Hallux valgus and cartilage degeneration in the first metatarsophalangeal joint

Hllux vlgus nd crtilge degenertion in the first mettrsophlngel joint P. Bock, K.-H. Kristen, A. Kröner, A. Engel From the Dnue Hospitl, Vienn, Austri This study reltes the extent of crtilge lesions within the first mettrsophlngel joint to hllux vlgus. We prospectively exmined 265 first mettrsophlngel joints of 96 ptients with men ge of 54.2 yers t opertion for the existence of crtilge lesions. Grde I lesions were found in 4 feet (5.5%), grde II in 82 (3.9%), grde III in 5 (9.3%), grde IV in 2 (7.5%). Only 7 (26.8%) showed no crtilge lesion. Crtilge lesions were found within the mettrsosesmoid nd mettrsophlngel comprtments in 66 feet (34.%), within the mettrsophlngel comprtment in 26 (3.4%) nd within the mettrsosesmoid comprtment in 2 (52.6%). A sttisticlly significnt correltion ws found etween the grde of crtilge lesion nd the hllux vlgus ngle, oth for the chnges within the mettrsophlngel nd the mettrsosesmoid joints. P. Bock, MD, Resident K.-H. Kristen, MD, Consultnt A. Kröner, MD, Resident A. Engel, PhD, Hed of Deprtment Deprtment of Orthopedic Surgery, Donuspitl Wien, Lngordenstrsse 22, A- 22 Wien, Austri. Correspondence should e sent to Dr P. Bock. 24 British Editoril Society of Bone nd Joint Surgery doi:.32/3-62x.86b5. 4766 $2. J Bone Joint Surg [Br] 24;86-B:669-73. Received 3 July 23; Accepted fter revision 3 Decemer 23 Hllus vlgus is common. It consists of lterl devition of the hllux reltive to the first mettrsl nd progressive suluxtion of the first mettrsophlngel joint. 2 With progression of hllux vlgus, clinicl nd rdiologicl signs of osteorthritis develop due to the incresing incongruity of the joint surfces.,3 As the sesmoids remin in plce while the distl spect of the first mettrsl displces medilly with progressive deformity, the mettrsosesmoid joint lso shows incongruity. Crtilginous thinning nd erosion, joint spce nrrowing nd mrginl prolifertion of one occur. These crtilge lesions re often neglected. Crtilge lesions re well documented in vrious other joints of the lower extremity. 4 Osteorthritis of the first mettrsophlngel joint is usully relted to hllux rigidus. There re only few reports on crtilge degenertion in the first mettrsophlngel joint 4,5 without symptoms relted to hllux rigidus. Although osteorthritis hs een mentioned s contrindiction 2,6,7 to joint preserving surgicl procedures for the correction of hllux vlgus, no report hs een found of the incidence nd extent of crtilge lesions within the first mettrsophlngel joint. At opertion no ccount is tken of the intr-opertive grde of chondrl lesion. This is why we crried out this study. Ptients nd Methods We prospectively exmined 265 feet of 96 ptients who were witing surgicl correction of hllux vlgus etween 998 nd 2. The series included 239 feet of 78 women nd 26 feet of 8 men. The men ge t the time of surgery ws 54.2 yers (23 to 8). The symptoms were pin over the medil eminence nd pressure from footwer. Surgery ws proposed fter filure of dequte non-opertive tretment including wide shoes, inserts, orthoses nd non-steroidl nti-inflmmtory mediction. Every ptient ws ssessed with regrd to oth the hind- nd forefoot. The rnge of movement of the first mettrsophlngel joint ws mesured nd the ptients exmined for pin nd crepitus in the first mettrsophlngel nd mettrsosesmoid joints which indicte degenertive joint disese. All ptients with symptoms relted to hllux rigidus with reduced dorsiflexion were excluded. The rnge of movement of the first mettrsophlngel joint ws more thn 4 dorsiflexion in ll ptients. Exclusion criteri included ny prior surgery or trum to the first mettrsophlngel joint or foot, nd typicl symptoms of hllux rigidus such s pin with movement nd limited dorsiflexion, 8 peripherl vsculr disese nd metolic or endocrine disorders which could ffect the rticulr crtilge. VOL. 86-B, No. 5, JULY 24 669

