Author(s): N. Böhler, Gerold Labek (auth.), Prof. Dr. George Bentley (eds.) Series: European Federation of National Associations of Orthopaedics and Traumatology 9 Publisher: SpringerVerlag Berlin Heidelberg, Year: 2009 ISBN: 9783642009655,9783642009662 Description: The individual lectures on orthopaedics and trauma topics collected in this book range from fractures of the cervical spine to the treatment of club foot in children. They contain essential information for trainees and the latest information on the developments in the field. Các bài giảng riêng lẻ về các chủ đề chấn thương và chỉnh hình được thu thập trong cuốn sách này bao gồm từ gãy xương cột sống cổ đến điều trị tật bàn chân ở trẻ em. Chúng chứa thông tin cần thiết cho các học viên và thông tin mới nhất về những phát triển trong lĩnh vực này.
EFORT IL Book Vol · 2009 European Instructional Lectures 10th EFORT Congress Vienna, Austria Edited by George Bentley (UK) 23 European Federation of National Associations of Orthopaedics and Traumatology European Instructional Lectures Volume 2009 European Federation of National Associations of Orthopaedics and Traumatology Committees and Task Forces EFORT Executive Committee Standing Committees EAR Committee Executive Board Prof Dr Karl-Gưran Thorngren, President Prof Dr Miklós Szendrői, Vice President Dr Manuel Cassiano Neves, Secretary General Prof Dr Wolfhart Puhl, Immediate Past President Mr Stephen R Cannon, Treasurer Prof Dr Enric Caceres Palou, Member at Large Prof Dr Pierre Hoffmeyer, Member at Large Prof Dr Maurilio Marcacci, Member at Large Co-Opted Members Mr John Albert Prof Dr Thierry Bégué Prof Dr George Bentley, Past President Prof Dr Nikolaus Böhler, Past President Dr Karsten Dreinhöfer Dr Roberto Giacometti Ceroni Prof Dr Klaus-Peter Günther Ass Prof Dr Per Kjaersgaard-Andersen Prof Dr Karl Knahr Scientific Coordination 10th EFORT Congress, Vienna 2009 Chairman Prof Dr Pierre Hoffmeyer Members Prof Dr George Bentley Prof Dr Nikolaus Böhler Prof Dr Enric Caceres Palou Mr Stephen R Cannon Dr Manuel Cassiano Neves Prof Dr Alfred Engel Prof Dr Roberto Giacometti Ceroni Prof Dr Martti Hämäläinen Prof Dr Karl Knahr Prof Dr Philippe Neyret Prof Dr Miklós Szendrői Prof Dr Nikolaus Böhler, Dr Gerold Labek Education Committee Prof Dr Enric Caceres Palou EIL Committee Prof Dr Wolfhart Puhl, Prof Dr Karl-Göran Thorngren Events Committee Dr Manuel Cassiano Neves Finance Committee Mr Stephen R Cannon, Prof Dr Pierre-Paul Casteleyn Health Service Research Committee Dr Karsten Dreinhöfer Portal Steering Committee Prof Dr Klaus-Peter Günther Publishing Committee Prof Dr George Bentley (Books), Prof Dr Klaus-Peter Günther (Portal), Prof Dr Wolfhart Puhl (Journal) Scientific Committee Prof Dr Pierre Hoffmeyer Venue Committee Prof Dr Miklós Szendrői Task Forces and Ad Hoc Committees Awards & Prizes Committee Prof Dr George Bentley Fora Prof Dr Thierry Bégué Liaison & Lobbying Committee Prof Dr Wolfhart Puhl Speciality Societies Committee Dr Roberto Giacometti Ceroni Travelling & Visiting Fellowships Prof Dr Maurilio Marcacci European Federation of National Associations of Orthopaedics and Traumatology European Instructional Lectures Volume 9, 2009 10th EFORT Congress, Vienna, Austria Edited by George Bentley Editor: Prof Dr George Bentley Royal National Orthopaedic Hospital Trust Stanmore, Middlesex HA 4LP, UK profgbentley@talktalk.net EFORT Central Office Technoparkstrasse 8005 Zürich, Switzerland www.efort.org ISBN: 978-3-642-00965-5 e-ISBN: 978-3-642-00966-2 DOI: 10.1007/978-3-642-00966-2 Springer Dordrecht Heidelberg London New York Library of Congress Control Number: 2009926014 © EFORT 2009 This work is subject to copyright All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer Violations are liable to prosecution under the German Copyright Law The use of general descriptive names, registered names, trademarks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book In every individual case the user must check such information by consulting the relevant literature Cover design: Frido Steinen-Broo, eStudio Calamar, Spain Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Foreword The 10th Congress of the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) is the most important combined congress of the national societies in Europe At present a total of 36 societies are members of this organisation The major goal of EFORT is to bring current knowledge of diseases and trauma of the musculoskeletal system to all European surgeons and additionally to welcome colleagues from all over the world to join us in sharing our daily work experience In the scientific programme the instructional lectures form a very basic and important part of the Congress In Vienna a total of 25 sessions are included in the programme The authors come from all over Europe and they discuss topics from many different fields of trauma and orthopaedics These lectures not only give the opportunity for us to be informed about various diseases, but they are also influenced by the authors’ experience based on the treatment philosophy in their own country – again an opportunity to widen the European horizon They are aimed at both the general orthopaedic surgeons and the young residents and trainees who want to widen their knowledge in different topics of orthopaedic and trauma surgery As the chairman of the Local Organising Committee I thank all the authors for providing their presentation for publication in this volume I also address my special thanks to Professor George Bentley for organising this edition I am confident that this book will have the same respected place in the library of the participating orthopaedic surgeons as all the previous ones Vienna, Austria Karl Knahr v Preface This is the 9th volume of the European Instructional Lectures, which contains more new material, which will be presented during the 10th EFORT Congress in Vienna by distinguished authors from across Europe As in former volumes the chapters cover a range of topics, concentrating on both the essentials of the subjects and the latest thinking and technology Additionally, the authors are from different countries and centres, which reflect the variety of modern European orthopaedic and traumatology practice and their special experience and philosophy Special thanks are due to these authors who have been called upon to other tasks, such as paper reviewing and chairing Specialist Symposia and Free Paper sessions, and all of them have responded generously Without this spirit of collaboration by our colleagues in the National and Specialty Societies, EFORT would not flourish The preparation and printing of this volume was by the Internationally-recognised Springer team, enthusiastically led by Gabriele Schroeder, to whom we are very grateful I wish also to thank Larissa Welti, Régine Brühweiler, Sabrina Wolf and the EFORT Central Office for their unfailing support EFORT has now exceeded 220 essays in the volumes of Instructional Lectures since the series first began at the opening Congress in Paris in 1993 With this in mind we wish to dedicate this volume to the memory of the life and work of our dear colleague Professor Frantz Langlais, tragically and prematurely taken from us in 2007 Stanmore, UK George Bentley vii Contents General Orthopaedics Current Status of Arthroplasty Registers in Europe N Böhler and Gerold Labek National Registration of Hip Fractures in Sweden Karl-Göran Thorngren 11 Current Status of Articular Cartilage Repair Emmanuel Thienpont 19 Thromboprophylaxis After Major Orthopaedic Surgery: State of the Art Alexander G.G Turpie 29 Paediatrics DDH: Diagnosis and Treatment Strategies R Graf 41 Slipped Capital Femoral Epiphysis C Zilkens, M Jäger, Y-J Kim, M.B Millis, and R Krauspe 47 Major Joint Contractures in Children Deborah M Eastwood 61 Trauma Damage-Control Orthopaedic Surgery in Polytrauma: Influence on the Clinical Course and Its Pathogenetic Background Hans-Christoph Pape 67 Fractures and Non-Unions of the Clavicle Patrick Simon 75 Proximal Humeral Fractures C Torrens 81 Fixation of Intertrochanteric Femoral Fractures Vilmos Vécsei and Stefan Hajdu 91 Surgical Management of Distal Tibial Fractures in Adults Mathieu Assal and Richard Stern 97 ix x Contents Upper Limb and Hand The Distal Radio-Ulnar Joint: Functional Anatomy, Biomechanics, Instability and Management Panayotis N Soucacos and Nickolaos A Darlis 115 Distal Radius Fractures: Evolution in the Treatment Standard of Care 2009 Antonio Abramo and Philippe Kopylov 125 Dupuytren’s Contracture Hanno Millesi 137 Spine Low Back Pain R Eyb and G Grabmeier 155 Hip Total Hip Arthroplasty: A Comparison of Current Approaches Martin Krismer 163 How to Do a Cemented Total Hip Arthroplasty Eduardo Garcia-Cimbrelo 177 How to Do a Cementless Hip Arthroplasty Klaus-Peter Günther, Firas Al-Dabouby, and Peter Bernstein 189 Knee How to Treat a Meniscal Lesion? Olivier Charrois and The GREC Group 205 Soft-Tissue Balance in Total Knee Arthroplasty David E