Non-union incidence of different joint preparation types, joint fixation techniques, and postoperative weightbearing protocols for arthrodesis of the first metatarsophalangeal joint in moderate-to-severe hallux valgus: a systematic review

in EFORT Open Reviews
Authors:
Wout Füssenich Department of Orthopedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

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https://orcid.org/0000-0001-9097-1051
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Gesine H Seeber Department of Orthopedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
University Hospital for Orthopaedics and Trauma Surgery Pius-Hospital, Medical Campus University of Oldenburg, Oldenburg, Germany

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Julian R Zwoferink Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

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Matthijs P Somford Department of Orthopedic Surgery, Rijnstate Hospital, Arnhem, The Netherlands

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Martin Stevens Department of Orthopedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

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Correspondence should be addressed to W Füssenich; Email: w.fussenich@umcg.nl
DOI:
https://doi.org/10.1530/EOR-22-0134
Volume/Issue:
Volume 8: Issue 3
Page Range:
101–109
Article Type:
Review Article
Online Publication Date:
14 Mar 2023
Copyright:
© the author(s) 2023
Category:
Foot & Ankle
Open access

Purpose

  • A systematic review to determine the effect of different types of joint preparation, joint fixation, and postoperative weight-bearing protocols on non-union frequency in first metatarsophalangeal joint (MTPJ) arthrodesis in patients with moderate-to-severe hallux valgus.

Material and methods

  • A systematic literature search (PubMed and EMBASE), adhering to PRISMA guidelines. Data on MTPJ preparation, fixation, weight-bearing, and non-union in patients with moderate-to-severe hallux valgus were collected. Quality assessment was performed using the Coleman Methodology Score.

Results

  • Sixteen studies (934 feet) were included, generally of medium quality. Overall non-union rate was 7.7%. At 6.3%, convex/concave joint preparation had the lowest non-union rate vs 12.2% for hand instruments and 22.2% for planar cuts. Non-union of 2.8% was found for joint fixation with a plate combined with a lag screw vs 6.5% for plate fixation, 11.1% for crossed screw fixation, and 12.5% for a plate with a cross plate compression screw. A 5.1% non-union frequency was found following postoperative full weight-bearing on a flat shoe vs 9.3% for full weight-bearing on a heel weight-bearing shoe and 0% for a partial weight-bearing regimen.

Conclusion

  • Based on medium-quality papers, joint preparation with convex/concave reamers and joint fixation with a plate using a lag screw show the lowest non-union rate. Full postoperative weight-bearing in a stiff-soled postoperative shoe is safe and not associated with non-union vs a more protective load-bearing regimen. Further research should focus on larger sample sizes, longer follow-ups, and stronger study designs.

Abstract

Purpose

  • A systematic review to determine the effect of different types of joint preparation, joint fixation, and postoperative weight-bearing protocols on non-union frequency in first metatarsophalangeal joint (MTPJ) arthrodesis in patients with moderate-to-severe hallux valgus.

Material and methods

  • A systematic literature search (PubMed and EMBASE), adhering to PRISMA guidelines. Data on MTPJ preparation, fixation, weight-bearing, and non-union in patients with moderate-to-severe hallux valgus were collected. Quality assessment was performed using the Coleman Methodology Score.

Results

  • Sixteen studies (934 feet) were included, generally of medium quality. Overall non-union rate was 7.7%. At 6.3%, convex/concave joint preparation had the lowest non-union rate vs 12.2% for hand instruments and 22.2% for planar cuts. Non-union of 2.8% was found for joint fixation with a plate combined with a lag screw vs 6.5% for plate fixation, 11.1% for crossed screw fixation, and 12.5% for a plate with a cross plate compression screw. A 5.1% non-union frequency was found following postoperative full weight-bearing on a flat shoe vs 9.3% for full weight-bearing on a heel weight-bearing shoe and 0% for a partial weight-bearing regimen.

Conclusion

  • Based on medium-quality papers, joint preparation with convex/concave reamers and joint fixation with a plate using a lag screw show the lowest non-union rate. Full postoperative weight-bearing in a stiff-soled postoperative shoe is safe and not associated with non-union vs a more protective load-bearing regimen. Further research should focus on larger sample sizes, longer follow-ups, and stronger study designs.

Keywords: arthrodesis; fusion; MTP1; first MTPJ; first metatarsophalangeal joint; hallux valgus; non-union; pseudoarthrosis

Introduction

Hallux valgus is a deformity of the first metatarsophalangeal joint (MTPJ), causing pain, functional disability, and impaired gait patterns (1, 2, 3, 4). With an estimated 36% prevalence in the elderly, it is a common problem in orthopedic clinics (1). Symptomatic hallux valgus can be treated non-operatively or with soft-tissue procedures, osteotomies or arthrodesis, or a combination of these (5). Arthrodesis of the first MTPJ is commonly chosen for moderate-to-severe hallux valgus (angle > 20° (6)), definitely when degeneration or rheumatoid arthritis is present (5).