67 P. BOCK, K.-H. KRISTEN, A. KRÖNER, A. ENGEL Pre-opertive nteroposterior nd lterl rdiogrphs of the feet were tken with the ptient weight-ering. The degree of rdiologicl osteorthritic chnge ws determined y single experienced rdiologist ccording to modified Kellgren-Lwrence scle 5 s follows: grde = norml; grde = mild osteophytic lipping, no sclerosis; grde 2 = moderte osteophytic lipping with or without osteophytic lipping; grde 3 = multiple osteophytic lipping, some sclerosis, nd possile deformity of one contour; grde 4 = severe osteophytes, sclerosis nd deformity of the ony contour. Mesurement of the lignment of the forefoot ws performed ccording to the guidelines ccepted y the Americn Orthopedic Foot nd Ankle Society. 9 The following rdiologicl criteri were ssessed: hllux vlgus ngle nd the ngle etween the first nd second mettrsls (intermettrsl ngle)., Joint preserving procedures were performed in ll ptients. A longitudinl midline skin incision ws mde on the medil side of the first mettrsophlngel joint. The joint cpsule nd the medil collterl ligment of the first mettrsophlngel joint were incised horizontlly nd the rticulr crtilge exposed. The crtilge lesions on the mettrsl hed were noted nd grded ccording to the Interntionl Crtilge Repir Society 2 (ICRS) s follows (Fig. ): grde = norml; grde I = nerly norml, superficil lesions, soft identtion nd/or superficil fissures nd crcks; grde II = norml, lesions extending down to <5% of crtilge depth; grde III = severely norml, crtilge defects extending down >5% of crtilge depth s well s down to the clcified lyer nd to ut not through the suchondrl one; grde IV = severely norml, crtilge defect extending through the suchondrl one. Three different zones were differentited: mettrsl hed rticulting with the proximl phlnx (mettrsophlngel comprtment), mettrsl hed rticulting with the medil sesmoid one nd mettrsl hed rticulting with the lterl sesmoid one (mettrsosesmoid comprtments). The medil nd lterl mettrsosesmoid joints together nd the mettrsophlngel comprtment ech contriuted 5% of the crtilge surfce. The dt were nlysed for correltion of grde nd loclistion of the crtilge lesion nd hllux vlgus ngle nd the first intermettrsl ngle y Spermn s correltion test, pired student s t-test nd liner regression (Sttview 5.5; SAS Institute Inc, Cry, North Crolin). The level of sttisticl significnce ws set t p <.5. Results The hllux vlgus ngle nd the men intermettrsl ngle ws 29.4 (5 to 6) nd 3.5 ( to 25) respectively preopertively. Of the 265 feet exmined for crtilge lesions, 7 (26.8%) did not hve ny lesion, 4 (5.5%) hd mximum grde I lesion, 82 (3.9%) mximum grde II lesion, 5 (9.3%) mximum grde III lesion nd 2 feet (7.5%) ICRS grde - norml ICRS grde I - nerly norml ICRS grde II - norml ICRS grde III - severely norml ICRS grde IV - severely norml Fig. Grding of crtilge lesion ccording to the Interntionl Crtilge Repir Society (reproduced with permission from the Interntionl Crtilge Repir Society). Grde norml; grde I nerly norml, superficil lesions ) soft indenttion nd/or ) superficil fissures or crcks; grde II norml, lesions extending down to <5% of crtilge depth; grde III severely norml. ) Crtilge defects extending down >5% of crtilge depth ) s well s down to clcified lyer c) down to ut not through the suchondrl one d) listers re included; grde IV severely norml. c d THE JOURNAL OF BONE AND JOINT SURGERY

