The comparison analysis of resection interposition arthroplasty and implant arthroplasty in hallux rigidus surgery

Authors

Abstract

Aim Hallux rigidus is a condition characterized by pain and dorsiflexion limitation, which develops due to degenerative and progressive arthritis in the first metatarsophalangeal joint. This study aimed to evaluate the superiority of surgical techniques in the treatment of advanced-stage hallux rigidus patients.
Materials and Methods Study participants included 19 feet from 19 patients. Demographic information of the patients was collected. The first MTP joint ROM and the AOFAS scores were recorded. AOFAS and 1st MTP joint ROM obtained in both groups were statistically significant.
Results In patients who underwent IA and RIA, there was no significant difference in preop and postop 1st MTP joint flexion range of motion (p = 0.123, 0.072). Significant differences were observed in preop and postop 1st MTP joint extension motion in patients who underwent IA (p = 0.023) and in those who underwent RIA (p = 0.027). There was a significant difference in preop and postop AOFAS scores in patients who underwent both IA and RIA (p < 0.001, p = 0.003). There was no statistically significant difference between the two groups in postoperative values of AOFAS, MTP Flexion Angle, and MTP Extension Angle (p > 0.05)
Discussion The results of this study indicate a significant effect on postop extension angles and AOFAS scores in patients who underwent both IA and RIA. However, no statistically significant difference was found between the two operations in terms of postop 1st MTP joint flexion, postop 1st MTP joint extension, and postop AOFAS scores.

Keywords

Introduction

Hallux rigidus (HR) is a common condition affecting the first metatarsophalangeal joint, second only to hallux valgus [1]. HR is a condition characterized by pain, dorsiflexion limitation, and dorsal osteophytes, which develop due to degenerative and progressive arthritis in the first metatarsophalangeal (MTP) joint [2, 3]. It tends to occur at earlier ages compared to other arthropathies, and it is estimated to be present in approximately 2.5% of the adult population [4].
For normal walking, the big toe should be able to dorsiflex in the range of 65-75° at the MTP joint. In HR, due to reduced dorsiflexion, the front part of the foot limits supination during the stance phase, hindering push-off onto the toes. Consequently, the lateral part of the foot bears more weight, leading to transverse pain in the forefoot, termed metatarsalgia [5]. It is believed that cartilage damage leads to synovitis, and synovitis, in turn, causes more cartilage destruction, osteophyte formation, and subchondral bone damage. In HR, degenerative arthritis signs in the first MTP joint are typical in anterior- posterior plain radiographs. Notably, in addition to joint space narrowing, significant osteophyte formations are particularly evident on the lateral edge and dorsal aspect of the joint [6]. Surgery for HR varies depending on the patient’s age, activity level, and expectations of surgery, as there is no standardized procedure for all patients [1]. The goal of surgical treatment is to alleviate pain, increase mobility, prevent the development of arthritis, and correct deformities associated with HR. Soft tissue procedures may be applied in the early stages of HR surgery where radiological changes are not present and conservative treatment is unresponsive. In advanced cases of HR, procedures such as cheilectomy, Keller resection arthroplasty, RIA, arthrodesis, and IA can be chosen based on the patient’s expectations and activity level [5, 7, 8, 9]. Although there is evidence-based information available in the literature regarding these techniques, debates still persist about which technique is superior.
The Coughlin and Shurnas classification (CSC) system is employed to categorize various stages of hallux rigidus, a degenerative condition affecting the first MTP joint (big toe joint), resulting in stiffness and restricted motion. This classification aids surgeons and healthcare professionals in evaluating the severity of hallux rigidus and determining appropriate treatment approaches [10, 11].
This study compared the efficacy of two surgical procedures, IA and RIA, for treating advanced-stage HR based on the Coughlin and Shurnas Classification (CSC). Preoperative (preop) and postoperative (postop) outcomes, including the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and range of motion at the 1st MTP joint, were compared between IA and RIA.

