Effect of joint pathology, surface preparation and fixation methods on union frequency after first metatarsophalangeal joint arthrodesis: A systematic review of the English literature.

BACKGROUND: The aim of this systematic review was to perform a qualitative synthesis of the current literature to determine the union frequencies for first metatarsophalangeal joint arthrodesis as well as the influence of pathology, joint preparation and fixation methods on union. METHODS: MEDLINE and EMBASE were searched to identify relevant studies reporting on first metatarsophalangeal joint union frequencies. RESULTS: 26 studies with 2059 feet met our inclusion criteria. The mean age was 60 years (range 18-84) and the mean follow-up was 32.6 months (range 1.5-156). The union frequency was 93.5% (1923/2059). The union frequencies were significantly higher when low velocity joint preparation methods were used (P<0.0001, Chi Square 22.5) and the pathology was hallux rigidus (P=0.002, Chi square 9.3). There were similarly high union frequencies with crossed screws, locking plate and non-locking plates. CONCLUSIONS: High union frequency can be expected following first metatarsophalangeal arthrodesis, especially when low velocity joint preparation methods are used in patients with hallux rigidus.

Effect of pathology on union of first metatarsophalangeal joint arthrodesis.

BACKGROUND: Arthrodesis is an established treatment for symptomatic degeneration of the first metatarsophalangeal (MP) joint. The published case series have often been small with different surgeons using a variety of joint preparation and fixation methods. The nonunion frequency comparing the different pathologies has not been described. We describe the senior author's results comparing the union of an MP arthrodesis in hallux valgus, hallux rigidus, inflammatory arthropathy, and salvage surgery with identical joint preparation and fixation methods. METHODS: The logbook of the senior author was used to identify the first MP joint arthrodeses from 2003 to 2011. The radiographic data were reviewed on the Picture Archiving and Communication system to assess the severity of deformity, radiographic union, type of fixation, and need for revision surgery. If there was no definite radiographic union of the last radiograph, the medical notes were reviewed. In all, 134 MP joint arthrodeses were performed in 78 females and 38 males, with a mean age of 65 ± 12 years (range, 20-94). Fixation was achieved by crossed screws (124) and dorsal plate (10). The primary diagnoses were hallux valgus in 49 joints (36.6%), hallux rigidus in 46 joints (34%), inflammatory arthropathy in 34 joints (25.4%), and salvage surgery in 5 joints (3.7%). RESULTS: The overall radiographic union rate was 91.8% (123/134). There were significantly more nonunions in the hallux valgus group (14.3% vs 0%, OR 16, P = .05). CONCLUSION: Biplanar cuts and crossed screw fixation gave similar union frequencies to published case series. Hallux valgus was associated with higher nonunion frequencies in this single surgeon series. It may be that the hallux valgus group needs a stronger construct to achieve comparable union frequencies to the hallux rigidus group. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Foot and ankle tuberculosis: case series and literature review.

Foot and ankle tuberculosis (TB) is a rare presentation of skeletal TB. The uncommon site along with low index of clinical suspicion in the western world leads to delays in the diagnosis and treatment. This can make joint sparing procedures less successful, especially in the midfoot where the joints can often be interconnected. Plain radiographs have low sensitivity and specificity and cross sectional imaging in the form of MRI or CT is more reliable. Treatment involves the use of multiple anti-tuberculous drugs in the first instance, followed by surgery to address any symptomatic deformity and/or secondary degenerative changes. We present our experience on the management of this rare problem and review the literature on the clinical presentation, diagnosis, imaging modalities and treatment.

Systematic review of proximal femoral arthroplasty for non-neoplastic conditions.

Proximal femoral arthroplasty (PFA) is an established treatment modality following oncological resection. Increasingly, these prostheses are being used for non-neoplastic conditions such as fractures and bone loss associated with septic or aseptic loosening. We performed a systematic review of the literature to determine the failure rates, mortality rates and hip outcome scores when PFAs were used in non-neoplastic conditions. There were 14 studies with an average follow-up of 3.8 years (range 0-14 years) describing 356 PFAs. Re-operation for any reason occurred in 23.8% (85/356) of cases. The most common complications were dislocation (15.7%) and infection (7.6%). The mortality rate ranged from 0% to 40%. PFA provides an acceptable surgical solution when confronted with massive bone loss, but it has a high re-operation rate for dislocation and infection.

Retrieval analysis of alumina ceramic-on-ceramic bearing couples.

BACKGROUND AND PURPOSE: Ceramic-on-ceramic (CoC) bearings have been in use in total hip replacement (THR) for more than 40 years, with excellent long-term survivorship. Although there have been several simulator studies describing the performance of these joints, there have only been a few retrieval analyses. The aim of this study was to investigate the wear patterns, the surface properties, and friction and lubrication regimes of explanted first-generation alumina bearings. MATERIALS AND METHODS: We studied 9 explanted CoC bearings from Autophor THRs that were revised for aseptic loosening after a mean of 16 (range 7-19) years. The 3D surface roughness profiles of the femoral heads and acetabular cups (Srms, Sa, and Ssk) were measured to determine the microscopic wear. The bearings were imaged using an atomic-force microscope in contact mode, to produce a topographical map of the surfaces of the femoral heads. Friction tests were performed on the bearing couples to determine the lubrication regime under which they were operating during the walking cycle. The diametral clearances were also measured. RESULTS: 3 femoral heads showed stripe wear and the remaining 6 bearings showed minimal wear. The femoral heads with stripe wear had significantly higher surface roughness than the minimally worn bearings (0.645 vs. 0.289, p = 0.04). High diametral clearances, higher than expected friction, and mixed/boundary lubrication regimes prevailed in these retrieved bearings. INTERPRETATION: Despite the less than ideal tribological factors, these first-generation CoC bearings still showed minimal wear in the long term compared to previous retrieval analyses.

A systematic review of endoprosthetic replacement for non-tumour indications around the knee joint.

BACKGROUND: Endoprosthetic replacement (EPR) for limb salvage is an established treatment modality for orthopaedic malignancies around the knee. Increasingly, they are being used for non-tumour indications such as fractures, bone loss associated with aseptic loosening, septic loosening and ligament insufficiencies. METHODS: We reviewed the evolution and biomechanics of knee EPRs. MEDLINE was searched using the PubMed interface to identify relevant studies pertaining to the use of knee EPRs in non-tumour conditions. Failures, mortality and knee scores were the main outcome measures. Subgroup analysis in the non-tumour conditions was also performed. RESULTS: There were nine studies with an average follow-up of 3.3years (Range 1-5years) describing 241 EPRs used in non-tumour conditions. Re-operation for any reason occurred in 17% (41/241) of cases. The most common complication was infection (15%) followed by aseptic loosening (5%) and periprosthetic fractures (5%). The mortality rate averaged 22%. Infected knee arthroplasties were less likely to have a successful outcome when salvaged with an EPR with failure rates up to 33%. CONCLUSIONS: Endoprosthetic replacement is a limb salvage option when other surgical options are unfeasible, especially in low demand elderly patients with limited life expectancy. They have low rates of failure in the medium term. LEVEL OF EVIDENCE: Level 1.