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Comparison of Arthrodesis and Metallic Hemiarthroplasty of the Hallux Metatarsophalangeal Joint
Steven M. Raikin, MD1; Jamal Ahmad, MD1; Aidin Eslam Pour, MD1; Nicholas Abidi, MD2
1 Department of Orthopaedic Surgery, Rothman Institute and Thomas Jefferson University Hospital, 925 Chestnut Street, Philadelphia, PA 19107
2 Santa Cruz Orthopaedic Institute, 1505 Soquel Drive, Suite 12, Santa Cruz, CA 95065
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Rothman Institute and Thomas Jefferson University Hospital, Philadelphia, Pennsylvania

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Sep 01;89(9):1979-1985. doi: 10.2106/JBJS.F.01385
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Abstract

Background: Currently, arthrodesis is the most commonly performed surgical procedure for the treatment of severe arthritis of the first metatarsophalangeal joint. The objective of this study was to compare the long-term clinical and radiographic outcomes of a metallic hemiarthroplasty with those of arthrodesis for the treatment of this condition.

Methods: A series of patients with osteoarthritis of the first metatarsophalangeal joint were treated with either a metallic hemiarthroplasty or an arthrodesis between 1999 and 2005. Postoperative satisfaction and function were graded with use of the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal Interphalangeal (AOFAS-HMI) scoring system, and pain was scored with use of a visual analogue scale.

Results: Twenty-one hemiarthroplasties and twenty-seven arthrodeses were performed in forty-six patients. Five (24%) of the hemiarthroplasties failed; one of them was revised, and four were converted to an arthrodesis. 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 hemiarthroplasty group were good or excellent for twelve feet, fair for two, and poor or a failure for seven. The mean pain score was 2.4 of 10. All twenty-seven of the arthrodeses achieved fusion, and no revisions were required. At the time of final follow-up (at a mean of thirty months), the satisfaction ratings in this group were good or excellent for twenty-two feet, fair for four, and poor for one. The mean pain score was 0.7 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.

Conclusions: Arthrodesis is more predictable than a metallic hemiarthroplasty for alleviating symptoms and restoring function in patients with severe osteoarthritis of the first metatarsophalangeal joint.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Jamal Ahmad, M.D.
    Posted on November 13, 2007
    Dr. Ahmad et al. respond to Mr. Mrak.
    Rothman Institute Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, PA

    We thank Mr.Mrak for his critique of our study(1).

    After careful review of Figures 2a and 2b, he is indeed correct that these images are of two different implants in two different patients. This was an oversight on our part as many different patients developed implant subsidence dorsally. Upon final postoperative follow-up, these two images were inadvertently mismatched. We apologize for any confusion with the initial and final post-operative position of the metallic hemiarthroplasty in the paper.

    While Mr. Mrak refers to additional papers (2-5) regarding the metallic hemiarthroplasty, we did not include these in our text as they are not truly peer-reviewed studies. The second reference was not published in a peer-reviewed orthopaedic journal, but rather in a periodical discussing operative techniques solely. The third through fifth references are co-authored by Dr. Townley, Dr. Taranow, or both. As these two surgeons helped to design the metallic hemiarthroplasty, these three papers may have inherent bias. In our independent and unbiased study, we were unable to reproduce the excellent results that Drs. Taranow and Townley have previously reported with use of the metallic hemiarthroplasty.

    Thank you for your critical analysis of our study. We look forward to any future discussion.

    References:

    1. Steven M. Raikin, Jamal Ahmad, Aidin Eslam Pour, and Nicholas Abidi Comparison of Arthrodesis and Metallic Hemiarthroplasty of the Hallux Metatarsophalangeal Joint J Bone Joint Surg Am 2007; 89: 1979-1985.

    2. Giza E, Sullivan MR. First Metatarsophalangeal Hemiarthroplasty for Grade III and IV Hallux Rigidus Techniques in Foot and Ankle Surgery 4(1):10-17,2005.

    3. Roukis TS, Townley CO. BIOPRO resurfacing endoprosthesis osteotomy for hallux rigidus: short-term follow-up Journal of Foot & Ankle Surgery 2003;42(6):350-8.

    4. Taranow WS, Townley CO. Metallic proximal phalangeal hemiarthroplasty for hallux rigidus. Operative Techniques in Orthopaedics 1999;9(1):33-6.

    5. Contemporary Approaches to Stage II and III Hallux Rigidus: The Role of Metallic Hemiarthroplasty of the Proximal Phalanx Warren S. Taranow, DO,*, Michael J. Moutsatson, DO, Jonathan M. Cooper, DO Foot Ankle Clin N Am 10 (2005) 713– 728

    David Mrak
    Posted on October 18, 2007
    Metallic Hemiarthroplasty of the Hallux Metatarsophalangeal Joint
    BioPro, Inc. Port Huron, MI

    To The Editor:

    In the recent article “Comparison of Arthrodesis and Metallic Hemiarthroplasty of the Hallux Metatarsophalangeal Joint”(1),the authors state that Fig 2-A is an initial post operative x-ray and that Fig 2-B is "the final evaluation" radiograph taken at 72 months post-operatively showing that the implant has subsided over time and is no longer perpendicular to the phalanx. However, upon inspection, one will notice that the implant in figure 2-A is porous coated. The coating on the stem is visible and the thickness of the implant is greater. In contrast, in figure 2-B, the implant is a non-porous coated implant. It is apparent to me that these are two different implants. Therefore, it is inaccurate to state that the implant has shifted when clearly the x-rays are from two different patients.

    In considering just figure 2B, it is possible that the implant was initially implanted at an incorrect angle, which is a technical error that may occur if the initial cut is not made perpendicular to the axis of the phalanx, but I do not believe that it can be concluded that the implant did shift from its initial position based on the x-rays provided.

    Also, there are additional peer reviewed studies published about this prosthesis that were not included in the references but which report substantially different results than those found in this study(2-5).

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (BioPro). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. Steven M. Raikin, Jamal Ahmad, Aidin Eslam Pour, and Nicholas Abidi Comparison of Arthrodesis and Metallic Hemiarthroplasty of the Hallux Metatarsophalangeal Joint J Bone Joint Surg Am 2007; 89: 1979-1985

    2. Giza E, Sullivan MR. First Metatarsophalangeal Hemiarthroplasty for Grade III and IV Hallux Rigidus Techniques in Foot and Ankle Surgery 4(1):10-17,2005

    3. Roukis TS, Townley CO. BIOPRO resurfacing endoprosthesis osteotomy for hallux rigidus: short-term follow-up Journal of Foot & Ankle Surgery 2003;42(6):350-8

    4. Taranow WS, Townley CO. Metallic proximal phalangeal hemiarthroplasty for hallux rigidus. Operative Techniques in Orthopaedics 1999;9(1):33-6

    5. Contemporary Approaches to Stage II and III Hallux Rigidus: The Role of Metallic Hemiarthroplasty of the Proximal Phalanx Warren S. Taranow, DO,*, Michael J. Moutsatson, DO, Jonathan M. Cooper, DO Foot Ankle Clin N Am 10 (2005) 713– 728

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