First MTPJ arthrodesis is reported to be appropriate surgical management for symptomatic hallux rigidus and hallux valgus because of good patient-reported outcomes and a relatively low risk of complications (7, 8, 9). However, non-union after first MTPJ arthrodesis is one of the most common complications, with an incidence range of 0–24% (10, 11, 12, 13, 14).

The reported incidence of non-union depends on joint fixation and joint preparation techniques, sex, comorbidity, and smoking (15). Multiple joint preparations and joint fixation techniques are available. The joint surfaces can be prepared manually using instruments such as rongeurs and curettes or power tools to achieve a flat-on-flat or convex and concave surface. The arthrodesis can be fixed with screws, Kirschner wires, staples, and/or locking or non-locking plates (12, 16). Each technique has its advantages and disadvantages, which are decisive to further rehabilitation (15).

A systematic review by Korim et al. reflected on literature up to 2016 and mentioned a difference in non-union rates between hallux rigidus and hallux valgus (17). More recent research suggests that non-union is more common in patients with hallux valgus (7, 16, 18). However, to our knowledge, no systematic review has yet been conducted with literature solely focusing on moderate-to-severe hallux valgus. That particular focus is essential because hallux valgus is a different disease than hallux rigidus, with relatively unknown outcomes of arthrodesis. Therefore, the objective of the current study is to conduct a systematic review to gain insight into the effect of different types of joint preparation, joint fixation techniques, and postoperative weight-bearing protocols on non-union frequency in first MTPJ arthrodesis in patients with moderate-to-severe hallux valgus.

Material and methods

This is a systematic review that includes a narrative synthesis. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) principles (19). See Appendix 1 (see section on supplementary materials given at the end of this article) for the PRISMA checklist. The review was registered in PROSPERO in advance (CRD42022351630).

Search strategy

The search strategy was developed with the help of an experienced scientific librarian of the Central Medical Library of the University Medical Center Groningen (UMCG). The electronic databases searched were PubMed and EMBASE. Keyword searches were ‘Hallux Valgus’ and ‘Arthrodesis’. Appendix 2 shows the search strategy, conducted with a search covering January 2012 to August 2022. It was limited to articles published in English, Dutch, and German that contained information on moderate-to-severe hallux valgus, joint preparation, fixation techniques, and postoperative weight-bearing protocol.

Eligibility criteria

Eligible study designs were randomized controlled trials, prospective and retrospective cohort studies, and case series. Cadaveric and biomechanical studies were excluded, as were systematic reviews and meta-analyses. Articles about pathology other than hallux valgus, such as hallux varus, hallux rigidus, and hallux limitus, precluded inclusion. Studies not reporting on non-union or studies in which the individual patient’s treatment plan was indistinguishable were likewise excluded.

Study selection and data collection process

The titles and abstracts identified from the electronic databases were exported to the program Rayyan (Robert Ayan, Cambridge, UK). De-duplication followed the guidelines proposed by Bramer et al. (20) Two independent authors (WF and JZ) reviewed the articles based on the title and abstract. An article was included when the two reviewers agreed that the paper met the inclusion criteria. In the event of a conflict, a third reviewer (MPS) was engaged to assess the conflict. After this first screening, the full texts were retrieved, read, and evaluated by the same two independent reviewers. The same third reviewer assessed conflicts.

Quality assessment

Quality assessment was performed using the Coleman Methodology Score (CMS) (21). This score is a frequently used instrument in orthopedic publications and an accurate and reproducible 10-item scoring system (see Appendix 3). Part A of the CMS gives information about study size and design, follow-up, description of used interventions, and postoperative protocol. Part B provides information about outcome criteria and the subject selection processes (22). The score ranges from 0 to 100, with 100 indicating a well-designed study with a low chance of bias or confounding variables and 0 indicating a poorly designed study with a high probability of bias or confounding variables. To our knowledge, no standard cut-off values for the qualification of methodological quality of the CMS are available. It was decided to rate a study with 0 to 40 points, 40 to 70 points, and over 70 points as low, medium, and high methodological quality, respectively.

Data extraction and analysis

Data on patient demographics, preoperative hallux valgus angle (HVA), joint preparation and joint fixation methods, and postoperative weight-bearing protocol were extracted from the selected articles. Tables that included information about the author and year, number of feet investigated, study design, sample size and subjects’ characteristics, follow-up period, type of preparation and fixation method, HVA, and non-union frequency were created. The outcome measure was the non-union frequency with different surgical techniques for joint preparation, joint fixation, and postoperative weight-bearing protocol. Data are presented as several patients or as a percentage of within-group non-union.