Materials and Methods

A prospective study was conducted in the Department of Orthopaedics and Traumatology at Kırıkkale University Faculty of Medicine. In the study, patients ages 18 and older diagnosed with stage 3 or stage 4 HR according to the CSC were enrolled in the outpatient clinic of the Department of Orthopedics and Traumatology. For inclusion, patients had to be willing to undergo surgery and desire pain-free movement in the MTP joint. Each participant signed an informed consent form. Patients with hallux valgus or a history of hallux valgus surgery, those with an additional rheumatologic disease, individuals who have undergone surgery involving the 1st metatarsal, proximal phalanx, and 1st MTP joint, and those with generalized joint laxity and neuromuscular diseases were excluded from the study.
Demographic information of the patients, such as age and gender, was collected. Stage of HR according to the CSC was calculated using Anteroposterior and Lateral radiographic images. Patients’ preoperative 1st MTP range of motion was evaluated, and the AOFAS Ankle-Hindfoot Scores were calculated. Postop AOFAS scores were evaluated by the surgeon who performed the surgery. First MTP range of motion was measured by goniometry by the surgeon performing the study.
Surgical Procedure
RIA was performed supine under spinal or general anesthesia, with a tourniquet applied. A longitudinal incision was made through the dorsomedial aspect of the first MTP joint, passing through the skin and subcutaneous tissue. Preserving the sensory nerve and extensor hallucis longus tendon on the dorsomedial side, the capsule was opened to expose the base of the proximal phalanx and the metatarsal head. The extensor hallucis brevis tendon was released dorsally along with the joint capsule. Osteophytes on the metatarsal head were removed. A resection was performed on the proximal one-third of the base of the proximal phalanx, ensuring that it remained proximal to the attachment site of the flexor hallucis longus tendon on the base of the proximal phalanx. The joint capsule, along with the extensor hallucis brevis tendon, was sutured in the plantar region of the joint space, covering the metatarsal head. One Kirschner wire was sent intramedullary from the distal phalanx to the first metatarsal, and another Kirschner wire was sent from the proximal phalanx to the first metatarsal to prevent rotation (Figure 1). Subcutaneous and skin layers were closed. Implant Arthroplasty (IA) involves operating on patients in the supine position under spinal or general anesthesia, while a tourniquet is applied. A longitudinal incision was made through the dorsomedial aspect of the first metatarsophalangeal (MTP) joint, passing through the skin and subcutaneous tissue. Preserving the sensory nerve and extensor hallucis longus tendon on the dorsomedial side, the joint capsule was longitudinally opened. Following the technique of the used implant, joint surfaces, and medullary canals were prepared on both sides. The press-fit technique was used to fix the prosthesis. After the prostheses were placed, stability control was conducted, and absorbable sutures were used to repair the joint capsule (Figure 2). The subcutaneous and skin layers were then closed.
Postoperative Follow-up and Evaluation
The RIA group was mobilized without bearing weight with crutches for the first three weeks. At the end of the third week, in the clinic setting, Kirschner wires were removed, allowing full weight-bearing. Directly after the third week, active and passive resisted exercises to increase the range of motion in the 1st MTP joint were initiated.
In the IA group, passive joint movements were initiated on the second day postoperatively. Weight-bearing mobilization with a rigid rocker-soled shoe was allowed starting from the first week.
Patients in both groups were called for weekly follow-ups during the initial 3 weeks. After the first month, patients were scheduled for monthly check-ups. Joint range of motion measurements and AOFAS scores were conducted at 6 months for statistical evaluation. All patients were then scheduled for follow-up visits every 3 months after the sixth month.
Statistical Analysis
Statistical analyses were conducted using IBM SPSS Statistics for Windows, version 20.0 (IBM Corp.; Armonk, New York, USA). The normal distribution fit of the variables was assessed analytically using the Kolmogorov-Smirnov/Shapiro-Wilk tests. Descriptive analyses were provided, presenting means and standard deviations for normally distributed variables, while medians and interquartile ranges were utilized for non- normally distributed variables. The Mann-Whitney U test was employed for comparing non-normally distributed numerical variables between groups, and Fisher’s Exact test was used for comparing categorical variables between groups. To evaluate changes over time, the Wilcoxon test was applied. Spearman correlation analysis was conducted to assess relationships between variables. Results with a p-value below 0.05 were considered statistically significant.
Ethical Approval
This study was approved by the Ethics Committee of Kırıkkale University Non-Interventional Clinical Research (Date: 2015- 06-08, No: 15/2).

