1. Functional Outcome Following First Metatarsalphalangeal Arthrodesis
27th Annual AOFAS Summer Meeting
July 14, 2011
Functional Outcome Following First Metatarsalphalangeal Arthrodesis

2. Alejandro E. Pino, MD Elizabeth Young, BS Lucas J. Bader, MD
Chloe Cheng, BS
Andrew J. Elliott, MD1
Matthew M. Roberts, MD
David S. Levine, MD
Jonathan T. Deland, MD2
Martin O’Malley, MD
1)Financial relationship with Bacterin )Financial relationship with Zimmer, Arthrex and Tornier

3. Introduction
First Metatarsophalangeal Joint (MTPJ) Arthrodesis offers reliable pain relief
Many accepted techniques
Stigma due to perceived functional limitation

4. Introduction Good functional outcomes described One technique
Single surgeon
Homogeneous patient population

5. Our Study Review functional outcomes after first MTPJ arthrodesis
Multiple surgeons
Different fixation techniques
Heterogeneous population

6. Hypothesis
Arthrodesis for the treatment of severe degeneration of the first MTPJ yields good functional outcomes regardless of fixation technique.
Principles of arthrodesis upheld

7. Methods HSS Dept of Foot/Ankle Surgery patient database CPT code
Five different surgeons

8. Methods
Pre/Postoperative FAOS, SF-12/36, activity/shoe wear specific questionnaire
Brodsky et al FAI 2005
Radiographic evaluation

9. Methods Subgroup analysis Arthrodesis technique Previous surgery
Cross screws versus Plate/lag screw
Previous surgery
Concomitant procedure

10. Inclusion
Failed conservative treatment
Minimum 1-year follow-up

11. Exclusion Concomitant lesser metatarsal head resections
Age less than 18

12. Demographics 51 patients (55 feet) M:F Average f/u 32 months (16-73)
Mean age 58.9 (42-74)
M:F
11:44
Average f/u 32 months (16-73)
67% Hallux Rigidus

13. Previous Procedures
22 patients

14. Fixation Technique Plate/lag screw Cross screw 32 Patients (34 Feet)
Isolated procedure

15. Concomitant Procedures

16. Results Preop Postop p-value SF score 69.9 (26.5-93) 79.5 (32.5-98.1)
0.0017
Sport*
58.2 (0-100)
77.6 (0-100)
0.0002
QOL*
38.2 (0-75)
75.2 ( )
<0.0001
Pain*
61.7 (25-100)
90.7 ( )
Symptoms*
61.6 ( )
86.6 ( )
Activity*
75.3 (25-100)
95.8 ( )
VAS (Pain)
5.5 (2-9)
2.5 (0-10)
*FAOS

17. Results 54% Denied shoe-wear limitations
89% Satisfied/highly satisfied

18. Functional Outcomes

19. Functional Outcomes

20. Radiographic Evaluation
82% Union rate
Plate/screw
Cross screw
p Value
Union
93%
62%
0.021
Satisfaction
85%
95%
ROH
14% 4%
screw younger than plate, equivalent outcome scores, of those not satisfied the majority c/o symptomatic plate/screw and c/o shoewear limitations.

21. Solitary Procedure Equivalent outcome scores Similar union rate
sol younger than mult, no difference in union rate, even b/w construct groups

22. Prior Procedure Equivalent outcome scores Union rate 90% vs 68%

23. Limitations Lack of standardization Concomitant procedures
Postoperative protocol
Technique
Concomitant procedures
calc bone graft 75% plate/screw 57% cross screw

24. Discussion Good functional results Rarely limits daily activities
In-line athletics
Concomitant/Previous procedures

25. Discussion Union rate Satisfaction rate Shoe wear limitations
Plate/screw vs Cross screw
Satisfaction rate
Shoe wear limitations
Difference in union rates did not affect outcome scores. difference in satisfaction b/w plate and cross 85% vs 95%. most unsatisfied pts c/o shoe wear limitations. half had complication (prominent hardware)

26. References
1. Baumhauer, JF; Nawoczenski, DA; DiGiovanni, BF; Wilding, GE: Reliability and validity of the American Orthopaedic Foot and Ankle Society Clinical Rating Scale: a pilot study for the hallux and lesser toes. Foot Ankle Int. 27: , Beertema, W; Draijer, WF; van Os, JJ; Pilot, P: A retrospective analysis of surgical treatment in patients with symptomatic hallux rigidus: long-term follow-up. J. Foot Ankle Surg. 45: , Bennett, GL; Sabetta, J: First metatarsalphalangeal joint arthrodesis: evaluation of plate and screw fixation. Foot Ankle Int. 30: , Bennett, GL; Kay, DB; Sabatta, J: First metatarsophalangeal joint arthrodesis: an evaluation of hardware failure. Foot Ankle Int. 26: , Brodsky, JW; Passmore, RN; Pollo, FE; Shabat, S: Functional outcome of arthrodesis of the first metatarsophalangeal joint using parallel screw fixation. Foot Ankle Int. 26: , Button, G; Pinney, S: A meta-analysis of outcome rating scales in foot and ankle surgery: is there a valid, reliable, and responsive system? Foot Ankle Int. 25: , Chen, L; Lyman, S; Do, H; Adam, S; Young, E; Deland, J; Ellis, S: Validation of the Foot and Ankle Outcome Score for Hallux Valgus. Hospital for Special Surgery Fellow Presentation, Coughlin, MJ; Shurnas, PS: Hallux rigidus. J. Bone Joint Surg. Am. 86-A Suppl 1: , Coughlin, MJ; Shurnas, PS: Hallux rigidus. Grading and long-term results of operative treatment. J. Bone Joint Surg. Am. 85-A: , 2003.

27. References
10. DeFrino, PF; Brodsky, JW; Pollo, FE; Crenshaw, SJ; Beischer, AD: First metatarsophalangeal arthrodesis: a clinical, pedobarographic and gait analysis study. Foot Ankle Int. 23: , Fuhrmann, RA: First metatarsophalangeal arthrodesis for hallux rigidus. Foot Ankle Clin. 16:1-12, Goucher, NR; Coughlin, MJ: Hallux metatarsophalangeal joint arthrodesis using dome-shaped reamers and dorsal plate fixation: a prospective study. Foot Ankle Int. 27: , Hope, M; Savva, N; Whitehouse, S; Elliot, R; Saxby, TS: Is it necessary to re-fuse a non-union of a Hallux metatarsophalangeal joint arthrodesis? Foot Ankle Int. 31: , Kumar, S; Pradhan, R; Rosenfeld, PF: First metatarsophalangeal arthrodesis using a dorsal plate and a compression screw. Foot Ankle Int. 31: , Poggio, D; de Retana, PF; Borda, D; Hortua, P; Asuncion, J; Rios, J: Analysis of the clinical score progressions during the first year after first MTPJ fusion. Foot Ankle Int. 31: , Raikin, SM; Ahmad, J; Pour, AE; Abidi, N: Comparison of arthrodesis and metallic hemiarthroplasty of the hallux metatarsophalangeal joint. J. Bone Joint Surg. Am. 89: , User's Manual for the SF-36v2 Health Survey, Second Edition, Chapter 3: van Doeselaar, DJ; Heesterbeek, PJ; Louwerens, JW; Swierstra, BA: Foot function after fusion of the first metatarsophalangeal joint. Foot Ankle Int. 31: , Womack, JW; Ishikawa, SN: First metatarsophalangeal arthrodesis. Foot Ankle Clin. 14:43-50, 2009.