Results

Search results

The literature search yielded 1056 articles. After removing 36 duplicates, the remaining articles were screened for titles and abstracts; 860 were excluded. Next, the remaining 160 full-text articles were assessed for eligibility; 144 were excluded. The reasons for exclusion are shown in Fig. 1. We requested missing patient data by emailing the authors of seven articles but the only data available was from Füssenich et al., 2020 (18, 23, 24, 25, 26, 27, 28). The other articles were therefore excluded. Ultimately 16 articles were included in the data extraction phase (9, 12, 16, 18, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40).

Figure 1
Figure 1

PRISMA flow diagram illustrating search strategy and number of records screened and one included.

Citation: EFORT Open Reviews 8, 3; 10.1530/EOR-22-0134

Study characteristics

There were six prospective cohort studies (9, 18, 30, 31, 32, 33) and ten retrospective articles (12, 16, 29, 34, 35, 36, 37, 38, 39, 40). Follow-up periods ranged from 6 to 29 months. The studies included 934 feet with no foot lost to follow-up. Patient characteristics are presented in Table 1.

Table 1

Patient and study characteristics. Due to our selection of patients with moderate-to-severe hallux valgus, there was data loss in articles that also included hallux rigidus. Data not available or not inducible for patients with moderate-to-severe hallux valgus only.
Study Study design Feet, n Age, years (range) Males, n Females, n
Asif et al. (29) Retrospective 104 - - -
Bass et al. (30) Prospective 13 62 (55–71) 2 11
Chan et al. (31) Prospective 3 66, 68, 48 1 2
Chien et al. (16) Retrospective 47 - - -
Dalat et al. (32) Prospective 208 62.4 (19–87) - 89%*
Doty et al. (33) Prospective 17 - - -
Dureja et al. (34) Retrospective 12 63 (36–83) 2 10
Füssenich et al. (18) Prospective 77 - - -
Gould et al. (9) Prospective 1 - - -
Hoveidaei et al. (35) Retrospective 15 - - -
Korim & Allen (12) Retrospective 49 - - -
Lee et al. (36) Retrospective 25 - 4 21
Maleki et al. (37) Retrospective 274 - - -
Riediger et al. (38) Retrospective 77 60 (39–83) 12 43
Rippstein et al. (39) Retrospective 8 - - -
Sarikaya et al. (40) Retrospective 4 - - -

*Percentage of females of the total participants.

Quality assessment

During the quality assessment, a consensus was reached between the two reviewers in >90% of the cases. One study scored a CMS of 70 (32), indicating high methodological quality. All other studies had CMS scores between 40 and 70 (9, 12, 16, 18, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40), suggesting medium methodological quality. The lowest CMS score was 43 (35) and the average CMS score was 55 points. On average, most points were lost on number of patients, mean follow-up, and study design. Further details can be found in Table 2.

Table 2

A methodological quality score of the included studies. Part A is scored on the study’s design, follow-up, and number of participants. Part B refers to the outcome measures. The total score is a summation of parts A and B.
Study Part A scores Part B scores Part A and B scores
1 2 3 4 5 6 7 Total 1 2 3 Total
Asif et al. (29) 10 0 10 0 5 5 5 35 8 8 10 26 61
Bass et al. (30) 0 2 10 10 5 5 5 37 10 3 5 18 55
Chan et al. (31) 0 0 10 10 5 5 5 35 10 3 5 18 53
Chien et al. (16) 7 0 10 0 5 5 5 32 8 8 5 21 53
Dalat et al. (32) 10 2 10 10 5 5 5 47 10 8 5 23 70
Doty et al. (33) 0 2 10 10 5 5 5 37 10 8 5 23 60
Dureja et al. (34) 0 0 10 0 5 5 5 25 10 8 5 23 48
Füssenich et al. (18) 10 2 10 10 5 5 5 47 10 3 5 18 65
Gould et al. (9) 0 2 10 10 5 5 5 37 10 8 5 23 60
Hoveidaei et al. (35) 0 0 10 0 5 5 0 20 10 8 5 23 43
Korim & Allen (12) 7 0 10 0 5 5 5 32 10 3 5 18 50
Lee et al. (36) 4 0 10 0 5 5 5 29 10 3 5 18 47
Maleki et al. (37) 10 2 10 0 5 5 5 37 10 8 5 23 60
Riediger et al. (38) 10 5 10 0 5 5 5 40 10 3 5 18 58
Rippstein et al. (39) 0 2 10 0 5 5 5 27 10 3 5 18 45
Sarikaya et al. (40) 0 5 10 0 5 5 5 30 6 8 5 19 49

Non-union frequency

The overall non-union frequency was 72 out of 934 feet (7.7%). Data on joint fixation, joint preparation, and postoperative weight-bearing protocols are presented in Table 3.