Beverland 213 Revision Total Knee Arthroplasty with Bone Loss Josef Hochreiter and Karl Knahr 219 Foot and Ankle Ankle Arthritis X Crevoisier 227 Hallux Rigidus: Arthroplasty or Not? S Giannini, F Vannini, R Bevoni, and D Francesconi 239 Contributors Preface Antonio Abramo Hand and Upper Extremity Unit, Department of Orthopaedics, Lund University Hospital, Lund, Sweden Firas Al-Dabouby Department of Orthopaedic Surgery, University Hospital Carl Gustav Carus Dresden, Fetscherstr 74, D-01307 Dresden, Germany Mathieu Assal Orthopaedic Surgery Service, University Hospital of Geneva, Switzerland, mathieu.assal@hcuge.ch Peter Bernstein Department of Orthopaedic Surgery, University Hospital Carl Gustav Carus Dresden, Fetscherstr 74, D-01307 Dresden, Germany David E Beverland Outcomes Unit, Musgrave Park Hospital, Belfast, BT9 7JB, UK, david.beverland@greenpark.n-i.nhs.uk Roberto Bevoni Via Pupilli 1, 40136 Bologna, Italy, bevoni@ior.it Nikolaus Böhler AKH Linz, Orthopaedic Department, Krankenhausstrasse 9, A-4020 Linz, Austria, nikolaus.boehler@efort.org Olivier Charrois Clinique Arago, 95 Boulevard Arago, 75014 Paris, France, charrois@noos.fr Xavier Crevoisier Centre Hospitalier Universitaire Vaudois (CHUV), Site Hôpital Orthopédique, Pierre-Decker 4, 1011 Lausanne, Switzerland, xavier.crevoisier@chuv.ch Nickolaos A Darlis Department of Orthopaedic Surgery, University of Athens, School of Medicine, Athens, Greece Deborah M Eastwood Department of Paediatric Orthopaedics, Great Ormond St Hospital for Children and the Royal National Orthopaedic Hospital, London, UK, d.m.eastwood@btinternet.com Richard Eyb Donauspital, Orthopädische Abteilung, Sozialmedizinisches Zentrum Ost, Langobardenstrasse 122, 1220 Wien, Austria, richard.eyb@wienkav.at D Francesconi Via Pupilli 1, 40136 Bologna, Italy, francesconi.dunia@alice.it Eduardo Garcia-Cimbrelo Hospital La Paz, Universidad Autónoma de Madrid, Paseo de la Castellana 261, Madrid 28046, Madrid, Spain, gcimbrelo@yahoo.es xi Ankle Arthritis total ankle replacement all are also indications for ankle arthrodesis Numerous techniques of fixation have been described and have evolved through the time [8] They include: cast fixation alone, compressive external fixation as developed by Charnley [41], and internal fixation with screws or plates Ankle arthrodesis can be achieved by open procedure or arthroscopically When compared with internal fixation, external compressive fixation has the disadvantage of a voluminous external device, of a higher non-union rate (21 vs 5%) and of the increased infection rate (15 vs 0%), mostly related to pin tracts [42] Nevertheless, external compressive fixation is still used in cases of bad softtissue condition, recent infection (Fig 5) and poor bone quality The antero-lateral approach (Fig 6) is most commonly used for open procedure and fixation is usually achieved using crossed screws (Figs and 8) [43] Studies comparing screw and plate fixation have shown a higher rate of fusion with screws [43–46] Less soft-tissue stripping and better compression at the fusion site may account for the better fusion rate [8] Furthermore, in vitro assessment of 231 Fig Intra-operative view of an ankle arthrodesis The anterolateral approach with distal peroneal osteotomy allows easy visualization of the ankle joint and permits good control of the fixation position, especially in the sagittal and coronal planes Fig Intra-operative view of ankle fusion with crossed screws The ankle has been positioned in neutral dorsiflexion, slight valgus and external rotation Fig Radiographs of an ankle arthrodesis performed for septic arthritis External compressive fixation as described by Charnley is still used for ankle arthrodesis in case of bad soft tissues condition or recent articular infection screw fixation has shown that crossed-screw fixation creates better primary stability than parallel-screw fixation [47] When compared with open procedures, arthroscopic ankle fusion has been shown to be associated with reduced morbidity and hospitalization time, and fusion rate up to 97% [48] Nevertheless, arthroscopic ankle arthrodesis is a difficult technique that is not to be used in case of significant mal-alignment [48] After ankle arthrodesis the total mobility of the foot relative to the lower leg decreases by 70% in the sagittal plane [49] Ankle immobility is partially compensated by increased sagittal motion in the hindfoot and midfoot (Figs and 10) and by increased coronal motion of the hindfoot [50, 51] In order to facilitate this compensatory motion, the ankle should be fused in neutral dorsiflexion (Figs and 8), in slight (5–10°) external rotation and in 232 X Crevoisier Fig Ap (a) and lateral (b) weight-bearing radiographs showing bone union months after ankle arthrodesis with compressive crossed screws Fig Lateral functional weight-bearing radiographs in maximal flexion (a) and maximal extension (b) of a fused ankle After ankle arthrodesis immobility is partially compensated by increased motion in the hindfoot and midfoot joints but this creates high constraints on these joints which potentially leads to secondary arthritis 5° of hindfoot valgus [49, 50] This position and the absence arthritis of the sub-talar joint are major determinant of postoperative function and long-term outcome [50, 52] Furthermore, footwear modification by adding a rocker-bottom sole allows almost normal ambulation after ankle arthrodesis has been performed [53] One of the most frequently reported complication following ankle arthrodesis is non-union Nevertheless, in recent series reporting the use of internal fixation with screws, the non-union rate did not exceed 10% [50, 52, 54, 55] Risk factors for non-union include infection, smoking, poor vascular condition, general status after high energy trauma, aseptic osteonecrosis of the talus, pre-existing sub-talar joint arthrodesis, poor patient compliance and inadequate surgical technique [54] In smokers the risk for non-union is four times higher than in non-smokers Infection is another important potential complication Infection rates ranging from to 19% have been reported [43, 50] In terms of outcome, despite a high short- and mid-term patient satisfaction more critical long-term studies have uniformly demonstrated arthritis and restricted articular motion of the neighbour hindfoot joints, functional deficit and a significant alteration of the quality of life [56, 57] Furthermore, 60% of patients with pre-existing sub-talar or mid-tarsal arthritis are expected to worsen these degenerative changes after ankle fusion [52, 58] To our knowledge, ankle arthrodesis has not been shown to have negative influence on the knee Ankle Arthritis 233 Fig 10 Clinical function of the foot after ankle arthrodesis The need for ankle fixation in neutral dorsiflexion is emphasized Thus, plantarflexion (a) is much easier compensated than dorsal extension (b) Total ankle replacement (TAR) The first total ankle arthroplasty was performed in 1970 using the concept of an inverted hip prosthesis [59] This technique, however, had to be abandoned soon because of a high failure rate Specific ankle implants were then designed These first generation ankle prostheses were of two types: constrained or unconstrained [59] The results were also poor with rates of implant loosening seen at up to 90% at 10 years Early loosening was mainly attributed to the over- or under-constraint, and to the cemented fixation [59–61] In the 1980s, semi-constrained second generation ankle prostheses were designed [5] Initially they included two components and necessitated syndesmosis fusion Most of the current models are now three-component mobile-bearing prostheses (Fig 11) They have the potential to minimize bone resection (Figs 11 and 12), maintain congruency, and respect the original anatomy of the ankle joint surfaces Economical bone resection is thought to create better conditions in case Fig 12 Intra-operative view of a TAR procedure showing economical osseous resection associated with second generation implants Fig 11 Weight-bearing a-p radiograph of the ankle after TAR Most of the current models are now three-component uncemented mobile-bearing prostheses that maintain congruency, respect the original anatomy of the ankle, and require minimal bone resection of implant failure requiring conversion of the replacement to a fusion All current ankle prostheses rely on bone ingrowth for implant fixation [5] Uncemented fixation has the advantages of a minimal bone resection, and the absence of exothermic reaction In vitro assessment of TAR has shown a better preservation of foot and ankle kinematics than after ankle arthrodesis [62] Compared to ankle arthrodesis, in vivo assessment of TAR has shown better kinematics of the foot (Figs 13 and 14), even if TAR does not restore normal movement or walking speed [63–65] Nevertheless, gait improvement and pain significant pain reduction has been observed Pain reduction is thought to be more determinant than articular