Youngswick osteotomy for treatment of moderate hallux rigidus: Thirteen years without arthrodesis

doi:10.1016/j.fas.2019.11.008

Foot and Ankle Surgery

Volume 26, Issue 8, December 2020, Pages 890-894

https://doi.org/10.1016/j.fas.2019.11.008 Get rights and content

Highlights

•
Surgical correction of hallux rigidus is indicated when conservative treatment fails to relieve pain.
•
The rationale of the Youngswick osteotomy is to obtain a longitudinal decompression of the joint by proximal translation of the metatarsal head and plantarflexing it as desired.
•
Our results showed satisfying long-term outcomes with regard to function, pain relief, and patient satisfaction of the Youngswick osteotomy in grade II as well as grade III hallux rigidus.

Abstract

Purpose

The purpose of this study was to evaluate the need for first metatarsophalangeal joint (MTPJ) arthrodesis as a measure of the Youngswick osteotomy survival, or any other secondary procedures in the long term follow up in patients with stage II and III hallux rigidus.

Methods

We retrospectively evaluated 61 patients with stage II and III hallux rigidus who had undergone Youngswick osteotomy and analyzed their outcomes in the long term using first metatarsophalangeal arthrodesis as an end point. The candidates for inclusion underwent clinical and radiographic evaluation, including the Foot and Ankle Outcome Score (FAOS).

Results

Mean follow-up time was 54.8 months. All patients had improved their FAOS, with all achieving postoperative scores >75 points at the final follow up (P < 0.05). Although 49 % (P < 0.05) of the patients depicted worsening of the radiological aspect of the MTPJ, over the long time, no patient needed a first MTPJ arthrodesis.

Conclusion

Our results show satisfying long-term outcomes with regard to function, pain relief, and patient satisfaction of the Youngswick osteotomy in grade II as well as grade III hallux rigidus that sustained over the follow up period; even in patients followed up for over 13 years.

Level of evidence

III.

Introduction

Hallux rigidus is a condition characterized by painand restriction in the motion of the first metatarsophalangeal joint (MTPJ), especially in dorsiflexion [[1], [2], [3]]. The symptoms commonly associated with degenerative arthritis of the first MTPJ were initially reported by Davies-Colley in 1887, although Cotteril is credited with proposing the term hallux rigidus [4]. The role of metatarsus primus elevatus (MPE) in the pathogenesis of hallux rigidus has been debated since its first description by Lambrinudi in 1938, but a recent study demonstrated how patients with hallux rigidus had more MPE, in particular in patients with grade 3 and 4. The same study hypothesized that with a higher grade of hallux rigidus, the plantar fascia windlass mechanism no longer functions. The hallux plantar plate contracts, thus limiting hallux dorsiflexion and forcing the first metatarsal into MPE as a secondary phenomenon [5].

As surgical treatment of this entity depends on the etiology and severity of the deformity [[6], [7], [8], [9]], operative procedures have been divided into joint preserving techniques (e.g., cheilectomy and phalanx and first metatarsal osteotomies) and joint sacrificing techniques (e.g., arthrodesis, arthroplasty). The ultimate goal of the treatment is to correct the underlying deformity, relieve the pain, and obtain long term functional results [10].

Although it was initially conceived for a long first metatarsal, Youngswick osteotomy showed good results in both harmonic and non-harmonic formulas, at alleviating pain and improving function over the short and intermediate terms [8]. Nevertheless, studies of this joint preserving procedure that assessed the overall results and the further need of a first metatarsal arthrodesis, reflecting the survival of the technique over the long term period, are lacking.

After using the Youngswick first metatarsal decompressive osteotomy for over 13 years, we decided to review a retrospective series of patients. The purpose of this study was to evaluate the need for first metatarsophalangeal joint arthrodesis as a measure of the Youngswick osteotomy survival, or any other secondary procedures in the long term follow up in patients with stage II and III hallux rigidus. Our secondary purpose was to measure the overall grade of satisfaction with the procedure.

