.4%), while 8 feet (4 with interposition of a bone graft) revealed signs of incomplete healing. These patients were advised to have an annual clinical and radiological reassessment performed.
OBJECTIVE: Fusion of the first metatarsophalangeal joint and realignment of the great toe in patients with painful arthritis to achieve pain-free walking. INDICATIONS: Hallux rigidus grade 3/4, hallux valgus et rigidus, claw toe deformity of the great toe, salvage after endoprosthesis or cheilectomy, avascular necrosis of the first metatarsal head arthritis of the first metatarsophalangeal joint. CONTRAINDICATIONS: Infection, painful arthritis of the interphanageal joint (relative contraindication), and severe osteoporosis (relative contraindication). SURGICAL TECHNIQUE: Dorsal approach to the first metatarsophalangeal joint. Removal of all osteophytes and circumferential capsular release. Debridement of the sesamoids. Cartilage resection (flat cuts or "cup and cone" reaming) and multiple drilling of the subchondral layer. In case of osseous defects, interposition of a corticocancellous bone graft. Trial reduction and assessment of the toe alignment. Fixation with two screws, one lag screw and dorsal plating, or dorsal plating only. Wound closure in layers. POSTOPERATIVE MANAGEMENT: Full weight bearing in a postoperative shoe or partial weight bearing in a short cast for 4-6 weeks. If the X-ray reveals sufficient bone healing, patients are allowed to wear sneakers with a stiff sole for 3-6 months. Sport activities with impact loading are limited for at least 3 months. Final X-ray control after 6 months. RESULTS: A total of 70 feet with a fusion of the first metatarsophalangeal joint were followed up after 28 months. Postoperative complications (7.3%): 5 wound slough, 1 infection, and 6 painful delayed union. Modified AOFAS forefoot score (max. 85 points) was 43 (32-58) points preoperatively and 82 (71-85) points postoperatively. Great toe alignment was perfect in 57 feet. Nine toes showed a valgus (> 20°) and 4 toes a varus malalignment. Fifty-four attained full ground contact. Eight patients reached the ground by flexion of the interphalangeal joint and 8 patients presented with dorsiflexion of the great toe. X-ray showed consolidation of the arthrodesis in 64 feet (91.4%), while 8 feet (4 with interposition of a bone graft) revealed signs of incomplete healing. These patients were advised to have an annual clinical and radiological reassessment performed.