motion for the normalization of gait [33] 234 X Crevoisier Fig 13 Clinical function of the foot in maximal flexion (a) and extension (b) after total replacement of the left ankle Even if TAR doesn’t restore physiologic motion, as illustrated in (b) where both ankles can be seen, it allows better kinematics than ankle fusion does The current follow-up time of second generation prostheses is still too short to demonstrate that TAR is associated with less secondary degenerative changes of the neighbour hindfoot joints than ankle arthrodesis Nevertheless, short and mid-term results are encouraging Patient satisfaction rate is 60–90% and survival rate of the implants is 80–90% at 10 years [63, 64, 66, 67] Complications associated with TAR include malleolar fractures in 6–10% of cases, skin necrosis in 2–14% of cases, aseptic loosening in 2–14% of cases, recurrent pain and stiffness in 3–5% of cases and infections in 4–5% of cases [63, 64, 67] Skin necrosis, malleolar fractures, pain, and stiffness can usually be treated without implant removal Major complications, however, frequently require conversion of the TAR to a fusion Fortunately, the 80–90% union rate of ankle arthrodesis after failed ankle arthroplasty has Fig 14 Lateral radiographs of a prosthetic ankle showing maximal flexion (a) and extension (b) These figures can be compared with Figs 9a and b Partial preservation of ankle motion in TAR is associated with less compensatory motion in the hindfoot and midfoot joints been shown to be almost equivalent to that of primary fusion [68, 69] Total ankle replacement vs arthrodesis: decision making A recent systematic review of the literature concluded that intermediate outcome of TAR appears to be similar to that of ankle arthrodesis [70] Nevertheless, the authors underlined the heterogeneity among existing studies and also concluded that their work exposed the major lack of objective, prospective, and controlled data on either procedure Careful patient selection is probably a very important predictive factor To be successful, TAR requires correct lower limb and hindfoot alignment, and adequate ligaments balancing In case of hindfoot mal-alignment arthrodesis will be the solution of choice, unless corrective osteotomies are performed prior to TAR [71] TAR is more appropriated for patients with low functional demand Ankle Arthritis Young age of the patient has not been demonstrated to have negative prognostic value for TAR [63, 66, 67] In young patients presenting bilateral ankle arthritis or ankle arthritis associated to sub-talar or Chopart joint arthritis TAR will be preferred to fusion In the following conditions ankle fusion will be preferred: recent or recurrent infection, severe osteopenia, osteonecrosis, poor skin quality, poor vascular condition Articular distraction Progressive articular distraction of the ankle in daily mm increments using an external fixation devices has been described in 1999 by Van Roermund and Lafeber [72] The same group of physicians reported that In 73% of the patients, significant clinical benefit from joint distraction of severe OA ankles was maintained for at least years [73] but that there was a need for further research to determine predictive factors of patient response to this treatment Supra-malleolar or/and hindfoot corrective osteotomies Few clinical studies reported the efficacy of peri-articular corrective osteotomies for ankle arthritis [74–76] One reason for performing these procedures is to offer young patients a surgical alternative to major procedures in case of ankle arthritis Another aim of corrective osteotomies is to provide favourable conditions for future TAR Most of the studies to date are too small to allow firm conclusion about efficacy of these techniques Nevertheless, there is one homogenous series of 25 patients that reported low tibial osteotomy to be indicated for varus-type osteoarthritis of stage or stage 3a [74] Arthroscopic ankle debridement The role of arthroscopy in the management of patients with ankle arthritis cannot be ascertained from the current literature A recent 5-year survival analysis revealed that over 50% of patients with osteoarthritic changes had major surgery or repeat arthroscopy at 5-year follow-up [77] Conclusion and Perspectives The aetiology and epidemiology of ankle arthritis are well known Trauma and its consequences has been identified as the major cause of ankle arthritis Nevertheless, since the ankle is the most frequently–injured joint of the human body the relatively low prevalence of ankle arthritis still remains a partial mystery Assessing the efficacy of the numerous treatment options for ankle arthritis is still a huge challenge and requires improvement in biomechanical understanding of the ankle, objective prospective evaluation, and development of ankle-specific outcome tools 235 References Lawrence RC, Helmick CG, Arnett FC, Deyo RA, Felson DT, Giannini EH, Heyse SP, Hirsch R, Hochberg MC, Hunder GG, Liang MH, Pillemer SR, Steen VD, Wolfe F Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States Arthritis Rheum 1998;41–5:778–99 Glazebrook M, Daniels T, Younger A, Foote CJ, Penner M, Wing K, Lau J, Leighton R, Dunbar M Comparison of health-related quality of life between patients with end-stage ankle and hip arthrosis J Bone Joint Surg Am 2008;90–3: 499–505 Hunsche E, Chancellor JV, Bruce N The burden of arthritis and nonsteroidal anti-inflammatory treatment A European literature review Pharmacoeconomics 2001;19 Suppl 1:1–15 Wang PP, Elsbett-Koeppen R, Geng G, Badley EM Arthritis prevalence and place of birth: findings from the 1994 Canadian National Population Health Survey Am J Epidemiol 2000; 152–5:442–5 Saltzman CL, Salamon ML, Blanchard GM, Huff T, Hayes A, Buckwalter JA, Amendola A Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic center Iowa Orthop J 2005;25:44–6 Cushnaghan J, Dieppe P Study of 500 patients with limb joint osteoarthritis I Analysis by age, sex, and distribution of symptomatic joint sites Ann Rheum Dis 1991;50–1:8–13 Lindsjo U Operative treatment of ankle fracture-dislocations A follow-up study of 306/321 consecutive cases Clin Orthop 1985;199:28–38 Thomas RH, Daniels TR Ankle arthritis J Bone Joint Surg Am 2003;85-A-5:923–36 Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B Etiology of ankle osteoarthritis Clin Orthop Relat Res Epub 2008/10/03 10 Toolan BC, Hansen ST, Jr Surgery of the rheumatoid foot and ankle Curr Opin Rheumatol 1998;10–2:116–9 11 Michelson J, Easley M, Wigley FM, Hellmann D Foot and ankle problems in rheumatoid arthritis Foot Ankle Int 1994;15–11:608–13 12 Stauffer RN, Chao EY, Brewster RC Force and motion analysis of the normal, diseased, and prosthetic ankle joint Clin Orthop 1977–127:189–96 13 Unsworth A Tribology of human and artificial joints Proc Inst Mech Eng [H] 1991;205–3:163–72 14 Shepherd DE, Seedhom BB Thickness of human articular cartilage in joints of the lower limb Ann Rheum Dis 1999; 58–1:27–34 15 Simon WH, Friedenberg S, Richardson S Joint congruence A correlation of joint congruence and thickness of articular cartilage in dogs J Bone Joint Surg Am 1973;55–8:1614–20 16 Wynarsky GT, Greenwald AS Mathematical model of the human ankle joint J Biomech 1983;16–4:241–51 17 Curtis MJ, Michelson JD, Urquhart MW, Byank RP, Jinnah RH Tibiotalar contact and fibular malunion in ankle fractures A cadaver study Acta Orthop Scand 1992;63–3:326–9 236 18 Clarke HJ, Michelson JD, Cox QG, Jinnah RH Tibio-talar stability in bimalleolar ankle fractures: a dynamic in vitro contact area study Foot Ankle 1991;11–4:222–7 19 Pereira DS, Koval KJ, Resnick RB, Sheskier SC, Kummer F, Zuckerman JD Tibiotalar contact area and pressure distribution: the effect of mortise widening and syndesmosis fixation Foot Ankle Int 1996;17–5:269–74 20 Cedell CA Supination-outward rotation injuries of the ankle A clinical and roentgenological study with special reference to the operative treatment Acta Orthop Scand 1967;Suppl 110:3+ 21 McDaniel WJ, Wilson FC Trimalleolar fractures of the ankle An end result study Clin Orthop Relat Res 1977;122: 37–45 22 Daniels TR, Smith JW Talar neck fractures Foot Ankle 1993;14–4:225–34 23 Marsh JL, Buckwalter J, Gelberman R, Dirschl D, Olson S, Brown T, Llinias A Articular fractures: does an anatomic reduction really change the result? J Bone Joint Surg Am 2002;84-A-7:1259–71 24 Harrington KD Degenerative arthritis of the ankle secondary to long-standing lateral ligament instability J Bone Joint Surg Am 1979;61–3:354–61 25 McBride DJ, Ramamurthy C Chronic ankle instability: management of chronic lateral ligamentous dysfunction and the varus tibiotalar joint Foot Ankle Clin 2006;11–3:607–23 26 Belt EA, Kaarela K, Maenpaa H, Kauppi MJ, Lehtinen JT, Lehto MU Relationship of ankle joint involvement with subtalar destruction in patients with rheumatoid arthritis A 20year follow-up study Joint Bone Spine 2001;68–2:154–7 27 Jaakkola JI, Mann RA A review of rheumatoid arthritis affecting the foot and ankle