Aims

Arthroplasty for end-stage hallux rigidus (HR) is controversial. Arthrodesis remains the gold standard for surgical treatment, although is not without its complications, with rates of up to 10% for nonunion, 14% for reoperation and 10% for metatarsalgia. The aim of this study was to analyze the outcome of a double-stemmed silastic implant (Wright-Medical, Memphis, Tennessee, USA) for patients with end-stage HR.

Introduction. There are a number of options available for surgical management of hallux rigidus. Ceramic implants of the first metatarsophalangeal joint (MTPJ) have been available for years; however there are no published long-term results existing. Methods. We performed a retrospective review of all consecutive first MTPJ replacements carried out for later stage hallux rigidus using second generation MOJE ceramic implant with press-fit design. Two specialised foot and ankle surgeons performed these operations at a tertiary referral centre. Patient underwent regular follow ups including clinical review, functional scoring (AOFAS and FFI) and assessment of radiographs. Kaplan Meyer Survival analysis was performed. Results. Our study included 31 prostheses in 24 female patients. Average age at operation was 55.3 years and average follow up time was 80 months. No patients were lost until follow up. Complications included one case of superficial infection and five cases of revision, reasons being fracture of the prostheses (1), unexplained pain (1), subluxation (1) and loosening/sinkage of the implant (2). Prosthesis survival rate was 85.2% at seven years. Assessment of the radiographs showed considerable sinkage of the prosthesis in 43%, tilting in 33% and loosening of the implant in 40.9%. Average postoperative AOFAS score was 71.6 and the average FFI was 27.7. 84% of the patients were satisfied with the results of their operation. Conclusion. Surgery has failed to preserve the function and increase the range of movement in most cases in the long duration. From the patients perspective however the satisfaction with the procedure suggests a success of the implant. Due to poor radiological results and high revision rate we do not recommend the routine use of this prosthesis and all patients that have this type of prosthesis need regular follow up consultations at least yearly with radiographs to assess the position of the implant

The December 2012 Wrist & Hand Roundup. 360. looks at: the imaging of scaphoid fractures; splinting to help Dupuytren’s disease; quality of life after nerve transfers; early failure of Moje thumbs; electra CMCJ arthroplasty; proximal interphalangeal joint replacement; pronator quadratus repair in distal radius fractures; and osteoporosis and wrist fractures

We systematically reviewed all the evidence published in the English language on proximal interphalangeal joint (PIPJ) replacement, to determine its effectiveness on the function of the hand and the associated post-operative complications.

Original studies were selected if they reported clinical outcome with a minimum of one year’s follow-up. Quality was assessed using the Cowley systematic review criteria modified for finger-joint replacements. Of 319 articles identified, only five were adequately reported according to our quality criteria; there were no randomised controlled trials. PIPJ replacements had a substantial effect size on hand pain of -23.2 (95% confidence interval (CI) -27.3 to -19.1) and grip strength 1.2 (95% CI -10.7 to 13.1), and a small effect on range of movement 0.2 (95% CI -0.4 to 0.8). A dorsal approach was most successful. Post-operative loosening occurred in 10% (95% CI 3 to 30) of ceramic and 12.5% (95% CI 7 to 21) of pyrocarbon replacements. Post-operative complications occurred in 27.8% (95% CI 20 to 37).

We conclude that the effectiveness of PIPJ replacement has not been established. Small observational case studies and short-term follow-up, together with insufficient reporting of patient data, functional outcomes and complications, limit the value of current evidence.

We recommend that a defined core set of patients, surgical and outcome data for this intervention be routinely and systematically collected within the framework of a joint registry.