Results

Descriptive statistics about patients included in the study are provided in Table 1. The study included 19 patients, 14 of whom were female (73.6%). A total of 19 feet were examined since each patient participated in the study only with one foot. Fifteen patients (87%) had their right foot involved. IA group, on average, was 56.9 years old (range: 49-65), while the RIA group, on average, was 55.0 years old (range: 45-65). The ages of the patients in the RIA group and those in the IA group did not differ statistically significantly (p = 0.481). RIA and IA did not differ statistically significantly based on gender (p = 1.000). The feet of those who underwent RIA and those who underwent IA were also not statistically significantly different (p = 1.000).
There was no statistically significant difference between preoperative and postoperative MTP flexion angles in the IA group (p = 0.123). In the IA group, there was a statistically significant difference between preoperative and postoperative MTP extension angles (p = 0.023). The postoperative AOFAS in the IA group was statistically significantly different from the preoperative AOFAS in the IA group (p = 0.003) (Table 2).
There was no statistically significant difference between preoperative and postoperative MTP flexion angles in the RIA group (p = 0.072). In the RIA group, there was a statistically significant difference between preoperative and postoperative MTP extension angles (p = 0.027). The postoperative AOFAS in the RIA group were statistically significantly different from the preoperative AOFAS in the RIA group (p < 0.001) (Table 2). There was no statistically significant difference between the two groups in postoperative values of AOFAS, MTP Flexion Angle, and MTP Extension Angle (Table 3). During RIA arthroplasty in one patient, an intraoperative rupture of the extensor hallucis longus tendon occurred. Due to tendon repair, Kirschner wires were removed in the fourth week. The same patient developed an infection at the surgical site, and upon examination during wound debridement, it was observed that the extensor hallucis longus tendon had re-ruptured.
In the IA group, in two patients who underwent total prosthesis fixation using the Press-Fit technique, intraoperative fractures occurred. Patients with fractures were provided with postoperative passive joint range of motion exercises, avoiding weight-bearing for two weeks, and started partial weight- bearing mobilization from the third week.
In the IA group, during the follow-up of one patient, persistent pain complaints in the 1st MTP joint and aseptic implant loosening led to implant removal in the postoperative first year. Iliac crest bone graft was harvested, and a plate and screw system was used for the 1st MTP joint arthrodesis.