Foot Ankle Int 2004;25–12:866–74 28 Michelson J, Easley M, Wigley FM, Hellmann D Foot and ankle problems in rheumatoid arthritis Foot Ankle Int 1994; 15–11:608–13 29 Friedman MA, Draganich LF, Toolan B, Brage ME The effects of adult acquired flatfoot deformity on tibiotalar joint contact characteristics Foot Ankle Int 2001;22–3:241–6 30 Fortin PT, Guettler J, Manoli A, 2nd Idiopathic cavovarus and lateral ankle instability: recognition and treatment implications relating to ankle arthritis Foot Ankle Int 2002;23–11:1031–7 31 Shih LY, Wu JJ, Lo WH Changes in gait and maximum ankle torque in patients with ankle arthritis Foot Ankle 1993;14–2:97–103 32 Khazzam M, Long JT, Marks RM, Harris GF Preoperative gait characterization of patients with ankle arthrosis Gait Posture 2006;24–1:85–93 33 Zerahn B, Kofoed H Bone mineral density, gait analysis, and patient satisfaction, before and after ankle arthroplasty Foot Ankle Int 2004;25–4:208–14 34 Martin RL, Stewart GW, Conti SF Posttraumatic ankle arthritis: an update on conservative and surgical management J Orthop Sports Phys Ther 2007;37–5:253–9 35 Ward ST, Williams PL, Purkayastha S Intra-articular corticosteroid injections in the foot and ankle: a prospective 1-year follow-up investigation J Foot Ankle Surg 2008;47–2: 138–44 X Crevoisier 36 Sun SF, Chou YJ, Hsu CW, Hwang CW, Hsu PT, Wang JL, Hsu YW, Chou MC Efficacy of intra-articular hyaluronic acid in patients with osteoarthritis of the ankle: a prospective study Osteoarthr Cartil 2006;14–9:867–74 37 Karatosun V, Unver B, Ozden A, Ozay Z, Gunal I Intraarticular hyaluronic acid compared to exercise therapy in osteoarthritis of the ankle A prospective randomized trial with long-term follow-up Clin Exp Rheumatol 2008;26–2:288–94 38 Kitaoka HB, Crevoisier XM, Harbst K, Hansen D, Kotajarvi B, Kaufman K The effect of custom-made braces for the ankle and hindfoot on ankle and foot kinematics and ground reaction forces Arch Phys Med Rehabil 2006;87–1:130–5 39 O’Reilly S, Doherty M Lifestyle changes in the management of osteoarthritis Best Pract Res Clin Rheumatol 2001;15–4: 559–68 40 Albert E Zur resektion des Kniegelenkes Wien Med Presse 1879;20:705–8 41 Charnley J Compression arthrodesis of the ankle and shoulder J Bone Joint Surg Br 1951;33B-2:180–91 42 Moeckel BH, Patterson BM, Inglis AE, Sculco TP Ankle arthrodesis A comparison of internal and external fixation Clin Orthop 1991–268:78–83 43 Holt ES, Hansen ST, Mayo KA, Sangeorzan BJ Ankle arthrodesis using internal screw fixation Clin Orthop 1991–268: 21–8 44 Chen YJ, Huang TJ, Shih HN, Hsu KY, Hsu RW Ankle arthrodesis with cross screw fixation Good results in 36/40 cases followed 3–7 years Acta Orthop Scand 1996;67–5:473–8 45 Maurer RC, Cimino WR, Cox CV, Satow GK Transarticular cross-screw fixation A technique of ankle arthrodesis Clin Orthop 1991;268:56–64 46 Morgan CD, Henke JA, Bailey RW, Kaufer H Long-term results of tibiotalar arthrodesis J Bone Joint Surg Am 1985; 67–4:546–50 47 Friedman RL, Glisson RR, Nunley JA, 2nd A biomechanical comparative analysis of two techniques for tibiotalar arthrodesis Foot Ankle Int 1994;15–6:301–5 48 Ferkel RD, Hewitt M Long-term results of arthroscopic ankle arthrodesis Foot Ankle Int 2005;26–4:275–80 49 Abdo RV, Wasilewski SA Ankle arthrodesis: a long-term study Foot Ankle 1992;13–6:307–12 50 Bertrand M, Charissoux JL, Mabit C, Arnaud JP [Tibio-talar arthrodesis: long term influence on the foot] Rev Chir Orthop Reparatrice Appar Mot 2001;87–7:677–84 51 Wu WL, Su FC, Cheng YM, Huang PJ, Chou YL, Chou CK Gait analysis after ankle arthrodesis Gait Posture 2000; 11–1:54–61 52 Ben Amor H, Kallel S, Karray S, Saadaoui F, Zouari M, Litaiem T, Douik M [Consequences of tibiotalar arthrodesis on the foot A retrospective study of 36 cases with 8.5 years of followup] Acta Orthop Belg 1999;65–1:48–56 53 Trouillier H, Hansel L, Schaff P, Rosemeyer B, Refior HJ Long-term results after ankle arthrodesis: clinical, radiological, gait analytical aspects Foot Ankle Int 2002;23–12: 1081–90 54 Cooper PS Complications of ankle and tibiotalocalcaneal arthrodesis Clin Orthop 2001;391:33–44 Ankle Arthritis 55 Takakura Y, Tanaka Y, Sugimoto K, Akiyama K, Tamai S Long-term results of arthrodesis for osteoarthritis of the ankle Clin Orthop 1999–361:178–85 56 Coester LM, Saltzman CL, Leupold J, Pontarelli W Longterm results following ankle arthrodesis for post-traumatic arthritis J Bone Joint Surg Am 2001;83-A-2:219–28 57 Fuchs S, Sandmann C, Skwara A, Chylarecki C Quality of life 20 years after arthrodesis of the ankle a study of adjacent joints J Bone Joint Surg Br 2003;85–7:994–8 58 Conti RJ, Walter JH, Jr Effects of ankle arthrodesis on the subtalar and midtarsal joints J Foot Surg 1990;29–4:334–6 59 Henne TD, Anderson JG Total ankle arthroplasty: a historical perspective Foot Ankle Clin 2002;7–4:695–702 60 Saltzman CL Perspective on total ankle replacement Foot Ankle Clin 2000;5–4:761–75 61 Neufeld SK, Lee TH Total ankle arthroplasty: indications, results, and biomechanical rationale Am J Orthop 2000; 29–8:593–602 62 Valderrabano V, Hintermann B, Nigg BM, Stefanyshyn D, Stergiou P Kinematic changes after fusion and total replacement of the ankle: part 1: Range of motion Foot Ankle Int 2003;24–12:881–7 63 Buechel FF, Sr., Buechel FF, Jr., Pappas MJ 10-year evaluation of cementless Buechel-Pappas meniscal bearing total ankle replacement Foot Ankle Int 2003;24–6:462–72 64 Anderson T, Montgomery F, Carlsson A Uncemented STAR total ankle prostheses to 8-year follow-up of fifty-one consecutive ankles J Bone Joint Surg Am 2003;85-A-7: 1321–9 65 Piriou P, Culpan P, Mullins M, Cardon JN, Pozzi D, Judet T Ankle replacement versus arthrodesis: a comparative gait analysis study Foot Ankle Int 2008;29–1:3–9 66 Kofoed H, Lundberg-Jensen A Ankle arthroplasty in patients younger and older than 50 years: a prospective series with long-term follow-up Foot Ankle Int 1999;20–8: 501–6 237 67 Wood PL, Deakin S Total ankle replacement The results in 200 ankles J Bone Joint Surg Br 2003;85–3:334–41 68 Kitaoka HB, Romness DW Arthrodesis for failed ankle arthroplasty J Arthroplasty 1992;7–3:277–84 69 Carlsson A, Markusson P, Sundberg M Radiostereometric analysis of the double-coated STAR total ankle prosthesis: a 3–5 year follow-up of cases with rheumatoid arthritis and cases with osteoarthrosis Acta Orthop 2005;76–4: 573–9 70 Haddad SL, Coetzee JC, Estok R, Fahrbach K, Banel D, Nalysnyk L Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis A systematic review of the literature J Bone Joint Surg Am 2007;89–9:1899–905 71 Clare MP, Sanders RW Preoperative considerations in ankle replacement surgery Foot Ankle Clin 2002;7–4:709–20 72 van Roermund PM, Lafeber FP Joint distraction as treatment for ankle osteoarthritis Instr Course Lect 1999;48: 249–54 73 Ploegmakers JJ, van Roermund PM, van Melkebeek J, Lammens J, Bijlsma JW, Lafeber FP, Marijnissen AC Prolonged clinical benefit from joint distraction in the treatment of ankle osteoarthritis Osteoarthr Cartil 2005;13–7: 582–8 74 Tanaka Y, Takakura Y, Hayashi K, Taniguchi A, Kumai T, Sugimoto K Low tibial osteotomy for varus-type osteoarthritis of the ankle J Bone Joint Surg Br 2006;88–7:909–13 75 Takakura Y, Tanaka Y, Kumai T, Tamai S Low tibial osteotomy for osteoarthritis of the ankle Results of a new operation in 18 patients J Bone Joint Surg Br 1995;77–1:50–4 76 Hintermann B, Knupp M, Barg A [Osteotomies of the distal tibia and hindfoot for ankle realignment] Orthopade 2008; 37–3:212–8, 20–3 77 Hassouna H, Kumar S, Bendall S Arthroscopic ankle debridement: 5-year survival analysis Acta Orthop Belg 2007; 73–6:737–40 Hallux Rigidus: Arthroplasty or Not? S Giannini, F Vannini, R Bevoni, and D Francesconi Introduction Hallux rigidus (HR) is characterized by restriction of motion at first metatarsophalangeal joint (MPTJ) [1] The gradual onset of pain and limitation of dorsi-flexion at the MPTJ is characteristic of the disease process, although often there may be a normal range of plantar-flexion [2] The great toe is either fixed in plantar-flexion or limited in dorsiflexion because of the proliferation of bone around the articular surface of the head of the first metatarsal, particularly on the dorsal aspect The severity of the degenerative changes is markedly dependent on the duration of symptomatology [2] The pain and limited motion associated with arthritis of hallux metatarsophalangeal (HMP) joint produces a syndrome of functional disability that may include progressive loss of the propulsion function of the foot, “transfer” lesser metatarsalgia and gait alteration [3] HR has been reported to affect one in forty-five individuals who are more than 50 years of age [4] After hallux valgus, it is the most common affliction of the great toe and the most common form of degenerative joint disease in the foot [5] There is no single cause for HR Trauma, organic disorders, previous surgery are to be considered common causes which favour the onset of HR [6, 7] Furthermore, anatomic abnormality