Proposed treatment algorithm for hallux rigidus

This study performs a literature review on the treatment of hallux rigidus and proposes a treatment algorithm.This literature systematic review expanded a similar study conducted in 2014 by the authors and analyzed the levels of recommendation according to scientific evidence.Most articles found in the search present scarce evidence (level IV or case series), we only found 8 articles with an at least moderate level of recommendation (B); of these, only one article had a level of evidence I.Conservative treatment is effective with the implementation of footwear modifications, use of insoles, and infiltrations with hyaluronic acid. Cheilectomy, either isolated or combined with Moberg osteotomy, shows good outcomes in stage III, or moderate, although its outcomes worsen after 5 years. Metatarsophalangeal joint (MTPJ) arthrodesis is still the gold standard in stage IV, or advanced. In recent years, the technique of interposition arthroplasty has re-emerged, especially with the use of a synthetic cartilage implant (Cartiva®), with outcomes at least similar to those of MTPJ arthrodesis in comparative studies. Level of Evidence III; Therapeutic Studies; Systematic Review of Level III Studies.

Interposition Arthroplasty in the Treatment of End-Stage Hallux Rigidus: A Systematic Review

Purpose Patients affected by moderate to severe hallux rigidus may opt for interposition arthroplasty to avoid the movement restrictions of arthrodesis and the complications related to prosthetic replacement. The propose of this article was to review the current literature about interposition arthroplasty to examine the overall outcomes and to evaluate the advantages and disadvantages of different types of technique, compared with more consolidated procedures. Methods A literature PubMed search was performed. Studies reporting the results of interposition arthroplasty in moderate to severe hallux rigidus were included. The data were pooled and weighted for number of patients in every study. Results The overall results for interposition arthroplasties are comparable to other alternatives for end-stage hallux rigidus, providing better plantar load distribution than arthrodesis and avoiding the drawbacks of prosthetic replacement. Among the various interposition arthroplasty techniques, the Modified Oblique Keller Capsular Interposition Arthroplasty technique preserves toe length and flexor hallucis brevis function, showing the highest satisfaction rate, with lowest metatarsalgia and revision rate. Conclusion Although long-term randomized controlled trials are lacking for interposition arthroplasty, it represents a valid alternative for the treatment of end-stage hallux rigidus also in the young active patient who wants to avoid a definitive intervention immediately. Level of evidence III (systematic review of level III-IV-V studies)

Poor Patient-Reported Outcomes following Surgical Treatment of Eaton Grade 1 Osteoarthritis of the Thumb Carpometacarpal Joint

Background Osteoarthritis of the thumb carpometacarpal joint (CMC-1 OA) is increasingly common with age. Conservative treatment with anti-inflammatory medication, thumb spica splinting, and steroid injection is recommended for early-stage OA, but some patients will continue to have refractory symptoms and surgery may be considered. We found it interesting to study outcomes of surgical treatment of cases with mild radiographic changes and yet symptoms severe enough to indicate surgery. The specific research question is, if there is a limit of radiographic changes, below which a poor patient-reported outcome (PRO) can be expected. Purpose In a retrospective cohort of patients with prospectively collected PROs, we intend to study the effect of the radiographic CMC-1 OA severity on the PRO improvement and satisfaction after interposition arthroplasty. Patients and Methods Radiographs of 347 patients, who had CMC-1 surgery, were retrospectively analyzed. Each rater independently assessed all radiographs classifying each according to the Eaton classification. All patients had surgery with CMC-1 interposition arthroplasty using three well-known techniques that all include a complete trapeziectomy. Comparison between stage 1 and stage 2–4 was done using Chi-square test and t-test. Results Patients with Eaton stage 1 had a mean improvement in Quick-DASH (Quick-Disability of the Arm, Shoulder, and Hand questionnaire) scores of 14.6 points. Patients with Eaton stage 2 to 4 had a mean improvement of 25.3 points. The difference between these two groups was 10.6 points (p = 0.009). Only 52% of patients with Eaton stage 1 OA were satisfied. However, 76% of patients with Eaton stage 2 to 4 were satisfied (p = 0.008, chi-square between stage 1 and stage 2–4). Conclusion Patients with Eaton stage 1 CMC-1 OA had poorer PROs, as compared with more advanced stages of OA, 6 months following surgical treatment with interposition arthroplasty. Based on our results, we advise against surgical treatment with interposition arthroplasty of the very mildest CMC-1 OA, regardless of the preoperative PROs.

INTERPOSITION-ARTHROPLASTY OF THE ELBOW: SYSTEMATIC REVIEW

ABSTRACT Objective: To perform a systematic review of the main methods and indications of interposition arthroplasty in the rigid elbow. Methods: The research was carried out by three independent researchers, in the databases PubMed, Medline and Embase, according to the descriptors selected as a research strategy and filters selected in the inclusion criteria. Results: In total, 21 studies were found with the afore mentioned descriptors and which were considered adequate according to the design and relevance according to the type of study and inclusion filters. There was a very strong correlation between the searches of the three researchers (k = 0.809). At the end, 14 complete studies were presented, all of which were included. Conclusion: The main finding of this study was to note that there is an evident lack of research with a high level of real effectiveness and indication for interposition arthroplasty in the rigid elbow. Most studies point to positive results when the patient is young and a total arthroplasty is not indicated. No meta-analysis or randomized clinical trial was found for this specific topic, despite being a technique applied in clinical practice for some decades and showing good results. Level of Evidence V, Systematic Review.