Section snippets

Material and methods

A retrospective review of 61 consecutive patients who had undergone Youngswick decompressive osteotomy by the same surgical team from May 2005 to May 2018 was performed.

The candidates for inclusion into the present study underwent a clinical evaluation preoperatively, and the clinical data recorded in the patients’ medical records were reviewed retrospectively. All clinical measurements were taken at the initial preoperative examination and at the final follow-up visit by a member of the

Results

Decompressive osteotomy was performed in 61 patients, including 41 (67.2%) right feet and 20 (32.8%) left feet, with no bilateral procedures. The patient population consisted of 45 females (78%), with an average age of 53.8 years (range 29–72). The mean follow-up time was 54.8 months (range 12–150). Forty-five patients (74%) were classified as grade II and 16 patients (26 %) as grade III. All patients who underwent this procedure, regardless the group, had improved their visual analog scale

Discussion

Surgical correction of hallux rigidus is indicated when conservative treatment fails to relieve pain. At the most basic level, the surgical options involve either preservation or destruction of the articular surfaces, and the decision to pursue one option over the other hinges on the degree of articular cartilage degeneration [7,8]. At moderate stages, joint preserving procedures constitute a more rational approach. Although still no known operative technique can be assigned a grade A

Conflict of interest

None.

Acknowledgements

None.

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Cited by (8)