Table 3

Data extraction table with different joint preparation, fixation, weight-bearing protocols, and non-union. Data are presented for number of patients undergoing the procedures.
Study Total Joint preparation Joint fixation Weight-bearing Follow-up, months Non-union, n (%)
F-O-F Cx/Cn HI P+S CPCS CS Plate Otherα FWFPS FWHWS PW No Yes
Asif et al. (29) 104 - 104 - - - 104 - - 104 - - 2 98 (94.2) 6 (5.8)
Bass et al. (30) 13 - 13 - 13 - - - - - 13 - 12 13 (100) 0 (0)
Chan et al. (31) 3 - 3 - - - - - 3β 3 - - 1.5 0 (0) 3 (100)
Chien et al. (16) 47 - 47 - 47 - - - - - 47 - 1.5 46 (97.9) 1 (2.1)
Dalat et al. (32) 208 - 208 - 208 - - - - 208 - - 18.6 202 (97.1) 6 (2.9)
Doty et al. (33) 17 - 17 - 17 - - - - - 17 - 12 16 (94.1) 1 (5.9)
Dureja et al. (34) 12 - 12 - - - - - 12γ - 12 - 4 12 (100) 0 (0)
Füssenich et al. (18) 77 5 - - - 5 - - - - 5 - 1.5 4 (80) 1 (20)
- 48 - - - 48 - - - 48 - 34 (70.8) 14 (29.2)
- 2 - - - - 2 - - 2 - 2 (100) 0 (0)
- - 16 - - 16 - - - 16 - 13 (81.3) 3 (18.7)
- - 6 - - - 6 - - 6 - 6 (100) 0 (0)
Gould et al. (9) 1 - 1 - - 1 - - - 1 - - 12 0 (0) 1 (100)
Hoveidaei et al. (35) 15 - - 15 - 15 - - - NA NA NA 6 14 (93.3) 1 (6.7)
Korim & Allen (12) 49 49 - - - - 49 - - - 49 - 3 38 (77.6) 11 (22.4)
Lee et al. (36) 25 - - 25 - - - 25 - - 25 - 6 20 (80) 5 (20)
Maleki et al. (37) 274 - 185 - - - 185 - - - 185 - 12 174 (94.1) 11 (5.9)
- 89 - - - - 89 - - 89 - 83 (93.3) 6 (6.7)
Riediger et al. (38) 77 - 77 - - - - 77 - - 77 - 24 75 (97.4) 2 (2.6)
Rippstein et al. (39) 8 - - 8 - - 8 - - - - 8 14.1 8 (100) 0 (0)
Sarikaya et al. (40) 4 - - 4 - - - - 4δ - - 4 29 4 (100) 0 (0)
Total 934 54 806 74 285 16 415 199 19 316 591 12 862 (92.3) 72 (7.7)

αThe group ‘other’ consisted of an intramedullary device, staples, and k-wires; βStaples; γIntramedullary device; δK-wires.

CPCS, cross plate compression screw; CS, crossed screws; Cx/Cn, convex/concave; F-O-F, flat-on-flat; FWFPS, full weight-bearing on flat postoperative shoe; FWHWS, full weight-bearing on heel weight-bearing shoe; HI, hand instruments; P+S, plate+screw; PW, partial weight-bearing.

Non-union frequencies comparing joint preparation techniques

The non-union frequency after a flat-on-flat joint preparation was 12 out of 54 (22.2%). For a convex/concave joint preparation, we saw a non-union rate of 51 out of 806 feet (6.3%). Hand instruments for joint preparation gave non-union in 9 out of 74 feet (12.2%) (Table 4).

Table 4

Results of non-union by joint preparation technique, fixation system and postoperative weight-bearing.
Study design Feet, n Union†, n (%) Non-union†, n (%)
Joint preparation
 Flat-on-flat 54 42 (77.8) 12 (22.2)
 Convex/concave 806 755 (93.7) 51 (6.3)
 Hand instruments 74 65 (87.8) 9 (12.2)
Joint fixation
 Plate + screw 285 277 (97.2) 8 (2.8)
 Crossplate compression screw 16 14 (87.5) 2 (12.5)
 Crossed screws 415 369 (88.9) 46 (11.1)
 Plate 199 186 (93.5) 13 (6.5)
 Other* 19 16 (84.2) 3 (15.8)
Weight-bearing
 Full weight-bearing on flat postoperative shoe 316 300 (94.9) 16 (5.1)
 Full weight-bearing on heel weight-bearing shoe 591 536 (90.7) 55 (9.3)
 Partial weight-bearing 12 12 (100) 0 (0)

*Includes intramedullary device, staples, and k-wires; †Data are presented for n (%) of patients.