of the first ray, especially in bilateral occurrence in the absence of other synovial joint involvement such as first ray elevation, has been identified as a predisposing factor [5] However all these causes result in a pathologic process of isolated arthritis of the first MTP joint that leads to the formation of osteophytes and a thinning of the articular space [2] Conservative management of symptomatic HR depends on a patient’s symptoms and the magnitude of the degen- erative process Use of NSAID’s, a stiff insole to reduce excursion of the MTP joint, orthoses providing rigidity to the forepart of the shoe can be effective in early first-grade disease [8] Typically grade II and III HR require surgical treatment [8] and different techniques such as Cheilectomy [9–11], dorsal wedge osteotomy [12], tendon arthroplasty [13], capsular interposition arthroplasty [14, 15], Keller’s arthroplasty [16], and even arthroscopic procedures [17] have been proposed over time A radiographic classification of HR has been developed by Regnauld [18] and a treatment algorithm has been previously proposed in order to choose the appropriate treatment accordingly [19–22] With grade III HR salvage procedures include arthrodesis [23–26], excisional arthroplasty [27], soft-tissue interpositional arthroplasty [13–15] or prosthetic replacement [28–30] Arthrodesis can be a satisfactory operation The functional excellence and durability of the results obtained are impressive, although sacrifice of joint movement is an obvious drawback of the technique [23] The value of prosthetic implants instead is still a theme for debate The advantages of the procedure include preservation of the motion and a wide variety of implants have been proposed over time [31–35] Nevertheless high risk of failure of the implant and serious complications have been reported [30, 36–41] The aim of this study is to review the literature in order to investigate the validity of the treatments currently proposed for end-stage HR Arthrodesis S Giannini (*) Via Pupilli 1, 40136 Bologna, Italy e-mail: Sandro.giannini@ior.it For patients who have severe arthritis of the first MPTJ, arthrodesis is still considered the gold standard particularly in younger and more active patients [42] G Bentley (ed.), European Instructional Lectures European Instructional Course Lectures 9, DOI: 10.1007/978-3-642-00966-2_24, © 2009 EFORT 239 240 Fusion ideally requires a set angle of 15° dorsi-flexion and 5–10° of valgus [22] Many techniques are available for first MTP joint arthrodesis and fixation such as wires, screws, plates Specificallydeveloped reamers have been described [43–45] Fusion rates between 90 and 100% have been reported [43–48] Wulker et al [26] reported that results of first MPTJ atrhrodesis were good and excellent in approximately 80% Fitzgerald and Wilkinson [23] in a review of the literature reported that the predictability and consistency of the result of arthrodesis with good results occurred in approximately 90% of cases DeFrino et al [36] studied 10 feet in patients with severe HR Arthrodesis of the first MTP joint was assessed with the AOFAS hallux score, by radiography and by dynamic pedobarography After 34 months on average, all pre-operative tests were repeated and gait analysed Their patients showed subjectively a significant clinical improvement The mean AOFAS score improved from 38 to 90 and the pedobarographic analysis demonstrated restoration of weight-bearing on the first ray with greater maximum force carried by the toe pad at toe-off However, kinematic data indicated a significantly shorter step length with some loss of ankle plantar-lexion at toe-off on the fused side The kinematic data indicated a reduction in both ankle torque and ankle power at push-off Nonetheless, there was effective pain relief and a high level of patient satisfaction Goucher et al [41] prospectively evaluated 50 patients who underwent first MTP arthrodesis using dome-shaped reamers to prepare the joint and a dorsal plate with a single compression screw for fixation (Level IV evidence) A 96% satisfaction rate, 92% union rate, and significant increase in AOFAS scores were achieved at an average follow-up of 16 months The revision rate was 4% Thirteen patients had single-grade radiographic progression of arthritic change at the interphalangeal joint Flavin and Stephens [49] prospectively followed 12 patients who underwent first MTP arthrodesis using dorsal plate fixation with an average follow-up of 18 months (Level IV evidence) All patients showed radiographic signs of union at weeks and there was a significant increase in AOFAS hallux and SF-36 scores No complications were reported in this small series Arthrodesis will provide predictable results with pain relief, but it is not free from complications [2] In 1984, Beauchamp et al [6] reported seven wound infections and five failed fusions in a report of 34 fusions of the first joint and non-union rates up to 13% of the patients have been described elsewhere [26] S Giannini et al Futhermore fusion sacrifices motion which may lead to patient dissatisfaction and some limitation in shoe wear and activity [50, 51] Arthroplasty Theoretically, arthroplasty should not only provide pain relief, but also restore motion and maintain joint stability Many different designs and solutions have been proposed over time [31–35] Different categories such as: silastic implants, hemi-arthroplasty, total metallic or ceramic implants and interposition arthroplasty have been described Silastic Implants Due to the initial success of silastic joint replacement in the hand, these implants were adapted for use in the MTP joint Silastic implants designed as a dynamic spacer able to maintain joint space and motion have been used widely in the past, generally with reported good outcomes, but unfortunately silicone particulate synovitis was common [31, 32, 38] Swanson et al reported the results of the procedure in 105 patients, predominately with rheumatoid arthritis, with a mean follow-up of 2.5 years with satisfactory radiographic results in 84 (Level IV evidence) [31] Cracchiolo et al [28] prospectively followed 86 patients with rheumatoid arthritis or RH for a mean duration of 5.8 years (Level IV evidence) Eighty-three percent of patients reported subjective satisfaction with an average range of motion of 42° Radiographically, however, osteophyte formation was noted in 23 patients and 12 of these had nearly 50% articular space encroachment Radiographic cysts were identified in 35% of patients and eight implants fractured Furthermore several authors reported data suggesting mechanical failure of the implants leading to siliconeinduced synovitis and osteolysis [37–41] Grandberry et al [37] in a 90 patient study using a silicone prosthesis, observed that, although clinical results were encouraging, in most of the cases there were alarming rates of fracture and deformation of the implant These findings increased with the duration of implantation To address this, new systems were designed for insertion with titanium grommets to reduce the stress applied to the silastic and to increase survival of the arthroplasty Sebold and Cracchiolo [34] reported on 47 patients with rheumatoid arthritis or HR who joints were replaced with this new design at an average follow-up of 51 months (Level IV evidence) Hallux Rigidus: Arthroplasty or Not? In this series, 30 patients were subjectively completely satisfied No implant fractured, although the arthroplasties developed peri-prosthetic radiolucencies in patients, and the implants subsided in 15 The authors contrasted their results with a similar group of 41 patients who had received hinged implants Thirty of these arthroplasties had radiolucencies and implants fractured The authors concluded that the use of titanium grommets protected the silicone prosthesis and improved longevity of the arthroplasty Nevertheless the potential effects of silicone debris leading to foreign-body reaction, synovitis and bone erosion in the hallux still are cause of concern In addition, the systemic effects of silicone microfragments invading the lymphoreticular system are still unknown and silastic implants are almost abandoned [39, 52] Hemi-Arthroplasty Metatarsal Hemi-Arthroplasty Townley and Taranow [3] performed a large retrospective review of 279 patients treated with a metallic hemiarthroplasty of the proximal phalanx after minimal metatarsal head resection, with follow-up ranging from months to 33 years (Level IV evidence) Pre-operative diagnoses included HR, rheumatoid arthritis and hallux valgus associated with osteoarthritis The authors reported good or excellent results in 95% of patients Only patients with a diagnosis of HR were dissatisfied with their result One patient had a post-operative infection while the other received an oversized implant The remaining failures occurred in patients with hallux valgus and with rheumatoid arthritis There was only one case of clinical or radiographic