SLR - August 2018 - Benjamin M. Kamel

Clinical Outcome Following Total Joint Replacement and Arthrodesis for Hallux Rigidus

Reference: Stevens J, de Bot RTAL, Hermus JPS, van Rhijn LW, Witlox AM. Clinical Outcomes Following Total Joint Replacement and Arthrodesis for Hallux Rigidus: A Systematic Review. JBJS Rev. 2017 Nov 14. doi: 10.2106/JBJS.RVW.17.00032

Scientific Literature Review

Reviewed By: Benjamin M. Kamel, DPM
Residency Program: Chino Valley Medical Center, Chino, CA

Podiatric Relevance:
Hallux rigidus is among one of the most common foot pathologies seen by a podiatric surgeon. There are a number of operations that have been proposed to provide successful clinical outcomes for patients experiencing hallux rigidus, such as cheilectomy, osteotomy, arthrodesis, implants, resection and interpositional arthroplasty. Two common approaches are total joint replacement and arthrodesis. Many studies have been published comparing the two approaches and their effects on clinical outcomes, fusion rates and patient satisfaction. This article was primarily designed to research which procedure was superior in terms of improved clinical outcomes and decreased patient pain and secondarily for which procedure had lower complications and revision rates. No hypothesis was clearly stated by the authors.

Methods: A Level IV systematic review of the PubMed/MEDLINE, Embase and Cochrane Library was conducted for studies assessing numerous outcomes scores, complications and revision rates. Two unidentified reviewers performed the screening of titles and abstracts, data collection, data extraction and study quality assessment independently. The PRISMA flow diagram of the study selection procedure was utilized. Study quality was determined with the use of risk-of-bias tools. Inclusion and exclusion criteria were determined by the participants, interventions, comparators, outcomes, timing and study design (PICOTS) framework. Results of included studies were presented in a qualitative manner, and the results of high-quality studies were pooled.

Results: Thirty-three studies out of an initial 1,309 studies, describing a total of 741 arthrodeses and 555 total joint replacements, were included in the qualitative analysis. Six different prostheses were used for total joint replacement, and various fixation techniques were used for arthrodesis. The results of 12 studies for total joint replacements and arthrodeses were pooled in the quantitative analysis. Pooled results showed superiority of arthrodesis compared with total joint replacement for improving clinical outcome (43.8 vs. 37.7 points on the AOFAS-HMI score) and reducing pain (a decrease of 6.56 vs. 4.65 points on the VAS pain score). The researchers were unable to make any comparisons of the FFI and SF-36 scores due to limited utilization in the selected studies. Fewer intervention-related complications (23.1 percent vs. 26.3 percent) and revisions (3.9 percent vs. 11 percent) were reported after arthrodesis as compared with total joint replacement, with nonunion and prosthetic loosening being the most commonly reported complications after arthrodesis and total joint replacement, respectively.

Conclusions: The authors of this systematic review indicated that arthrodesis is superior for improving clinical outcome and reducing pain, with less complications and revision rates, compared with total joint replacement in patients with symptomatic hallux rigidus. One of the major limitations of this study was that most of the 33 selected articles were retrospective cohort studies or case series, which are more prone to bias. This is the first systematic review on this topic, and although there are flaws, it still adds value. Other than the use of mostly retrospective cohort studies, this article had a quality design and provides information that may be of benefit to healthcare providers. A high-quality prospective randomized trial is needed to strengthen the conclusions of this study. 

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