HALLUX VALGUS AND CARTILAGE DEGENERATION IN THE FIRST METATARSOPHALANGEAL JOINT 67 8 6 4 2 7 4 82 5 Grde Grde I Grde II Grde III ICRS score 2 Grde IV ICRS score 3 2.5 2.5.5.6.43 2.3 2. 2.55 <25º 25º to 3º 3º to 35º 36º to 4º >4º Hllux vlgus ngle Fig. 2 Fig. 4 Grde of chondrl lesion t time of surgery ccording to ICRS score. Men grde of chondrl lesion ccording to the ICRS score for n incresing hllux vlgus ngle. ICRS index 4.5 4 3.5 3 2.5 2.5.5 -.5 5 2 25 3 35 4 45 5 55 6 65 Hllux vlgus ngle Y =,878 +,26 * X; R^2 =,3 2 8 6 4 2 88 57 9 Grde Grde I Grde II Grde III Grde IV Fig. 3 Fig. 5 Hllux vlgus ngle versus grde of crtilge lesion (ICRS score). As the hllux vlgus ngle increses the grde of crtilge lesion increses. A correltion coefficient of.3 quntifies this reltionship. Rdiologicl scoring of pre-opertive osteorthritis ccording to modified Kellgren-Lwrence scle (grde to grde IV). mximum grde IV lesion within one of the three comprtments (Fig. 2). In 93 feet (35.%) crtilge lesions were found on the hed of the first mettrsl within the mettrsophlngel comprtment, in 66 (62.6%) lesions were found on the mettrsl hed within the medil mettrsosesmoid comprtment nd in 55 (58.5%) they were on the mettrsl hed within the lterl mettrsosesmoid comprtment. In the mettrsosesmoid joint (7 feet), lesions were found concomitntly in the medil nd lterl sides in 5 feet (88.8%), medilly in 5 (8.8%) nd lterlly in four (2.4%). Of the 94 feet with crtilge lesions, 2 (52.6%) hd lesion within the mettrsosesmoid comprtment, 26 (3.4%) within the mettrsophlngel comprtment nd 66 (34.%) in oth zones. The men mximum grde of crtilge lesion did not show sttisticlly significnt difference in the three comprtments with men of 2.8 within the mettrsophlngel comprtment, 2.8 in the medil mettrsosesmoid comprtment nd 2.6 in the lterl mettrsosesmoid comprtment (p >.5). Spermn s correltion test showed sttisticlly significnt correltion etween the mximum chondrl lesion grde nd the hllux vlgus ngle (p <., r =.3) (Fig. 3). The higher the hllux vlgus ngle the higher the grde of crtilge lesion. If grdes of crtilge lesion of the different comprtments in one joint were dded, highly sttisticlly significnt correltion ws found for the sum of crtilge lesions nd the hllux vlgus ngle (p <., r =.47) nd for the intermettrsl ngle (p <., r =.75). For hllux vlgus ngle less thn 25 the men mximum grde of crtilge lesion ws.6,.43 for n ngle etween 25 nd 3 ; 2.3 for n ngle etween 3 nd 35 ; 2. for n ngle etween 36 nd 4 ; nd 2.55 for n ngle greter thn 4 (Figs 4 nd 5, Tle I). Rdiologicl exmintion ccording to modified Kellgren-Lwrence Scle 5 showed 88 feet (33.2%) t grde, (37.7%) t grde I, 57 (2.5%) t grde II, 9 (7.2%) VOL. 86-B, No. 5, JULY 24

672 P. BOCK, K.-H. KRISTEN, A. KRÖNER, A. ENGEL Tle I. Hllux vlgus ngle nd percentge of feet ffected y different grdes of chondrl lesion Hllus vlgus ngle < 25 25 to 3 3 to 35 36 to 4 > 4 grde 42 32. 7..3 4.5 grde I 2.7 2.3 8.4 24. 3.6 grde II 8.9 38.3 39. 24. 3.8 grde III 4.9 4.8 25.4 27.7 22.8 grde IV 2.5 2.5.2 3.8 27.3 2 5 5 44 Rdiologiclly underestimted Fig. 6 Equl Rdiologiclly overestimted Rdiologicl (Kellgren-Lwrence) versus intr-opertive (ICRS) score. t grde III nd (.4%) t grde IV (Fig. 5). Compred with the intr-opertive grding on the ICRS 2 score 44 feet (54.3%) hd lower rdiologicl thn intr-opertive score, 92 (34.7%) hd n equl score nd 29 (.