Introduction: Osteoarthritis of the first metatarsopha-langeal joint (MTPJ) is common. A range of surgical treatment options is described, including different designs of total arthroplasty. The MOJE is a ceramic-on-ceramic press fit arthroplasty. We present a maximum 8 year follow up of 32 procedures. Methods: 32 MOJE arthroplasties were undertaken by the senior author (MF) in 30 patients (9 male, 21 female; mean age 61.9, range 37–76) over six years. Patients were followed up in special clinics where symptoms, levels of function and radiographs were subjectively and objectively scored using the SF-36, modified Kitaoka and AOFAS systems. Results: 100% follow-up was achieved, with mean time since surgery 58 months (range 25–97). Mean scores were: Kitaoka 53.8 (15–75, maximum possible 75), AOFAS score was 61.3/100 (range 18–100, maximum 100), SF-36 physical score 48.6 (27.6–58.7) SF-36 mental score 52.2 (19.5–62.2). Eight implants had required revision; two for component fracture. Radiologically, 15 showed component subsidence, 9 demonstrating radiolucency around one or both components. In one case where the patient had not undergone reoperation component fracture was seen on x-ray. Clinically, in patients who had not undergone subsequent fusion, 15 had less than 36 degrees of movement, 9 had between 36–45 degrees, 4 were in the 46–60 range and only one had more than 60 degrees. There were no cases of infection. Discussion: Although several previous studies have suggested favourable initial outcomes with this implant, all focus only on early results. The longest follow-up we found was 29 months; these authors quote excellent early outcomes but acknowledge the need for longer-term follow-up. In our series, the reoperation rate of 25% up to 8 years is worryingly high. Whilst a cohort of patients clearly have satisfactory results with the MOJE, we would suggest that surgeons contemplating its use give due consideration to these outcomes before proceeding

We prospectively assessed a consecutive series of patients undergoing MTPJ arthroplasty with the MOJE prosthesis. All patients entered into the study were assessed preoperatively with the AOFAS 100-point Hallux Meta-tarsophalangeal-Interphalangeal Joint Scale and the range of motion was recorded. Patients were assessed on table postoperatively for range of motion (ROM) and then at 3, 12 and 24 months with AOFAS scores and ROM. Forty-two toes (40 patients) were recruited into the study. There were 24 women and 16 men. The mean patient age on the day of surgery was 59 (range 37 to 73). 18 operations were carried out on the left hallux and 24 on the right. All operations were carried out for a diagnosis of hallux rigidus (although one patient also had hallux valgus, with an intermetatarsal angle of 24° and a hallux valgus angle of 40°). The mean pre-op AOFAS score increased from 36.0 to 82.2 at 3 months (p< 0.001) and was 87.0 at 12 months and 84.2 at 24 months. There was no significant change in scores from 3 months onwards. Only 2 patients had a follow-up of 36 months; both of them had AOFAS scores of 95. The mean arc of motion reduced from 70.8° on-table to 33.3° by 24 months (p< 0.001). The difference in arc of motion from 3 months to 12 months was a decrease from 45.6 to 40.0 which was borderline significant. In 4 radiographs there was evidence of progressive loosening (figure 4). This was at 24 months in all 4 cases. For 3 of the patients the AOFAS score was 85. For the 4th patient the AOFAS score was 65. One patient had a spontaneous fusion of the toe. There were also three episodes of wound breakdown, one patient had intra-operative division of the EHL tendon that was repaired. We also noted post-operatively that: three feet developed Morton’s neuromata; one patient developed tarsometatarsal joint osteoarthritis of the great toe, one sesamoid osteoarthritis and one plantar fasciitis. At the most recent follow-up appointment 33 out of 40 patients (82.5%) were satisfied with the results of their operation, 2 were dissatisfied (5%) and results regarding satisfaction were not available for 5 patients. The results obtained in this paper demonstrate good, prospective, short-term results with the press-fit zirconium ceramic Moje implant. We believe that in the correct patient group good short term results can be achieved in the treatment of 1st MTPJ osteoarthritis as an alternative to fusion, particularly in those patients who are unwilling to have permanent stiffness in this joint for cosmetic or functional reasons

