Video Gallery

Video Gallery

To View the Video

Current Concepts in the Management of Advanced/End-Stage Hallux Rigidus

March 01, 2019

Contributors: Tyler Gonzalez, MD; David B Thordarson, MD; Timothy Charlton, MD; Timothy Charlton, MD

Polyvinyl alcohol (PVA) implants are used in many areas of orthopaedic surgery. A PVA implant currently available on the market can be used to manage end-stage hallux rigidus. This implant is touted to improve range of motion, function, and pain without the need for fusion. The literature on hydrogel implants is thorough. Prospective randomized trials report good outcomes in patients who undergo treatment with a hydrogel implant, with 2- and 5-year results demonstrating almost 100% implant survivorship, improved range of motion, and maintained pain and functional relief. A noninferiority study reported that hydrogel implants are noninferior to fusion with a 15% margin. Therefore, at least 85% of patients who undergo treatment with a hydrogel implant will have pain and functional outcomes as good as those of patients who undergo fusion. Hydrogel implants are more beneficial than metatarsophalangeal (MTP) joint arthroplasty because minimal bone loss occurs; therefore, conversion to MTP fusion may be easier in patients who undergo treatment with a hydrogel implant. Studies on conversion from a hydrogel implant to MTP fusion demonstrate that, if the implant fails, conversion to fusion results in the same fusion rate and functional outcomes as primary fusion for the management of end-stage hallux rigidus. In the past 22 months, we have performed 90 hydrogel implant procedures. The results demonstrate good pain relief, excellent functional outcomes, and good implant survivorship. We had to revise three implants because of subsidence, and one implant required conversion to fusion. Overall, our experience with hydrogel implants has been positive; however, we realize the limitations of this device. Approximately 25% of our patients required a dorsiflexion osteotomy of the proximal phalanx during the index procedure to improve dorsiflexion. Approximately one-third of our patients had stiffness and inflammation 3 months postoperatively and required dorsal capsule injection. We have been integrating the use of dynamic splints into our postoperative protocol. We recognize that our data are limited; however, our patients appear to have improved range of motion and pain scores. Our indications for a hydrogel implant have changed in the past 22 months. Patients with stiffness and limited range of motion, mild or moderate hallux valgus, or sesamoid pain are not ideal candidates for a hydrogel implant. We believe these variables have led to less-than-satisfactory outcomes. We have modified the surgical technique described in the literature. We leave the implant 2 to 3 mm proud rather than 0.5 to 1.5 mm proud, which is recommended by the technique guide. We do not bottom out the reamer, and we use a freer elevator to ensure the reamer does not fully advance. We believe that overreaming may be the reason we observed subsidence in our first patients. Since limiting reamer depth, we observed no subsidence and improved joint space on radiographs. Desired passive range of motion was not achieved intraoperatively in approximately 15% to 20% of our patients; therefore, a dorsiflexion osteotomy of the proximal phalanx was required to improve dorsiflexion. We have retrospectively collected Patient-Reported Outcomes Measurement Information System data on our patients. Overall, our current Patient-Reported Outcomes Measurement Information System data is positive, with a mean physical function score of 42.4, a mean pain interference score of 56.8, and a depression score of 50.6 at a mean follow up of 6 months. We acknowledge this is not long-term data but feel it shows positive results in many of our patients. Overall, our experience with hydrogel implants has been positive; however, our indications have narrowed, and our surgical technique and rehabilitation protocols have changed. We believe hydrogel implants are valuable for the management of hallux rigidus, especially in patients who require specific shoes for work or social activities and patients with jobs/activities that require dorsiflexion of the hallux MTP joints. Appropriate informed consent must be given to patients undergoing treatment with a hydrogel implant, and patients must understand that they will likely require revision or conversion to MTP fusion. In patients who understand these risks and are good candidates for the procedure, hydrogel implants are a good treatment option for management of end-stage hallux rigid and an alternative to hallux MTP fusion.

Results for "Foot & Ankle"

1 of 7
1 of 7

X