%) higher rdiologicl thn intr-opertive score (Fig. 6). 92 29 Discussion Only 26% of ll joints did not show ny crtilge lesion within the joint, nd pproximtely 6% of ll feet reveled lesions of grde II or higher. Crtilge lesions of grde II nd III were the most frequent (Fig. 2). Unger et l 5 did not find ny mettrsl heds without crtilge lesion. There were 8.2% with grde I, 33.3% with grde II, 35.4% with grde III nd 3.% with grde IV lesions. They used similr clssifiction system to ours. These results re not directly comprle s Unger et l 5 performed cdver study nd the men ge, 73.6 yers for men nd 77.8 yers for women ws higher thn in this study. In ddition, these uthors did not specificlly ddress the prolem of hllux vlgus. A correltion etween the intermettrsl ngle nd the grde of crtilge lesion ws found in women ut the rdiologicl ssessment did not include stndrd rdiogrphs in weight-ering position. The sites of crtilge lesions within the joint were not recorded. 5 Our study demonstrtes cler tendency towrds crtilge lesions within the mettrsosesmoid comprtment of the first mettrsophlngel joint. Nerly two thirds of ll feet hd crtilge lesion within the mettrsosesmoid comprtment compred with more thn one third in the mettrsophlngel comprtment. The grde of crtilge lesions did not differ significntly. Most of the joints hd crtilge lesions within oth the medil nd lterl prts of the mettrsosesmoid comprtment. These findings indicte tht the lod pttern chnges within the first MTP joint, ffect the mettrsosesmoid comprtment, oth lterlly nd medilly, nd then the mettrsophlngel comprtment of the joint. The fct tht kinemtics re chnged within ll comprtments with hllux vlgus ws shown y Shereff et l. 3 They stted tht the mettrsophlngel joints of feet in hllux vlgus displyed irregulrities in the kinemtic pttern compred with norml joints. Both the grde of crtilge lesion within the mettrsophlngel nd the mettrsosesmoid comprtments were positively correlted with n increse of the hllux vlgus ngle. Thus, the proility of crtilge lesions within the first mettrsophlngel joint ecomes higher with n incresing hllux vlgus ngle. Different crtilge chrcteristics do not seem to ply mjor role in reltion to where chondrl lesions will develop. Athnsiou et l 4 did not find mismtch in the mechnicl properties of the crtilge surfce of the different zones within the first mettrsophlngel joint. The pre-opertive rdiologicl exmintion underestimted the grde of chondrl lesion in more thn 5% of ll feet. The mettrsosesmoid comprtment ws difficult to ssess. Mny surgeons thus choose their opertion ccording to the degree of rdiologicl degenertion without knowing the exct extent of the degenertive chnges. Osteorthritis within the first mettrsophlngel joint is considered contrindiction to joint preserving surgicl procedures. 2,6,7 There hs not een report which grded the crtilge lesions within the first MTP joint in hllux vlgus or stted to wht extent crtilge lesions cn e ccepted when performing joint preserving surgery for the correction of hllux vlgus. Mnn, Rudicel nd Grves 5 reported tht in 8 feet (74%) of their series no osteorthritis ws dignosed pre-opertively. He does not give ny informtion out the remining joints. Until now no correltion hs een drwn etween the extent of crtilge lesion nd the possile influence on the outcome of hllux vlgus surgery. Therefore it is importnt to hve n ide of the incidence of crtilge defects in order to evlute its