Recurrent Hallux Rigidus: Options Other than Arthrodesis Gregory C Berlet, MD FRCS(C), FAOA Orthopedic Foot and Ankle Columbus, Ohio Columbus, Ohio orthofootankle.com Disclosures Consultant/Speaker Bureau/Royalties/ Stock: Wright Medical, Stryker, ZimmerBiomet, DJO, Plasmology 4, Amniox Medical, United Orthopedic Group, Paragon 28, CrossRoads, Ossio 55 year old Male Athletic, competitive Medical device sales Former patient who did very well with Brostom Wants the same magic for his toe 1
Non Surgical EBM Guidelines Grady et al (2002 ): Level III study 772 patients with symptomatic HR 428 (55%) were treated successfully with the use of an orthosis Grade C recommendation for use of modifications in footwear, insoles and orthotics Grady et al JAPMA 92(2), 2002 King et al Cureus epub Jan 2017 2
preop postop Short Term Results are Good Easley et al (1999): 57 patients, minimum 3-year follow-up AOFAS score improved from 45 to 85 90% satisfaction Dorsiflexion improved ~ 20 degrees Progression of grade of HR on xrays in >50% with time! Easley ME et al, FAI 20(3) 1999 Good But Not a Normal Joint Dorsal cheilectomy is effective in: Re-establishing symmetrical plantar pressure loading Increasing 1 st MTP dorsiflexion and abduction But resting posture is not normal with an average equinus posture of 10 0 May explain accelerated djd Nawoczenskiet al. FAI 29(3), 2008 3
Ok for 5 years and Now Pain Complication: Progression of Arthritis and Symptoms Hallux Rigidus: Grade 3 Grade Motion Pain X-rays 1 20-50% loss 2 50-75% loss 3 75-100% loss Mild at extremes Moderate; increasing at extremes Nearly constant; minimal mid ROM Dorsal spurs; minimal narrowing Spurs surrounding joint Narrowing cystic degeneration 4 100% loss Constant; all ROM painful Joint absent Coughlin M, Shurnas P. JBJS 2003 Nov;85-A(11) 4
Options For Grade III HR 1. Cheilectomy + osteotomy 2. Interposition arthroplasty i. Soft tissue allograft ii. Soft tissue autograft iii. Prosthetic vinyl implant 3. Arthrodesis Cheilectomy + Periarticular Osteotomies O Malley et al (2013): 81 patients with Grade III HR Cheilectomy + proximal phalangeal extension osteotomy ( Moberg) O Malley et al JBJS 95(7), 2013 Cheilectomy + Moberg Mean f/u of 4.3 years Sig increased DF: 32.7 0 to 59.7 0 No progressive IP arthritis on x-ray 85% satisfied 5% went onto an arthrodesis O Malley et al JBJS 95(7), 2013 5
Other Osteotomies Watermann Youngswick Valenti Head Decompression Osteotomy Complication: Avascular Necrosis 6
Systematic Review: 1 st Metatarsal Osteotomies for Hallux Rigidus Roukis (2010): Only 73% satisfaction rate 30.5% of patients developed post operative metatarsalgia or stress fractures routine use of periarticular osteotomies of the 1 st metatarsal for hallux rigidus should be performed with caution Roukis JFAS 49(6), 2010 7
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New Kid on the Block Interposition Arthroplasty using a Synthetic Polyvinyl Alcohol (PVA) implant ( Cartiva) Similar to articular cartilage in: H 2 O content Compressive modulus Tensile strength PVA Implant vs Arthrodesis Baumhauer et al (2015): Prospective randomized multi-center End Point: Pain, Function, Safety 152 Implant : 50 arthrodesis 24 month follow up Baumhauer et al FAI 37(5), 2016 9
PVA Implant vs Arthrodesis Results VAS, FAAM sports and activities of daily living subscores sig improved in both arthrodesis and PVA interposition Improvement of 6 0 of DF motion in PVA 9.2% implants converted to fusion Equivalent pain relief and functional outcomes to arthrodesis Baumhauer et al FAI 37(5), 2016 PVA Interposition Arthroplasty Daniels et al (2017): 5 year follow up with xray, clinical scores and validated scoring systems Active DF averaged 18.2 0 Sig improvement in clinical scores No implant related complications Daniels et al FAI 38(3), 2017 55 year old male Grade 3 10
Complications of PVA Conversion to fusion was less than 10%, at 2 years, in the Baumhauer prospective study No device related adverse events reported in the Daniels study Best results with HV < 20 0 and modest motion 11
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