Non-union frequencies comparing joint fixation techniques

Non-union frequency after a plate with lag screw joint fixation was 8 out of 285 feet (2.8%); after a plate with cross plate compression screw joint fixation, 2 out of 16 feet (12.5%); after crossed screw joint fixation, 46 out of 415 feet (11.1%); and after a plate joint fixation, 13 out of 199 feet (6.5%). Joint fixation techniques in the group ‘others’ resulted in a non-union frequency of 3 out of 19 feet (15.8%) (Table 4). The group ‘others’ consisted of an intramedullary device, staples, and k-wires. The non-union frequency with the intramedullary device was zero out of 12 feet (0%). For staples, the non-union frequency was 3 out of 3 feet (100%). K-wires resulted in zero non-unions out of 4 feet (0%).

Non-union frequencies comparing postoperative weight-bearing protocol

Our results suggest a non-union frequency of 16 out of 316 feet (5.1%) after full weight-bearing on a flat postoperative shoe. Full weight-bearing on a heel weight-bearing shoe had a non-union frequency of 55 out of 591 feet (9.3%). Non-union frequency after partial weight-bearing was zero out of 12 feet (0%) (Table 4).

Discussion

This systematic review found a non-union percentage for moderate-to-severe hallux valgus of 7.7%, based on studies of overall medium quality. The results were higher than the 4.3–6.5% seen in other systematic reviews of first MTPJ arthrodesis due to hallux rigidus or hallux valgus combined (7, 17, 41). These findings are in line with our hypothesis that the difference in pathogenesis might explain this difference in non-union frequency. While hallux rigidus is characterized by a painful stiffening of the first MTPJ, hallux valgus involves joint hypermobility or axial joint instability (42, 43). We suggest that intrinsic axial instability increases the risk of non-union after the first MTPJ arthrodesis.

Joint preparation

Convex/concave joint preparation had the lowest non-union rate of 6.3%, compared to 12.2% for hand instruments and 22.2% for planar cuts. Although these results should be interpreted with caution due to the unbalanced sample size between techniques, the findings are supported by a biomechanical study by Curtis et al. that suggests convex/concave joint configuration is biomechanically the most stable and planar cuts the least (44). Other biomechanical studies indicate the opposite (45, 46). The convex/concave configuration makes it relatively easy to correct the deformation due to the congruent and matching hemispherical joint interface (47). With planar cuts, it is technically more challenging to correct the hallux valgus in the desired position because the resection wedge must be estimated. Since it is essential to properly correct the valgus deformity, we hypothesize that this may explain our findings (25). However, we do not have data on postoperative HVA to support this hypothesis. Recent research shows that planar cuts are suitable for performing the desired angle correction (48).

Joint fixation

In joint fixation with a plate combined with a lag screw, we found a non-union of 2.8% compared to 6.5% for plate fixation, 11.1% for crossed screw fixation, and 12.5% for a plate with a cross plate compression screw. Superior biomechanical stability explains the low non-union frequency of fixation with a plate with a lag screw (49, 50, 51) However, a plate alone surprisingly has a lower non-union frequency than crossed screws, which is biomechanically more stable than a plate alone (49).

The fixation must hold the arthrodesis in the new, corrected position. The deformity is not always fully corrected. The fixation must thus resist the remaining deforming forces of the adductor hallucis, flexor hallucis brevis, and extensor hallucis longus (17, 52). A lateral release is rarely performed in arthrodesis surgery for hallux valgus, which can put extra stress on the final construct (17).

Based on the outcomes of this systematic review, a plate with cross plate compression screw is less efficient than a plate-and-screw technique, which Cichero et al. also found (53). In the category ‘other’, we see that less commonly used and outdated methods like staples and k-wires perform poorly. The intramedullary device is not widely used in the included studies. Studies using the intramedullary device were all developer-initiated. Hence, more independent research using this technique is strongly warranted before any valid conclusion can be drawn.

Postoperative weight-bearing

We found 5.1% vs 9.3% vs 0% non-union frequencies following postoperative full weight-bearing on a flat shoe, full weight-bearing on a heel weight-bearing shoe, and a partial weight-bearing regimen, respectively. Studies investigating weight-bearing after first MTPJ arthrodesis concluded that there is little difference between postoperative weight-bearing protocols (54, 55). It can be argued that a patient should be limited as little as possible during recovery. The result could show bias because the orthopedic surgeon is more likely to opt for a more protective mobilization regimen when poor fixation or poor bone quality is found. In general, this is difficult to conclude when the percentages are close together and the sample size is small. Remarkable is that the lowest non-union rate happens at the highest load; we hypothesize this is due to the positive effect of mechanical stimulation on bone healing (56, 57, 58).

Strengths, limitations, and future research

To our knowledge, this systematic review is the first to evaluate the non-union incidence of different joint preparation and fixation techniques and postoperative weight-bearing protocols for first MTPJ arthrodesis in patients with moderate-to-severe hallux valgus. Contrary to previous reviews (7, 17), the review was conducted following the PRISMA guidelines, and the study was preregistered in PROSPERO. We also built the search strategy in collaboration with a scientific librarian.