evidence of loosening which occurred in a patient with rheumatoid arthritis and poor bone quality Botto-van Bemden and SanGiovanni [53] reported on the early follow-up results of 24 first metatarsal head re-surfacing procedures that were performed with use of the hemicontoured articular prosthesis (HemiCAP; Arthrosurface, Franklin, MA) for the treatment of advanced HR Concomitant osseous and soft-tissue procedures were included for the correction of deformity and improvement of dorsi-flexion motion After an average follow-up of 12 months, the average AOFAS score improved from 54.7 pre-operatively to 70 post-operatively, the average visual analogue pain score improved from 6.4 to 3.5, and average dorsi-flexion increased from 20.2 to 51° While the authors considered this prosthesis to be a reliable alternative for the treatment of 241 advanced HR, the device was recommended primarily for the treatment of arthritis pain and not for the restoration of motion Phalangeal Arthroplasty Metallic implants have been available for arthroplasties of the great toe for many years [38, 54] Brage and Ball [55] while supporting fusion, note the value of a metallic hemi-arthroplasty, in its ability to allow restoration of alignment and maintenance of motion, length and strength in the great toe, which they consider to be fundamental in attaining a good clinical result In a 10 patient (13 toes) study at 66 months follow-up, Konkel and Menger [35] evaluated the results of a titanium (Swanson) hemi-great toe implant All the titanium prosthesis had subsided to varying degrees with lucencies around the implant The rate of subsidence was most rapid during the first years One implant (8 years after insertion) was removed because of pain and stiffness that occurred after a hyperextension injury with fracture that the patient sustained while running One patient had “transfer” metatarsalgia involving the second metatarsal Four great toes in three patients with the greatest subsidence had mild great toe clawing and no visible great toe push-off during normal walking One patient developed fullthickness ulcerations One patient developed a scar contracture with hyperextension of the great toe At last follow-up, 37–105 months post-operatively, pain was absent in six toes, mild and occasional in five toes, moderate and daily in one toe and severe with vigorous activity in one toe The outcome from a clinical trial of 23 cobalt-chrome hemi-arthroplasty implants in 19 patients has been recently evaluated by Sorbie and Saunders [56] The patients’ ages ranged from males 41 to 61 (average age, 51.6) years and females 35 to 70 (average age, 54) years The implant used was made of quality wrought cobalt, chromium-28 and molybdenum-6 alloy as specified in ASTM-F1537 (American Society for Testing Materials, Philadelphia, PA) The implant was aimed to be positioned in the proximal phalanx after a minimal amount of subchondral bone resection The follow-up time from the day of surgery averaged 68 (range, 34–72) months At follow-up a statistically significant improvement was found in all the cases No complications were described in the paper with the exception of patients dissatisfied of the range of motion gained 242 Total Metallic or Ceramic Implants Recent improvements in the biomaterials and understanding of biomechanics of the first MTP joint have revived the concept of total joint replacement With the success of cobaltchrome alloy and polyethylene in hip and knee arthroplasties, some systems for great toe replacement have been introduced [33] In MTP joint arthroplasty, these are designed as two-component, semi-constrained or non-constrained articulations Papagelopoulos et al [33] reported their experience with 93 primary implants (79 patients) of the first MTP joint using cemented metal and polyethylene components and silicone implants The mean age of their patients was 56 (19–75) years The average duration of follow-up evaluation in 75 patients who were alive and without re-operation was 12 (2–7) years At 10 years, implant survival was 82% in patients 57 years of age or younger, and 90% in patients older than 57 years The authors concluded that the overall probability that an implant would be in situ was 82% at 15 years after arthroplasty Survivorship was higher in patients who were older than 58 years Koenig and Horwitz [57] reported a 5-year study of 61 total joint arthroplasties using the Biomet total toe system Of the 61 cases, 49 had a diagnosis of HR and 12 had a diagnosis of hallux valgus Ten involved revision of failed silastic elastomer implant arthroplasty The patients’ age ranged from 29 to 72 (mean of 54.5) years All patients had end-stage arthrosis They reported overall excellent results in 51 of 61 (83%) with 10 having various levels of compromised results Pulavarti et al [58] reviewed the intermediate results of 32 patients (36 replacements) with a minimum follow-up of 36 months The Bio-Action great toe implant (OsteoMed, Addison, TX) a non-constrained, two-component total joint replacement system with a phalangeal component, was chosen.At the latest follow-up, there was significant improvement in the degree of pain, functional abilities, and footwear requirements as compared with pre-operative status Twenty-five of 32 patients (79%) returned to normal or an occasionally affected lifestyle after the operation Twenty-six of 32 of patients (81%) wore conventional footwear, and of 32 patients (9%) wore footwear with inserts No patient had significant “transfer” metatarsalgia Twenty-eight of 32 patients (88%) had improvement in function Three patients who continued to have pain after the operation rated the result as poor Two of these three patients had revision surgery One patient had removal of the implant and excision arthroplasty, and the other patient had arthrodesis of the joint 30 months after the primary S Giannini et al replacement There was no obvious cause for the poor results in all the three cases Failures due to foreign-body granulomatous infiltration associated with metallic wear debris with peri-implant osteolysis leading to aseptic loosening and failure of titanium single-stem hallux implants were described by Ghalambor et al [59] Interposition Artrhroplasty Since the first description by Keller [60] in 1904, resection arthroplasty of the proximal part of the proximal phalanx has been an easy and commonly-performed operation The patient, however, loses the big toe as a functional digit Contracture of soft-tissues may produce an ugly, displaced, uncontrollable, cosmetically unattractive, great toe Reducing the amount of resected bone risks continued pain and poor function Interpositional arthroplasty, in which a biologic substance is utilized as an interpositional spacer in the first MTP joint, was developed as an alternative for the treatment of advanced HR [55] Barca [13] placed the rolled plantaris tendon at the base of the first phalanx in 12 cases He claimed that after 21 months, there was improved motion and reduced pain Hamilton and Hubbard [14] felt that capsular interposition arthroplasty could give predictable pain relief in carefully selected individuals with severe (Grade III) HR They used minimal resection of the phalanx, and interposed the dorsal capsule and the extensor hallucis brevis tendon in the space created However, approximately 30% of the patients undergoing the procedure experienced some degree of post-operative, transfer metatarsalgia and required an orthosis for sports A study by Lau and Daniels [42] was a retrospective comparison of cheilectomy with a capsular interpositional arthroplasty technique involving the use of an EHB tendon graft, on 11 cases (5 females and males) Reported complications included asymptomatic callouses (3/11, 27.3%), post-operative weakness of the great toe (8/11, 72.7%) and metatarsalgia (3/11, 27.3%) In addition, one patient suffered a stress fracture of the second metatarsal, which was treated non-operatively, and one patient was awaiting arthrodesis Mroczek and Miller [61] used a modest metatarsal cheilectomy with an oblique resection of the phalanx base preserving the flexor hallucis brevis attachment combined with interposition arthroplasty of the dorsal joint capsule They claimed that such a modification produced a satisfactory outcome while maintaining plantar -flexion power and the length of the toe Hallux Rigidus: Arthroplasty or Not? In twenty-two feet with grade-3 HR (18 feet in elderly patients or in patients with low functional demands, three feet in young patients who refused arthrodesis, and one foot in a professional soccer player), an arthroplasty with a biore-absorbable poly(DL-lactic acid) spacer was performed The implant is inserted after minimal resection of the metatarsal head and reaming of the medullary canal One foot had a localized infection at the MPTJ with sinus formation The implant did not require revision, but the infection resulted in ankylosis in an acceptable position Sufficient ROM and good pain