SLR - August 2014 - Craig Costa

Comparison of Arthrodesis, Resurfacing Hemiarthroplasty, and Total Joint Replacement in the Treatment of Advanced Hallux Rigidus

Reference: Erdil M, Elmadag NM, Polat G, Tuncer N, Bilsel K, Ucan V, Erkocak OF, Sen C. Comparison of Arthrodesis, Resurfacing Hemiarthroplasty, and Total Joint Replacement in the Treatment of Advanced Hallux Rigidus. Journal of Foot and Ankle Surgery, 52(5): 588-592 2014.

Scientific Literature Review

Reviewed By: Craig Costa, DPM
Residency Program: Hoboken University Medical Center, Hoboken, NJ

Podiatric Relevance: Hallux Limitus/ Rigidus is a common degenerative disease affecting the first metatarsophalangeal joint. The current understanding as to the pathology is not clearly defined, but many causative factors contribute to it including improper shoe gear, long first metatarsal, repetitive micro trauma, and acute trauma. This study reports a comparison of three surgical treatments and functionality of procedures for late stage Hallux rigidus.

Methods: The study design was a retrospective analysis of 38 patients operated on for Grade 3 and 4 Hallux Rigidus. Patients were separated into three groups: 12 patients in Total Joint Replacement (group A), 14 Metatarsal head resurfacing hemiarthroplasty (group B), and 12 MTPJ arthrodesis (group C). Exclusion criteria included pre-operative deformity of hallux valgus, pes planus, pes cavus, pre-existing instability of a lessor MTPJ, inflammatory arthritis, post-infectious arthritis and Charcot neuropathy. Twenty-seven patients were female and eleven were male with a mean age of 59 years. Operative technique involved a dorsal approach to expose the first tarsometatarsal joint. In all groups a tourniquet and prophylactic antibiotic was used. For the total joint implant group, a TOEFIT-PLUS implant was inserted into the proximal phalanx and first metatarsal head. In the metatarsal head resurfacing and hemiarthroplasty group, a Hemi-CAP implant was impacted in the first metatarsal head. The arthrodesis group technique included removal of the articular cartilage from both proximal phalanx and first metatarsal head to flat surface and then two crossing headless fully-threaded compression screws across first metatarsophalangeal joint. Postoperative treatment for all three surgical groups included CAM boot and partial weight bearing with crutches. In the total joint implant and hemi-implant with resurfacing groups, passive ROM exercises were begun early in post-op period and active ROM exercises started after removal of sutures.

Results: The change in score for AOFAS-HMI in group A was 45.42 to 92.67, group B was 38.41 to 86.14, and group C was 33.58 to 76.08 (p < 0.001). In group C the first MPJ arthrodesis AOFAS- HMI score was significantly lower than group A and B (p<0.05) due to loss of 1st MPJ motion. VAS score decreased in all groups (p<0.05), VAS scores were noted to be significantly lower in group C (MPJ arthrodesis) compared to Group A (TJR) (p=0.002) and group B (Hemiarthroplasty) (p=0.018). No statistical difference was
noted between Group A and B (p=0.307).

Conclusions: The authors concluded that all three surgical interventions provided good relief of pain and an increase in patient functional assessment. The authors stressed each surgical intervention can be effective for late stage Hallux Rigidus. These procedures all improved functionality and pain levels in patients receiving total joint replacement and resurfacing with hemiarthroplasty having improved range of motion at the 1st MPJ compared to arthrodesis. This study was limited by its short follow-up period, small sample size, and its retrospective nature. The authors cite multiple authors (Carpenter et al, Hasselmann and Shields) to support their conclusion that all three surgical procedures provide strong relief. There are previous studies by Raikin et al comparing arthrodesis and hemiarthroplasty and reporting better results with arthrodesis of 1st MPJ. Longer follow up and more studies are needed comparing these three methods as two of the procedures main complication is failure. 

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