A limitation is the narrative design and descriptive analysis. There was no possibility of conducting a meta-analysis due to study heterogeneity, missing data, and the absence of randomized controlled trials. In general, studies on first MTPJ arthrodesis do not distinguish clearly between hallux rigidus and moderate-to-severe hallux valgus. This made it difficult to determine the outcomes for this specific group and resulted in the exclusion of seven articles (18, 23, 24, 25, 26, 27, 28). In addition, not every study identified age, sex, and HVA in the subgroups.

In terms of evaluation of methodological quality, no standard cut-off values for the qualification of methodological quality of the CMS are available; therefore, we chose these cut-off values ourselves arbitrarily. Last, we limited our search to articles written in English, Dutch, and German. This is because the authors were only proficient in these languages.

Future research should consider a larger sample size and RCT or prospective study design. Also, patient characteristics such as age, sex, comorbidity, weight, and preoperative and postoperative HVA must be more clearly described.

Conclusion

Based on the results of the studies informing this systematic review, the incidence of non-union after the first MTPJ arthrodesis in patients with moderate-to-severe hallux valgus is 7.3%. Joint preparation with convex/concave reamers and joint fixation with a plate with a lag screw shows the lowest non-union rate. Full postoperative weight-bearing in a stiff-soled postoperative shoe is safe and is not associated with non-union vs a more protective load-bearing regimen. These conclusions are drawn based on overall medium-quality papers. Further research should focus on larger sample sizes, longer follow-up, and stronger study designs.

Supplementary materials

This is linked to the online version of the paper at https://doi.org/10.1530/EOR-22-0134.

ICMJE Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Statement

This work did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.

Author contribution statement

All authors delivered substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; and Drafting the work or revising it critically for important intellectual content; and Final approval of the version to be published; and Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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    Bennett GL, & Sabetta J. First metatarsalphalangeal joint arthrodesis: evaluation of plate and screw fixation. Foot and Ankle International 2009 30 752–757. (https://doi.org/10.3113/FAI.2009.0752)

    • PubMed
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  • 12.↑

    Korim MT, & Allen PE. Effect of pathology on union of first metatarsophalangeal joint arthrodesis. Foot and Ankle International 2015 36 51–54. (https://doi.org/10.1177/1071100714549046)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.↑

    Roukis TS, Meusnier T, & Augoyard M. Incidence of nonunion of first metatarsophalangeal joint arthrodesis for severe hallux valgus using crossed, flexible titanium intramedullary nails and a dorsal static staple with immediate weightbearing in female patients. Journal of Foot and Ankle Surgery 2012 51 433–436. (https://doi.org/10.1053/j.jfas.2012.02.008)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.↑

    Füssenich W, Scholten R, Rijnberg W, & Somford M. High incidence of non-union following arthrodesis of the first metatarsophalangeal joint. Clinical Research on Foot and Ankle 2018 6 2016–2019. (https://doi.org/10.4172/2329-910x.1000269)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.↑

    LaCoste KL, Andrews NA, Ray J, Harrelson WM, & Shah A. First metatarsophalangeal joint arthrodesis: a narrative review of fixation constructs and their evolution. Cureus 2021 13 e14458. (https://doi.org/10.7759/cureus.14458)

    • PubMed
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  • 16.↑

    Chien C, Alfred T, Freihaut R, & Pit S. First metatarsophalangeal joint arthrodesis in hallux valgus versus hallux rigidus using cup and cone preparation compression screw and dorsal plate fixation. Cureus 2017 9 e1786. (https://doi.org/10.7759/cureus.1786)

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  • 17.↑

    Korim MT, Mahadevan D, Ghosh A, & Mangwani J. Effect of joint pathology, surface preparation and fixation methods on union frequency after first metatarsophalangeal joint arthrodesis: a systematic review of the English literature. Foot and Ankle Surgery 2017 23 189–194. (https://doi.org/10.1016/j.fas.2016.05.317)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.↑

    Füssenich W, Brusse-Keizer MGJ, & Somford MP. Severe hallux valgus angle attended with high incidence of nonunion in arthrodesis of the first metatarsophalangeal joint: a follow-up study. Journal of Foot and Ankle Surgery 2020 59 993–996. (https://doi.org/10.1053/j.jfas.2020.05.007)

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  • 19.↑

    Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021 372. (https://doi.org/10.1136/bmj.n71)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.↑

    Bramer WM, Giustini D, De Jong GB, Holland L, & Bekhuis T. De-duplication of database search results for systematic reviews in endnote. Journal of the Medical Library Association 2016 104 240–243. (https://doi.org/10.3163/1536-5050.104.3.014)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.↑