reduction was provided by the procedure in the remaining cases [22] Miller and Maffulli [62] recommend interposition arthroplasty using the ipsilateral gracilis tendon for patients who did not want an arthrodesis Kennedy et al [63] report on 18 patients (21 feet) with severe joint cartilage loss, who had interpositional arthroplasty at an average age of 56 years and at a mean time of 38 months follow-up All had relief of pain The mean increase of range of motion was 37° and follow-up AOFAS mean was 78.4 They had a 6% complication rate Berlet et al [64] used a minimally-invasive soft tissue arthroplasty, inserting human acellular regenerative tissue matrix as a spacer The sesamoid articulation also was resurfaced They described preliminary (mean, 10.1 months) results in patients with an average age of 50.2 years The pre-operation AOFAS score averaged 66.7 and 89.6 at follow-up No complications were reported, there was no incidence of first metatarsal shortening, hallux hammer-toe deformities, or transfer metatarsalgia, Finally, at a mean length of follow-up of 10.1 months, there were no reported failures, suggesting early durability of the procedure Discussion The objectives of operative treatment of HR are relief of pain and restoration of as much function of the joint as possible giving special consideration to preservation of length and alignment of the great toe The ideal surgical procedure for the management of HR remains a controversial subject The consistently favourable results reported in many Level II and IV studies constitute fair evidence (Grade B recommendation) to support the use of arthrodesis for the treatment of advanced-stage HR [48, 49, 51] In order to further investigate the general impression that the results after first MTPJ replacement are inferior to those after MTPJ arthrodesis, Gibson and Thomson [65] proposed 243 a controlled randomized trial to compare the clinical outcomes of arthrodesis with total joint arthroplasty since no comparative prospective randomized studies were available In 63 patients (77 feet) affected by first MTPJ osteoarthritis, arthrodesis was compared to first MTP joint prosthesis The toe replacement chosen (BIOMET-Merck Ltd., Warsaw, IN) was an unconstrained joint The metatarsal prosthesis was manufactured from cobalt chrome with a titanium plasma-spray coating (0.18–0.25 μm) In contrast, the phalangeal component was cast from pure titanium with a grit blasted surface and UHMW polyethylene (ArCom®) insert All of the arthrodeses united, while six of the patients who received arthroplasty required revision within years In the remaining patients there was no difference at years in the level of satisfaction in respect to pain relief between patients of the two groups, but more patients in the arthrodesis group preferred both their functional result and the appearance of their toe after arthrodesis Nevertheless at 24 months, one patient (3%) after arthrodesis and 12 (40%) after arthroplasty (not including the six revisions) would not have undergone the same surgery again The authors concluded that the 82% improvement at years after arthrodesis exceeded that after successful arthroplasty (45%), and arthrodesis had a lower complication rate and cost less In a level III study, Raikin et al [66] investigated the results of a series of patients with osteoarthritis of the first MPTJ treated with either a metallic hemi-arthroplasty or an arthrodesis between 1999 and 2005 Eight of the feet in which the hemiprosthesis had survived had evidence of plantar cutout of the prosthetic stem on the final follow-up radiographs At the time of final follow-up (at a mean of 79.4 months), the satisfaction ratings in the hemi-arthroplasty group were good or excellent for 12 feet, fair for and poor or a failure for The mean pain score was 2.4 of 10 All 27 of the arthrodeses achieved fusion, and no revisions were required At the time of final follow-up (at a mean of 30 months), the satisfaction ratings in this group were good or excellent for 22 feet, fair for and poor for The mean pain score was 0.7 out of 10 Two patients required hardware removal, which was performed as an office procedure with the use of local anesthesia The AOFAS-HMI and visual analogue pain scores and satisfaction were significantly better in the arthrodesis group The conclusion was that Arthrodesis is more predictable than a metallic hemi-arthroplasty for alleviating symptoms and restoring function in patients with severe osteoarthritis of the first MPTJ Given these unfavourable results in multiple studies with different implants confirmed by prospective comparative studies by Gibson and Thomson [65] and by Raikin et al [66], hemi-arthroplasty cannot be recommended at 244 this time for the management of HR The results of Gibson’s prospective, randomized trial constitute a Grade B recommendation of arthrodesis as a predictable surgery able to eliminate painful motion and to maintain stability of the first ray with limited incidence of “transfer” metatarsalgia instead of arthroplasty However, intrinsic stiffness connected with arthrodesis can lead to patient dissatisfaction In addition, gait patterns can be altered, with a decreased step length and some loss of ankle plantar-flexion at toe-off on the fused side and these disadvantages should lead to search for new solutions [36] Still controversial is also the role of interposition arthroplasty The relatively high incidence of complications and the lower post-operative AOFAS score observed in the Lau and Daniel study [42] may lend support to the Roukis et al [67] theory asserting that many of the capsular interpositional arthroplasty techniques are merely modifications of the original Keller procedure and, hence, are associated with the same complications Encouraging results were otherwise reported with interposition arthoplasties with minimal bony resection of the metatarsal head Among these good results was reported the use of a human acellular dermal regenerative tissue matrix or Poly-D-L-lactic-acyd as a spacer aimed to induce the formation of a fibrous tissue at the joint space that can maintain the stability and length of the toe [22, 64] The same philosophy of minimal bone resection in order to preserve MTP joint function, is shared by the hemi-contoured articular prosthesis HemiCAP Arthrosurface, with encouraging results Small numbers and short follow-up interval are limitations of this studiey [53] Larger, prospective randomized studies directly comparing the various soft-tissue interpositional spacer materials or Arthrosurface may assist in determining the optimal spacer for performing interpositional arthroplasty Further research about biomimetic materials and autologous cells may be an interesting topic of research aimed to obtain in the future reabsorbable implants or spacers able to stimulate formation of a regenerative tissue as close as possible to the native joint Reference Shereff, M J and Baumhauer, J F.: Hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint J Bone Joint Surg Am 80:898–908, 1998 Mann, R A., Coughlin, M J., and DuVries, H L.: Hallux rigidus: A review of the literature and a method of treatment Clin Orthop 57–63, 1979 S Giannini et al Townley, C O and Taranow, W S.: A metallic hemiarthroplasty resurfacing prosthesis for the hallux metatarsophalangeal joint Foot Ankle Int 15:575–580, 1994 Gould, N.: Hallux rigidus: Cheilotomy or implant? Foot Ankle 1:315–320, 1981 Horton, G A., Park, Y W., and Myerson, M S.: Role of metatarsus primus elevatus in the pathogenesis of hallux rigidus Foot Ankle Int 20(12):777–780, 1999 Beauchamp, C G., Kirby, T., Rudge, S R., Worthington, B S., and Nelson, J.: Fusion of the first metatarsophalangeal joint in forefoot arthroplasty Clin Orthop 249–253, 1984 McMaster, M J.: The pathogenesis of hallux rigidus J Bone Joint Surg Br 60:82–87, 1978 Coughlin, M J.: Arthritides In Coughlin, M J and Mann, R A (eds), Surgery of the foot and ankle, Seventh ed., pp 560–650 St Louis, Mosby, 1999 Feldman, R S., Hutter, J., Lapow, L., and Pour, B.: Cheilectomy and hallux rigidus J Foot Surg 22:170–174, 1983 10 Mackay, D C., Blyth, M., and Rymaszewski, L A.: The role of cheilectomy in the treatment of hallux rigidus J Foot Ankle Surg 36:337–340, 1997 11 Heller, W A and Brage, M E.: The effects of cheilectomy on dorsiflexion of the first metatarsophalangeal joint Foot Ankle Int 18:803–808, 1997 12 Blyth, M J., Mackay, D C., and Kinninmonth, A W.: Dorsal wedge osteotomy in the treatment of hallux rigidus J Foot Ankle Surg 37:8–10, 1998 13 Barca, F.: Tendon arthroplasty of the first metatarsophalangeal joint in hallux rigidus: Preliminary communication Foot Ankle Int 18:222–228, 1997 14 Hamilton, W G and Hubbard, C E.: Hallux rigidus Excisional arthroplasty Foot Ankle Clin 5:663–671, 2000 15 Hamilton, W G., O’Malley, M J., Thompson, F M., and Kovatis, P E.: Roger Mann Award 1995 Capsular interposition arthroplasty for severe hallux rigidus Foot Ankle Int 18:68–70, 1997 16 Wrighton, J