Complications of First Tarsometatarsal Joint Arthrodesis

Abstract

Category: Bunion Introduction/Purpose: Hallux valgus, a term introduced by Carl Hueter (1) to define static subluxation of the first metatarsophalangeal joint characterized by lateral deviation of the hallux and medial deviation of the first metatarsal, (1,2) is a disease for which different corrective surgical techniques can be used, depending on its severity. First tarsometatarsal joint (TMTJ) arthrodesis, also known as Lapidus, is one of the surgical procedures used in the treatment of severe hallux valgus, among other alterations (3-5). Despite the high satisfaction rate and high corrective power, this technique is not without complications. The main com- plications include delayed union, malunion, chronic edema, persistent pain, nonunion, joint stiffness, recurrent deformity, and varus deformity (6). However, there is little scientific evidence of these complications after first TMTJ arthrodesis. The purpose of this study was to report the complications of first TMTJ arthrodesis performed by orthopedic surgeons specializing in foot and ankle surgery. Methods: This study was approved by the institutional research ethics committee and registered at Plataforma Brasil. We evaluated 16 patients undergoing first TMTJ arthrodesis, who denied any comorbidities. The procedures were performed by 7 different orthopedic surgeons specializing in foot and ankle surgery with different levels of experience, ranging from 1 to 29 years of experience in the field. All patients underwent arthrodesis with plates and screws. The plate was placed on the plantar aspect of the first tarsometatarsal in 4 patients and on the anteromedial aspect in all other patients. The dorsomedial incision was used, centered on the first TMTJ, for the 12 cases in which the plate was positioned in the dorsomedial region, and the medial incision was used for the 4 cases in which the plate was positioned on the plantar aspect. Also, articular cartilage was resected using a chisel and microperforations. All 16 patients were followed up in an outpatient clinic at 1, 2, 4, 6, 12, and 24 weeks postoperatively. The follow-up visits included the evaluation of anteroposterior, lateral, and oblique radiographs of the foot, clinical alignment of the hallux, and patients' signs and symptoms. For all patients, postoperative care included immobilization in a non-weight-bearing cast for 4 weeks, initiation of physical therapy with range of motion gain at 4 weeks, and partial weight- bearing at 6 weeks Results: We evaluated 16 patients operated on over an 18-month period (from February 2017 to August 2018). We measured preoperative and postoperative hallux valgus and intermetatarsal angles (Table 1). Eight patients had either major or minor complications (Table 2). Three patients had recurrent deformity (1 with associated nonunion), 2 had delayed union, 2 had hardware loosening (Figure 1) - 1 with associated nonunion (Figure 2), and 1 had wound dehiscence. Conclusion: Based on our study, we can conclude that first TMTJ arthrodesis requires greater care in choosing the surgical technique for the treatment of hallux valgus. In addition, some points should be considered to avoid complications as much as possible, such as the use of implants to increase stability, instruments for better articular cartilage resection, and improvement in the correction of the pronation deformity of the hallux. The limitations of our study prevent us from drawing a robust conclusion and defining consistent parameters related to the main factors that may affect the various complications described in the study. Therefore, we believe that data are still scarce to provide a concrete basis, and further studies are needed to make substantiated conclusions.