    Coleman BD, Khan KM, Maffulli N, Cook JL, & Wark JD. Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scandinavian Journal of Medicine and Science in Sports 2000 10 2–11. (https://doi.org/10.1034/j.1600-0838.2000.010001002.x)

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    Maffulli N, Papalia R, Palumbo A, Del Buono A, & Denaro V. Quantitative review of operative management of hallux rigidus. British Medical Bulletin 2011 98 75–98. (https://doi.org/10.1093/bmb/ldq041)

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  • 23.↑

    Kannan S, Bennett A, Chong HH, Hilley A, Coorsh J, Murty A, Townshend D, Kakwani R, & Bhatia M. A multicenter retrospective cohort study of first metatarsophalangeal joint arthrodesis. Journal of Foot and Ankle Surgery 2021 60 436–439. (https://doi.org/10.1053/j.jfas.2020.05.015)

    • PubMed
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  • 24.↑

    Weber C, Yao D, Schwarze M, Andersson K, Andric V, Kinkelin M, Claassen L, Stukenborg-Colsman C, & Waizy H. Risk analysis of nonunion after first metatarsophalangeal joint arthrodesis. Foot and Ankle Specialist 2021 14 120–125. (https://doi.org/10.1177/1938640019899829)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.↑

    Weigelt L, Redfern J, Heyes GJ, Butcher C, Molloy A, & Mason L. Risk factors for nonunion after first metatarsophalangeal joint arthrodesis with a dorsal locking plate and compression screw construct: correction of hallux valgus is key. Journal of Foot and Ankle Surgery 2021 60 1179–1183. (https://doi.org/10.1053/j.jfas.2020.12.007)

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  • 26.↑

    Whitt KJ, Rincker SA, & Hyer CF. Sustainability of forefoot reconstruction for the rheumatoid foot. Journal of Foot and Ankle Surgery 2016 55 583–585. (https://doi.org/10.1053/j.jfas.2016.02.003)

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    Mehtar M, Saragas NP, & Ferrao PN. Outcomes of bilateral simultaneous hallux MTPJ fusion. Foot and Ankle Surgery 2021 27 213–216. (https://doi.org/10.1016/j.fas.2020.04.012)

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    Desmarchelier R, Besse JL, Fessy MH & French Association of Foot Surgery (AFCP). Scarf osteotomy versus metatarsophalangeal arthrodesis in forefoot first ray disorders: comparison of functional outcomes. Orthopaedics and Traumatology, Surgery and Research 2012 98(Supplement) S77–S84. (https://doi.org/10.1016/j.otsr.2012.04.016)

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    Asif M, Qasim SN, Kannan S, & Bhatia M. A consecutive case series of 166 first metatarsophalangeal joint fusions using a combination of cup and cone reamers and crossed cannulated screws. Journal of Foot and Ankle Surgery 2018 57 462–465. (https://doi.org/10.1053/j.jfas.2017.10.026)

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    Dureja K, & Bhardwaj SH. The functional outcome of hallux metatarsophalangeal joint arthrodesis using hallux intramedullary fusion device. Indian Journal of Orthopaedics 2021 55 103–109. (https://doi.org/10.1007/s43465-020-00194-4)

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    Cichero MJ, Yates BJ, Joyce ASD, Williamson DM, & Walsh TP. Different fixation constructs and the risk of non-union following first metatarsophalangeal joint arthrodesis. Foot and Ankle Surgery 2021 27 789–792. (https://doi.org/10.1016/j.fas.2020.10.006)

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Online ISSN:
2058-5241
Copyright:
© the author(s) 2023
Article Type:
Review Article
Page Range:
101–109
Published Online:
14 Mar 2023
Keywords:
arthrodesis; fusion; MTP1; first MTPJ; first metatarsophalangeal joint; hallux valgus; non-union; pseudoarthrosis
  • Figure 1
    View in gallery
    Figure 1

    PRISMA flow diagram illustrating search strategy and number of records screened and one included.

Figure 1

PRISMA flow diagram illustrating search strategy and number of records screened and one included.
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    Mandell D, Karbassi J, Zhou H, Burroughs B, Aurigemma P, & Patel AR. A locking compression plate versus the gold-standard non-locking plate with lag screw for first metatarsophalangeal fusion: A biomechanical comparison. Foot 2018 34 69–73. (https://doi.org/10.1016/j.foot.2017.11.001)

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    Gould AER, Logan K, Lin Z, Marsland D, & Elliot RR. A prospective evaluation of first metatarsophalangeal fusion using an innovative dorsal compression plating system. Journal of Foot and Ankle Surgery 2021 60 891–896. (https://doi.org/10.1053/j.jfas.2021.02.011)

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    Bennett GL, & Sabetta J. First metatarsalphalangeal joint arthrodesis: evaluation of plate and screw fixation. Foot and Ankle International 2009 30 752–757. (https://doi.org/10.3113/FAI.2009.0752)

    • PubMed
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  • 12.