D.: A ten-year review of Keller’s operation Review of Keller’s operation at the Princess Elizabeth Orthopaedic Hospital, Exeter Clin Orthop 89:207–214, 1972 17 van Dijk, C N., Veenstra, K M., and Nuesch, B C.: Arthroscopic surgery of the metatarsophalangeal first joint Arthroscopy 14:851–855, 1998 18 Regnauld, B (ed): Disorders of the great toe In: The foot, pp 269–349 Berlin, Springer, 1986 19 Feltham, G T., Hanks, S E., and Marcus, R E.: Age-based outcomes of cheilectomy for the treatment of hallux rigidus Foot Ankle Int 22:192–197, 2001 20 Mann, R A and Clanton, T O.: Hallux rigidus: Treatment by cheilectomy J Bone Joint Surg Am 70:400–406, 1988 21 Trantalis, J J.: The role of cheilectomy in the treatment of hallux rigidus J Foot Ankle Surg 37:171, 1998 22 Giannini, S., Ceccarelli, F., Faldini, C., Bevoni, R., Grandi, G., and Vannini, F.: What’s new in surgical options for hallux rigidus? J Bone Joint Surg Am 86-A (Suppl 2):72–83, 2004 23 Fitzgerald, J A and Wilkinson, J M.: Arthrodesis of the metatarsophalangeal joint of the great toe Clin Orthop 70–77, 1981 Hallux Rigidus: Arthroplasty or Not? 24 Lipscomb, P R.: Arthrodesis of the first metatarsophalangeal joint for severe bunions and hallux rigidus Clin Orthop 48–54, 1979 25 Trnka, H J.: Arthrodesis procedures for salvage of the hallux metatarsophalangeal joint Foot Ankle Clin 5:673–686, ix, 2000 26 Wulker, N.: [Arthrodesis of the metatarsophalangeal joint of the large toe] Orthopade 25:187–193, 1996 27 Shapiro, F and Heller, L.: The Mitchell distal metatarsal osteotomy in the treatment of hallux valgus Clin Orthop 225–231, 1975 28 Cracchiolo, A., III, Weltmer, J B., Jr., Lian, G., Dalseth, T., and Dorey, F.: Arthroplasty of the first metatarsophalangeal joint with a double-stem silicone implant Results in patients who have degenerative joint disease failure of previous operations, or rheumatoid arthritis J Bone Joint Surg Am 74:552–563, 1992 29 Jarde, O., Wable, E., Havet, E., de Lestang, M., and Vives, P.: [Interpositioned metallic prosthesis for hallux rigidus: Review of 42 cases with a metatarsophalangeal prosthesis] Rev Chir Orthop Reparatrice Appar Mot 87:67–72, 2001 30 Shankar, N S.: Silastic single-stem implants in the treatment of hallux rigidus Foot Ankle Int 16:487–491, 1995 31 Swanson, A B., Lumsden, R M., and Swanson, G D.: Silicone implant arthroplasty of the great toe: A review of single stem and flexible hinge implants Clin Orthop 142:30–43, 1979 32 Swanson, A B.: Implant arthroplasty for the great toe Clin Orthop 85:75–81, 1972 33 Papagelopoulos, P J., Kitaoka, H B., and Ilstrup, D M.: Survivorship analysis of implant arthroplasty for the first metatarsophalangeal joint Clin Orthop 302:164–172, 1994 34 Sebold, E J and Cracchiolo, A 3rd: Use of titanium grommets in silicone implant arthroplasty of the hallux metatarsophalangeal joint Foot Ankle Int 17(3):145–151, 1996 35 Konkel, K F and Menger, A G.: Mid-term results of titanium hemi-great toe implants Foot Ankle Int 27(11):922– 929, 2006 36 DeFrino, P F., Brodsky, J W., Pollo, F E., Crenshaw, S J., and Beischer, A D.: First metatarsophalangeal arthrodesis: A clinical, pedobarographic and gait analysis study Foot Ankle Int 23:496–502, 2002 37 Granberry, W M., Noble, P C., Bishop, J O., and Tullos, H S.: Use of a hinged silicone prosthesis for replacement arthroplasty of the first metatarsophalangeal joint J Bone Joint Surg Am 73:1453–1459, 1991 38 Gordon, M and Bullough, P G.: Synovial and osseous inflammation in failed silicone-rubber prostheses J Bone Joint Surg Am 64:574–580, 1982 39 Shereff, M J and Jahss, M H.: Complications of silastic implant arthroplasty in the hallux Foot Ankle 1:95–101, 1980 40 Johnson, K A and Buck, P G.: Total replacement arthroplasty of the first metatarsophalangeal joint Foot Ankle 1:307–314, 1981 41 Lemon, R A., Engber, W D., and McBeath, A A.: A complication of Silastic hemiarthroplasty in bunion surgery Foot Ankle 4:262–266, 1984 245 42 Lau, J T and Daniels, T R.: Outcomes following cheilectomy and interpositional arthroplasty in hallux rigidus Foot Ankle Int 22:462–470, 2001 43 Coughlin, M J and Shurnas, P S.: Hallux rigidus: Demographics, etiology, and radiographic assessment Foot Ankle Int 24(10):731–743, 2003 44 Goucher, N R and Coughlin, M J.: Hallux metatarsophalangeal joint arthrodesis using dome-shaped reamers and dorsal plate fixation: A prospective study Foot Ankle Int 27(11):869–876, 2006 45 Phillips, J E and Hooper, G.: A simple technique for arthrodesis of the first metatarsophalangeal joint J Bone Joint Surg 68-B:774–775, 1996 46 Southgate, J J and Urry, S R.: Hallux rigidus: The longterm results of dorsal wedge osteotomy and arthrodesis in adults J Foot Ankle Surg 36:136–140, 1997 47 Thomson, C E., Westland, E., Maguire, D., and Gibson, J N A.: Evaluation of in-shoe plantar pressures and patient satisfaction following first metatarsophalangeal joint arthrodesis J Bone Joint Surg.82-B (Suppl III ):218, 2000 48 Mann, R A and Thompson, F M.: Arthrodesis of the first metatarsophalangeal joint for hallux valgus in rheumatoid arthritis J Bone Joint Surg Am 66:687–692, 1984 49 Flavin, R and Stephens, M M.: Arthrodesis of the first metatarsophalangeal joint using a dorsal titanium contoured plate Foot Ankle Int 25(11):783–787, 2004 50 Fadel, G., Abboud, R., and Rowley, D.: Implant arthroplasty of the hallux metatarsophalangeal joint The Foot 12:1–9, 2002 51 Fitzgerald, J.: A review of long-term results of arthrodesis of the first metatarsophalangeal joint J Bone Joint Surg 51-B:488–493, 1969 52 Shiel, W C Jr and Jason, M.: Granulomatous inguinal lymphadenopathy after bilateral metatarsophalangeal joint silicone arthroplasty Foot Ankle 6(5):216–218, 1986 53 Botto-van Bemden, A L and SanGiovanni, T P.: A new technique for the surgical management of advanced hallux rigidus with or without deformity A poster presented on Specialty Day at the Annual Meeting of the American Academy of Orthopaedic Surgeons 2007 Feb 17; San Diego, CA; pp 218 54 Leavitt, K M., Nirenberg, M S., Wood, B., and Yong, R M.: Titanium hemigreat toe implant: A preliminary study of its efficacy J Foot Surg 30:289–293, 1991 55 Brage, M E and Ball, S T.: Surgical options for salvage of end-stage hallux rigidus Foot Ankle Clin 7:49–73, 2002 56 Sorbie, C and Saunders, G A.: Hemiarthroplasty in the treatment of hallux rigidus Foot Ankle Int 29(3):273–281, 2008 57 Koenig, R D and Horwitz, L R.: The biomet total toe system utilizing the Koenig score: A five-year review J Foot Ankle Surg 35:23–26, 1996 58 Pulavarti, R S., McVie, J L., and Tulloch, C J.: First metatarsophalangeal joint replacement using the bio-action great toe implant: Intermediate results Foot Ankle Int 26(12):1033–1037, 2005 59 Ghalambor, N., Cho, D R., Goldring, S R., Nihal, A., and Trepman, E.: Microscopic metallic wear and tissue response in failed titanium hallux metatarsophalangeal implants: Two cases Foot Ankle Int 23(2):158–162, 2002 246 60 Keller, W L.: The surgical treatment of bunions and hallux valgus NY Med J 80:741–742, 1904 61 Mroczek, K J and Miller, S D.: The modified oblique Keller procedure: A technique for dorsal approach interposition arthroplasty sparing the flexor tendons Foot Ankle Int 24:521–522, 2003 62 Miller, D and Maffulli, N.: Free gracilis interposition arthroplasty for severe hallux rigidus Bull Hosp Joint Dis 62:121–124, 2005 63 Kennedy, J G., Chow, F Y., Dines, J., Gardner, M., and Bohne, W H.: Outcomes after interpositional arthroplasty for treatment of hallux rigidus Clin Orthop Rel Res 445:210–215, 2006 64 Berlet, G C., Hyer, C F., Lee, T H., Philbin, T M., Hartman, J F., and Wright, M L.: Interpositional arthroplasty of the S Giannini et al first MTP joint using a regenerative tissue matrix for the treatment of advanced hallux rigidus Foot Ankle Int 29(1): 10–21, 2008 65 Gibson, A and Thomson, C E.: Arthrodesis or total replacement arthroplasty for hallux rigidus Foot Ankle Int 26(9):680–690, 2005 66 Raikin, S M., Ahmad, J., Pour, A E., and Abidi, N.: Comparison of arthrodesis and metallic hemiarthroplasty of the hallux metatarsophalangeal joint J Bone Joint Surg Am 89(9):1979– 1985, 2007 67 Roukis, T S., Landsman, A S., Ringstrom, J B., and Kirschner, P.: Wuenschel MDistally based capsule-periosteum interpositional arthroplasty for hallux rigidus Indications, operative technique, and short-term follow-up J Am Podiatr Med Assoc 93(5):349–366, 2003 .. .European Federation of National Associations of Orthopaedics and Traumatology European Instructional Lectures Volume 2009 European Federation of National Associations of Orthopaedics and Traumatology. .. Chairman Prof Dr Pierre Hoffmeyer Members Prof Dr George Bentley Prof Dr Nikolaus Böhler Prof Dr Enric Caceres Palou Mr Stephen R Cannon Dr Manuel Cassiano Neves Prof Dr Alfred Engel Prof Dr Roberto... Giacometti Ceroni Prof Dr Martti Hämäläinen Prof Dr Karl Knahr Prof Dr Philippe Neyret Prof Dr Miklós Szendrői Prof Dr Nikolaus Böhler, Dr Gerold Labek Education Committee Prof Dr Enric Caceres