Aim: To assess medium term results of MOJE arthroplasty for degenerative Hallux Rigidus. Materials and Methods: Patients over 18 years of age with symptomatic degenerative hallux rigidus, with at least three years follow up were included in the study. Patients who had previous surgery for hallux rigidus were excluded. A press fit Moje ceramic on ceramic prosthesis was implanted using the standard technique. Patients were non-weight bearing for the initial two weeks followed by physiotherapy according to the Moje protocol. All patients were assessed radiologically and clinically using the AOFAS (American Orthopaedic Foot and Ankle Society) and Foot Function Index (FFI – R, short form) as the primary outcome measure and a Visual Analogue Pain score (VAS) as the secondary outcome measure. Radiological assessment was carried out independently by two authors. Prosthesis loosening was defined as more than 5mm subsidence (sum of proximal and distal components), implant tilting and presence of osteolytic lesions. Revision of arthroplasty was taken as an end point to define failure. Results: 27 Moje replacements of the first metatarso-phalangeal joint in 25 patients operated by one surgeon were included in the study. There were 22 female and 3 male patients with a mean age of 61 (range: 48–83). Mean preoperative range of movement (sum of dorsi and plantar flexion) was 310 (range: 10–65). Mean preoperative FFI – R score was 100 (range: 53–183); mean preoperative AOFAS score was 45 (range: 28–64); mean preoperative VAS was 8 (range: 3–10). The average follow up was 49 months (range: 36–60). There were no wound complications. Postoperatively, 5 joints (19%) required closed manipulation and 3 joints (11%) required open arthrolysis to improve the range of movement. Three joints (11%) drifted into valgus, two of them requiring a corrective Akin osteotomy of the proximal phalanx. One patient (4%) required open reduction for dislocation and one patient required excision of the medial sesamoid for persistent pain. In all, 12 replacements (44%) were symptomatic enough to require a further procedure. None of the joints required revision. The mean postoperative range of movement was 350 (range: 15–60, p=0.85, Relative Risk=1.069, 95% Confidence Interval: 0.72–1.59). There was improvement in postoperative FFI–R score (mean: 41, Range: 27–66, p=0.007, RR=0.53, 95% CI: 0.34–0.83), AOFAS score (mean: 83, range: 68–100, p=0.07, RR: 1.5, 95% CI: 0.98–2.38) and VAS (mean: 1, range: 0–5, p=0.04, RR: 0.80, 95% CI: 0.0.66–0.97). Radiologically, there were signs of loosening of prosthesis in 4 joints (15%) without an adverse outcome in pain and functional scores. Discussion: There is a high incidence of stiffness requiring further surgical procedure to improve the range of movement following this replacement. Although pain and function scores improve with Moje arthroplasty, patients should be counselled that their range of movement may not improve and annual long-term clinical and radiological surveillance would be necessary to assess the integrity of this prosthesis. Further studies including larger number of patients with longer follow up are required to assess the long-term results of this procedure

Background: The painful 1st metatarso-phalangeal joint (MTPJ) is a common presentation in outpatient clinics. Options for treatment include arthroplasty and arthrodesis. Previous MTPJ replacement implant designs have had poor mid-term success. The Moje prosthesis was designed to overcome some of the problems with earlier implants, and employs ceramic bearing surfaces and a press-fit tapered stem design. Previous studies have reported good early results in small numbers of patients. Methods: Between February 2002 and December 2006 the senior author implanted 55 components in 48 patients. AOFAS hallux scores and satisfaction scores (0 to 10) were recorded at follow-up. Radiographs were analysed for component alignment, implant bone coverage and subsidence. The mean age of patients at implantation was 56 years (34–77). Average follow-up was 42 months (15 to 74). Results: There were no patients lost to follow-up. Average AOFAS score was 72 (25 to 100) and satisfaction score was 8.2 (range 1 to 10). 82% stated they would have the same procedure again and 82% reported minimal or no pain. There were no deep infections but 35% of patients reported altered sensation. Four implants have been removed (8%) because of worsening pain and implant loosening. 50% of metatarsal implants and 80% of phalangeal implants were implanted within 5 degrees of the long bony axis. Average bony coverage was 80%, resulting in subsidence of 90% of metatarsal and 70% of phalangeal implants at follow-up. Discussion: Despite the poor radiographic appearance in the majority of cases, this procedure has good clinical outcome at the mid-term stage with 92% implant survival. The long-term clinical significance of the radiographic appearances is currently unknown. Improved surgical technique, including better bony coverage, may reduce the risk of implant subsidence

Introduction: The treatment of stage 3 hallux rigidus is controversial. Cheilectomy, fusion and total joint replacement have all been advocated. No consensus is agreed on the best optimal management. We present our results of a ceramic on ceramic MOJE metatarsophalangeal (MTP) joint replacement. Aim: To find out the medium to long term outcome following MOJE MTP joint replacement. Material and Methods: A sample of 95 patients was identified, between January 1999 to July 2006 from our data base who underwent MOJE metatarsophalangeal joint replacement. We divided these patients into three groups. First group had screw fit ceramic MOJE joint replacement; second group Mark 1 ceramic on ceramic press fit MOJE joint replacement and third group Mark 2. Indications of the surgery were osteoarthritis (primary or secondary), osteochondral defects, inflammatory arthropahty, previous infections and previously failed surgery. The outcome was analysed clinically, radiologically and functionally (using AOFAS and QALY scoring system). Results: This study shows that the early results are promising but the medium and long term results show early radiological loosing. The significance of this is not known but based on these results we would advice caution on the use of these implants and further long term studies are required