Discussion

HR is a disease with degenerative findings accompanied by joint movement limitation and pain, and whose etiology is comprised of trauma, metabolic and congenital diseases, and whose pathogenesis is not clearly known [1]. Cheliectomy, IUD, IA, and arthrodesis can be applied in the surgical treatment of HR [7, 8, 9].
RIA is a procedure applied in more advanced cases compared to cheilectomy. In a study conducted by Ozan F. et al. in 2010, RIA was performed on 18 patients with stage 3 and one patient with stage 4 hallux rigidus. According to 21-month follow-up results, a significant improvement was observed in postoperative total AOFAS scores as well as in the first MTPJ range of motion [12]. Hamilton et al. performed cheilectomy combined with resection of the proximal phalanx base and interposition arthroplasty (suturing the extensor hallucis brevis tendon to the flexor hallucis brevis tendon) in young and active patients with stage 3 hallux rigidus. They reported a significant increase in AOFAS scores in 94% of the cases [13]. In our study, we transferred the extensor hallucis brevis muscle along with the joint capsule to the metatarsal head. We considered that suturing the flexor hallucis brevis to the extensor hallucs brevis would increase the duration of surgery, require more extensive dissection, and raise the risk of infection. Similar to previous studies, we also observed significant improvements in AOFAS scores and first MTPJ range of motion.
Pain remains the primary indication for surgical intervention in patients with hallux rigidus. Reize et al. reported a postoperative pain relief rate of 83.3%, while Schenk et al. reported a rate of 95.4% [14]. Both studies also demonstrated significant improvements in total AOFAS and functional scores [15]. In our study, a noticeable reduction in pain was observed beginning at the 6-month postoperative follow-up. Although studies by Reize et al., Hamilton et al., and Kennedy et al. reported favorable outcomes, the absence of prospective design and control groups limited the strength of their findings, and thus, these studies do not constitute high-level clinical evidence [13, 14, 16]. In contrast, our study was designed as a randomized, prospective trial including a control group, thereby providing level I evidence. The results indicate that the success of Resection Interposition Arthroplasty (RIA) is at least comparable to that of implant arthroplasty. It is important to note that resections involving less than one-third of the base of the proximal phalanx may lead to insufficient decompression of the first metatarsophalangeal joint (MTPJ), whereas excessive resections may result in instability and dysfunction of the great toe [17]. In the study conducted by Ozan F. et al., a mean postoperative increase of 30.1 degrees in the first MTPJ range of motion was observed, and 84.2% of patients (16 feet) reported being very satisfied or satisfied with the surgical outcome [12]. Kennedy et al. applied RIA to 18 feet of 18 patients and reported that at the end of an average 38-month follow-up, 1. MTFE range of motion increased by 37° compared to preoperative levels, and pain disappeared in 16 patients [16]. In our study, a statistically significant improvement was observed between preoperative and postoperative metatarsophalangeal extension angles in patients who underwent RIA.
In their comparative study, Gibson and Thomson evaluated 30 patients who underwent total joint arthroplasty (TJA) and 34 patients treated with arthrodesis [17]. They assessed preoperative and postoperative AOFAS scores and first MTPJ range of motion. Among the 27 patients who received TJA (involving 34 feet), higher functional outcomes and AOFAS scores were observed. However, loosening of the proximal phalangeal component and the need for revision surgery were reported in this group. Additionally, the cost of TJA was found to be more than twice that of arthrodesis. Roukis and Townley compared 108 patients treated with TJA to a group who underwent periarticular osteotomy and hemiarthroplasty [18]. They reported a significant improvement in first MTPJ extension in the hemiarthroplasty group, but no significant difference in AOFAS scores or flexion range between the groups. In a study conducted by Raikin et al., hemiarthroplasty was compared with arthrodesis, and greater improvements in AOFAS scores were noted in the arthrodesis group [19]. Silicone joint replacements are not mechanically suited to withstand the stresses associated with ambulation. Failures due to wear, osteolysis, subchondral cyst formation, and foreign body reactions have been reported [20]. Although early outcomes of total joint arthroplasties using metal and silicone components or older generation endoprostheses limited to the proximal phalanx base have been favorable, long-term follow- ups have revealed complications such as soft tissue reactions, joint stiffness, subluxation, silicone synovitis, and osteolysis. These can ultimately lead to implant failure and poor functional results [21].
We observed a statistically significant improvement in first MTPJ extension postoperatively compared to preoperative values. However, no significant change was noted in the flexion range of motion. Additionally, patients demonstrated a significant increase in AOFAS scores following surgery when compared to their preoperative scores.
In patients who underwent total joint arthroplasty, implantation was performed using the press-fit technique. In patients who underwent IA, complications such as synovitis, reflex sympathetic dystrophy, implant loosening, osteolysis, subluxation, periprosthetic fracture, and infection have been reported in the literatüre [17, 22]. In two patients where the press-fit technique was applied, periprosthetic fractures occurred during metatarsal implantation. As a result, patients were mobilized with full weight-bearing starting from the second postoperative week. In one patient who underwent prosthesis implantation, implant loosening was observed at the end of the first year, and implant removal followed by arthrodesis with a tricortical bone graft taken from the iliac crest was performed. Reflex sympathetic dystrophy was not observed in the IA patients, as active and passive joint motion exercises were initiated on the first postoperative day, and patients were mobilized with full weight-bearing. No infections occurred, as patients received preoperative and postoperative prophylactic antibiotic treatment, and wound dressings were regularly performed.
Our study showed that both RIA and IA arthroplasty can be applied to patients in the treatment of hallux rigidus, and there is no significant difference between them.

Limitations

Several limitations must be acknowledged when interpreting the findings of this study. First, as it is a single-surgeon series, there is a potential source of bias, as surgical skill and experience may influence the outcomes. The main limitation of our study is the small sample size and the lack of long-term follow-up data. The presence of widely varying survival rates in the literature underscores the need for long-term studies to further assess these outcomes.

Conclusion

In conclusion, the results obtained from both RIA and IA demonstrate that the clinical and functional outcomes of these two techniques are similar. Both RIA and IA procedures were found to have a statistically significant positive impact on postoperative extension angles and AOFAS scores. However, no statistically significant differences were observed between the two procedures regarding postoperative MTFE flexion, postoperative MTFE extension, and postoperative AOFAS scores. Since no increase in the expected first MTF range of motion was achieved in patients undergoing RIA and IA, it was concluded that neither technique holds superiority over the other. However, while technique-related complications may occur with IA, both techniques appear to have a comparable rate of complications. In this regard, RIA emerges as a more cost-effective treatment option. However, further clinical studies with larger patient groups and longer follow-up periods will be required to determine the clinical and functional efficacy of these two methods and to assess the complication rates.

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