influence. Kristen et l 6 descried correltion etween higher pre-opertive hllux vlgus ngle nd the post-opertive Kitok et l 7 score. The higher the preopertive hllux vlgus ngle, the lower the post-opertive score. The uthors could not give ny explntion for this trend. The nswer to this question might lie with the higher proility for crtilge lesions with greter hllux vlgus ngle, s shown in this study, or higher ge rnge nd thus worse post-opertive result. Further studies re required for clrifiction. There were more crtilge lesions within the mettrsosesmoid comprtment thn within the mettrsophlngel comprtment. The degree nd extent of crtilge lesions re clerly correlted with the degree of hllux vlgus ngle proving tht mlligned joint is more prone to crtilge degenertion. THE JOURNAL OF BONE AND JOINT SURGERY

HALLUX VALGUS AND CARTILAGE DEGENERATION IN THE FIRST METATARSOPHALANGEAL JOINT 673 These results provide further evidence of possile effect of crtilge degenertion on the outcome of hllux vlgus surgery. The effects of mettrsl osteotomy on the first mettrsophlngel joint my e similr to those of tiil osteotomy on the knee. No enefits in ny form hve een received or will e received from ny commercil prty relted directly or indirectly to the suject of this rticle. References. Jhss MH. The dult foot. In: Jhnss MH, ed. Disorders of the foot nd nkle: medicl nd surgicl mngement. 2nd edition, Vol 2. Phildelphi: W.B. Sunders Compny, 99:943-74. 2. Coughlin MJ. Hllux vlgus. J Bone Joint Surg [Am] 996;78-A:932-66. 3. Weingeld SB, Schon LC. Hllux mettrsophlngel rthritis. Clin Orthop 998; 349:9-9. 4. Muehlemnn C, Breither D, Huch K, Cole AA, Kuether KE. Prevlence of degenertive morphologicl chnges in the joints of the lower extremity. Osteorthritis crtilge 997;5:23-37. 5. Unger K, Rhimi F, Breither D, Muehlemn C. The reltionship etween rticulr crtilge degenertion nd one chnges of the first mettrsophlngel joint. J Foot Ankle Surg 2;39:24-32. 6. Wülker N. Hllux vlgus. Orthopede 997;26:654-64. 7. Mnn RA. Decision-mking in union surgery. Instr Course Lect 99;39:3-3. 8. Shereff MJ, Bumhuer JF. Hllux rigidus nd osteorthrosis of the first mettrsophlngel joint. J Bone Joint Surg [Am] 998;8-A:898-98. 9. Smith RW, Reynolds JC, Stewrd MJ. Hllux vlgus ssessment: report of reserch committee of Americn Foot nd Ankle Society. Foot Ankle 984;5:92-3.. Schneider W, Knhr K. Mettrsophlngel nd intermettrsl ngle: different vlues nd interprettion of postopertive results dependent on the technique of mesurement. Foot Ankle Int 998;9:532-6.. Mitchell CL, Fleming JL, Allen R, Glenney C, Snford GA. Osteotomy-unionectomy for hllux vlgus. J Bone Joint Surg [Am] 958;4-A:4-6. 2. Interntionl Crtilge Reserch Society. The crtilge stndrd evlution form. Spring Newsletter 998. 3. Shereff MJ, Bejjni FJ, Kummer FJ. Kinemtics of the first mettrsophlngel joint. J Bone Joint Surg [Am] 986;68-A:392-8. 4. Athnsiou KA, Liu GT, Lvery LA, Lnctot DR, Schenck RC. Biomechnicl topogrphy of humn rticulr crtilge in the first mettrsophlngel joint. Clin Orthop 998;348:269-8. 5. Mnn RA, Rudicel S, Grves SC. Repir of hllux vlgus with distl soft-tissue procedure nd proximl mettrsl osteotomy: long-term follow-up. J Bone Joint Surg [Am] 992;74-A:24-9. 6. Kristen KH, Berger C, Stelzig S, et l. The SCARF osteotomy for the correction of hllux vlgus deformities. Foot Ankle Int 22;23:22-9. 7. Kitok HB, Alexnder IJ, Adelr RS, et l. Clinicl rting systems for nklehindfoot, midfoot, hllux, nd lesser toes. Foot Ankle Int 994;5:349-53. VOL. 86-B, No. 5, JULY 24