We retrospectively reviewed 27 patients who underwent an uncemented total Moje ceramic arthroplasty of hallux rigidus. Out of 33 patients who had the above procedure, 27 were available for review. Clinical and functional outcome were assessed using the American orthopaedic foot and ankle society (AOFAS) fore-foot score, and the SF-36 health assessment score. All patients had an antero-posterior and a lateral weight bearing radiograph. The primary pathology was oesteo-arthritis (Hallux Rigidus). All procedures were performed by the senior author or under his supervision. All patients were female with an average age at surgery of 52.6 years (range 45.8–64.7). The average follow up was 39.5 months (range 14–46). The average post-operative AOFAS forefoot score was 80/100 (range 40–100). The average subscore for pain was 29.39/40 (range 10–40). Twenty five patients 92.5% were satisfied with the outcome, and 22 (81%) were able to wear high heel foot wear. The functional outcome as assessed using the SF-36 health score was compatible with an age matched population. The alignments of component were measured in relation to the shaft of the metatarsal and to the proximal phalange. There was no statistical correlation between the alignment and the functional scores. Although, arthrodesis remains the gold standard procedure, total ceramic first MTP joint arthroplasty has a place in the management of some cases of advanced but not end stage hallux rigidus. Careful patient selection is essential to achieve a favourite outcome

25 First metatarso phalangeal joint replacements using the MOJE implant were prospectively assessed. There were 13 females and 10 males, with an average age of 60 years (range 45–71 years). The main indication for surgery was a symptomatic Hallux Rigidus. The minimum follow up period was 2 years (range 24–38 months). The patients were assessed before and after surgery using the AOFAS (American Orthopaedic Foot and Ankle Society Hallux Score). The mean pre operative AOFAS score was 45.60 and this improved to 85.63 after surgery. There was a significant improvement in the sub scale for pain, from 4.58 pre operatively to 31.25 post operatively. A 9.5. 0. improvement in the range of motion was noted. The authors conclude that their study demonstrates that the use of the MOJE implant for the treatment of Hallux Rigidus is a safe and useful option, although a more long term follow up is indicated

We retrospectively reviewed 27 patients who underwent an uncemented total Moje ceramic arthroplasty of hallux rigidus. Out of 33 patients who had the above procedure, 27 were available for review. Clinical and functional outcome were assessed using the American orthopaedic foot and ankle society (AOFAS) fore-foot score, and the SF-36 health assessment score. All patients had an anteroposterior and a lateral weight bearing radiograph. The primary pathology was oesteo-arthritis (Hallux Rigidus). All procedures were performed by the senior author or under his supervision. All patients were female with an average age at surgery of 52.6 years (range 45.8–64.7). The average follow up was 39.5 months (range 14–46). The average post-operative AOFAS forefoot score was 80/100 (range 40–100). The average subscore for pain was 29.39/40 (range 10–40). Twenty five patients 92.5% were satisfied with the outcome, and 22 (81%) were able to wear high heel foot wear. The functional outcome as assessed using the SF-36 health score was compatible with an age matched population. The alignments of component were measured in relation to the shaft of the metatarsal and to the proximal phalange. There was no statistical correlation between the alignment and the functional scores. Although, arthrodesis remains the gold standard procedure, total ceramic first MTP joint arthroplasty has a place in the management of some cases of advanced but not end stage hallux rigidus. Careful patient selection is essential to achieve a favourite outcome

This implant seemed to overcome the failings of previous designs. It is a ceramic bearing screwed into a titanium screw, which bonded to bone. The bearing surface was also coated with calcium phosphate to enhance secondary stability.

An initial study examined 40 patients over three years. No patients had any loosening, screw breakages, fractures, or local osteoporosis. The patient satisfaction was good with only two dissatisfied. On the basis of this, Orthosonics introduced it to the UK in 1999. Following problems with the device we conducted a survey with Orthosonics and the MDA.

In total 160 implants were implanted by 46 surgeons. We received replies from 33 surgeons representing 119 patients. There were 93 implants with a successful outcome but 17 had failed and been revised. The commonest mode of failure was osteolysis secondary to metallic wear debris. Also six implants showed radiographic loosening with symptoms, but had not been revised. There were three that showed radiographic loosening, but were symptom free.

A failure rate of 19% at one year is unacceptable. We are of the view that products of this type should be introduced in a controlled fashion as part of a prospective trial.