    Korim MT, & Allen PE. Effect of pathology on union of first metatarsophalangeal joint arthrodesis. Foot and Ankle International 2015 36 51–54. (https://doi.org/10.1177/1071100714549046)

    • PubMed
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    • Export Citation
  • 13.

    Roukis TS, Meusnier T, & Augoyard M. Incidence of nonunion of first metatarsophalangeal joint arthrodesis for severe hallux valgus using crossed, flexible titanium intramedullary nails and a dorsal static staple with immediate weightbearing in female patients. Journal of Foot and Ankle Surgery 2012 51 433–436. (https://doi.org/10.1053/j.jfas.2012.02.008)

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    • Search Google Scholar
    • Export Citation
  • 14.

    Füssenich W, Scholten R, Rijnberg W, & Somford M. High incidence of non-union following arthrodesis of the first metatarsophalangeal joint. Clinical Research on Foot and Ankle 2018 6 2016–2019. (https://doi.org/10.4172/2329-910x.1000269)

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    • Export Citation
  • 15.

    LaCoste KL, Andrews NA, Ray J, Harrelson WM, & Shah A. First metatarsophalangeal joint arthrodesis: a narrative review of fixation constructs and their evolution. Cureus 2021 13 e14458. (https://doi.org/10.7759/cureus.14458)

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    • Export Citation
  • 16.

    Chien C, Alfred T, Freihaut R, & Pit S. First metatarsophalangeal joint arthrodesis in hallux valgus versus hallux rigidus using cup and cone preparation compression screw and dorsal plate fixation. Cureus 2017 9 e1786. (https://doi.org/10.7759/cureus.1786)

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  • 17.

    Korim MT, Mahadevan D, Ghosh A, & Mangwani J. Effect of joint pathology, surface preparation and fixation methods on union frequency after first metatarsophalangeal joint arthrodesis: a systematic review of the English literature. Foot and Ankle Surgery 2017 23 189–194. (https://doi.org/10.1016/j.fas.2016.05.317)

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  • 18.

    Füssenich W, Brusse-Keizer MGJ, & Somford MP. Severe hallux valgus angle attended with high incidence of nonunion in arthrodesis of the first metatarsophalangeal joint: a follow-up study. Journal of Foot and Ankle Surgery 2020 59 993–996. (https://doi.org/10.1053/j.jfas.2020.05.007)

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    Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021 372. (https://doi.org/10.1136/bmj.n71)

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  • 20.

    Bramer WM, Giustini D, De Jong GB, Holland L, & Bekhuis T. De-duplication of database search results for systematic reviews in endnote. Journal of the Medical Library Association 2016 104 240–243. (https://doi.org/10.3163/1536-5050.104.3.014)

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  • 21.

    Coleman BD, Khan KM, Maffulli N, Cook JL, & Wark JD. Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scandinavian Journal of Medicine and Science in Sports 2000 10 2–11. (https://doi.org/10.1034/j.1600-0838.2000.010001002.x)

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  • 22.

    Maffulli N, Papalia R, Palumbo A, Del Buono A, & Denaro V. Quantitative review of operative management of hallux rigidus. British Medical Bulletin 2011 98 75–98. (https://doi.org/10.1093/bmb/ldq041)

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    • Export Citation
  • 23.

    Kannan S, Bennett A, Chong HH, Hilley A, Coorsh J, Murty A, Townshend D, Kakwani R, & Bhatia M. A multicenter retrospective cohort study of first metatarsophalangeal joint arthrodesis. Journal of Foot and Ankle Surgery 2021 60 436–439. (https://doi.org/10.1053/j.jfas.2020.05.015)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Weber C, Yao D, Schwarze M, Andersson K, Andric V, Kinkelin M, Claassen L, Stukenborg-Colsman C, & Waizy H. Risk analysis of nonunion after first metatarsophalangeal joint arthrodesis. Foot and Ankle Specialist 2021 14 120–125. (https://doi.org/10.1177/1938640019899829)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Weigelt L, Redfern J, Heyes GJ, Butcher C, Molloy A, & Mason L. Risk factors for nonunion after first metatarsophalangeal joint arthrodesis with a dorsal locking plate and compression screw construct: correction of hallux valgus is key. Journal of Foot and Ankle Surgery 2021 60 1179–1183. (https://doi.org/10.1053/j.jfas.2020.12.007)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Whitt KJ, Rincker SA, & Hyer CF. Sustainability of forefoot reconstruction for the rheumatoid foot. Journal of Foot and Ankle Surgery 2016 55 583–585. (https://doi.org/10.1053/j.jfas.2016.02.003)

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