Cheilectomy With Decompression Osteotomy for Treatment of Hallux Limitus and Rigidus: A Retrospective Study With 5-Year Outcomes
2023, Journal of Foot and Ankle Surgery
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Saur et al reported a mean increase in first MTPJ dorsiflexion of 9° in a retrospective analysis of patients who underwent decompressive oblique distal osteotomy (6). Slullitel et al found that following decompression osteotomies, patients experienced a statistically insignificant decrease in MTPJ ROM even after 5-year follow-up (7). Elliott et al evaluated patients undergoing joint-destructive and joint-preserving hallux rigidus surgeries at 1 year and 15 years after their procedures (8).
We examined outcomes following metatarsophalangeal joint cheilectomy with decompression osteotomy to evaluate the efficacy of this technique for treatment of hallux limitus/rigidus. At a minimum follow-up of 5 years, we identified 94 patients who fit the inclusion criteria. Chart review was performed to obtain range of motion (ROM) of the first metatarsophalangeal joint (MTPJ) preoperatively and at 6 weeks, 6 months, and 5 years postoperatively. Additionally, time to traditional shoe gear return, need for revision arthrodesis, radiographic findings, and postoperative visual analog scale (VAS) pain scores were reviewed. Statistical analysis was conducted by 1-way analysis of variance with post-hoc analysis and independent sample t-test. At an average follow-up of 6.3 ± 0.9 years, 42.3% (33/78) of females and 25.0% (4/16) of males reported limited ROM of the first MTPJ with 5 patients requiring first MTPJ arthrodesis. MTPJ ROM improved on average from 11.0° to 36.3° by 5-year minimum follow-up after surgery (p < .001). Analysis of variance revealed a significant difference of the preoperative ROM when compared to all postoperative time points (F[3,368] = 69.4, p < .001). Mean postoperative VAS pain scores after decompression osteotomy of the 5 patients who required MTPJ fusion were higher when compared to the rest of the patient cohort at final follow-up (7.4 ± 0.6 vs 1.5 ± 1.3; p < .001). Cheilectomy with decompression osteotomy for treatment of hallux limitus/rigidus leads to satisfactory long-term outcomes.
Shortening first metatarsal osteotomies for hallux rigidus – Is there a place for them? A systematic review
2023, Foot and Ankle Surgery
Citation Excerpt :
Ceccarini et al. found no difference in the post-operative scores between stage 2 and 3 HR but noticed higher range of motion in stage 2 [36]. Satisfaction rates were presented in 5 studies: the lowest was 84% satisfied or very satisfied patients [35]; all others were 90% or above [27,28,33,36]. For the analysis of the complications, we excluded the study of Cöster et al., because their description was not sufficient [35]; therefore, we consider a total of 329 cases.
Evidence-based recommendations for shortening first metatarsal osteotomies as joint-preserving procedures for hallux rigidus are insufficient. Because these surgeries continue to be widely used, we aimed to evaluate their published outcomes and complications.
Through a systematic review, we critically analyzed 7 articles, including 444 feet submitted to Youngswick-type or distal oblique osteotomies.
High patient satisfaction and statistically significant improvement in outcome scores and range of motion was demonstrated by most authors. Transfer metatarsalgia was the most common complication, but surgical management was rarely needed. Although no significant differences in outcomes were found according to the stage of hallux rigidus, we believe these osteotomies are not adequate for stage 4 of Coughlin and Shurnas classification.
Shortening first metatarsal osteotomies can be an alternative to arthrodesis in stage 2 (and eventually 3) hallux rigidus, as they appear effective and safe. However, further prospective and comparative studies are required.
Influence of sesamoid position after scarf osteotomy for hallux valgus on patient-reported outcome. A prospective cohor study
2022, Foot and Ankle Surgery
Citation Excerpt :
However, in a similar study by Grle et al. [21], although there was no significant difference between groups in AOFAS score at two postoperative years after chevron osteotomy, the group with release had a more significant improvement in the position of the sesamoids and a higher rate of satisfied patients. In presence of hallux rigidus, the scarf osteotomy is ineffective in relieving pain, and other procedures have been proposed [22]. As far as we know, this is the first prospective study analyzing the patient-reported outcome related to sesamoid position after scarf osteotomy.
The objective was to evaluate the influence of the postoperative sesamoid position as measured with conventional radiographs on the patient-reported outcome after scarf osteotomy. The hypothesis was that incomplete reduction of the sesamoid would result in a decreased functional outcome.
Eighty-two patients who underwent scarf osteotomy for hallux valgus were prospectively assessed for up to two postoperative years. The Self-Reported Foot and Ankle Score (SEFAS) was used to assess the quality of life, and the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale (AOFAS) for the functional outcome. A visual analogue scale (VAS) assessed pain, and Likert scale for patient satisfaction. Radiologically, hallux valgus angle (HVA), first-second intermetatarsal angle (IMA), and sesamoid position were analyzed. According to the final sesamoid position, patients were classified as normal position (48 patients) and outlier position (34 patients). A power analysis, conventional and logistic regression statistical analysis were performed.
At the final follow-up, significant improvements in all clinical scores were observed for both groups (p = 0.001) with no significant difference in AOFAS score (p = 0.413), but SEFAS score (p = 0.023), VAS-pain (p = 0.006), and satisfaction (p = 0.014) were significantly better in the normal group than in the outlier group. There were significant differences between groups in final HVA (p = 0.042) and IMA (p = 0.040). In multivariate analysis, only lower VAS-pain score (OR 0.4, 95% CI 0.2–0.6; p = 0.039) and normal sesamoid position (OR 2.4, 95% CI 1.6–3.2; p = 0.012) were significant predictor of patient satisfaction.
At two postoperative years, normal sesamoid position as measured on weight-bearing radiographs was associated with lower pain and better patient satisfaction in patients underwent scarf osteotomy for moderate to severe hallux valgus.
Sliding Oblique Metatarsal Osteotomy Fixated With K-Wires Without Cheilectomy for All Grades of Hallux Rigidus: A Case Series of 76 Patients
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Youngswick osteotomy for treatment of moderate hallux rigidus: Thirteen years without arthrodesis

Highlights

Abstract

Purpose

Methods

Results

Conclusion

Level of evidence

Introduction

Section snippets

Material and methods

Results

Discussion

Conflict of interest

Acknowledgements

J Foot Ankle Surg

Foot Ankle Surg

J Foot Ankle Surg

Validation of the foot and ankle outcome score for hallux rigidus

HSS J

Validation of the foot and ankle outcome score for ankle ligament reconstruction

Foot Ankle Int

Radiographic considerations of hallux valgus versus hallux rigidus

Foot Ankle Int

Stiffness of the great toe in adolescents

BMJ

Weightbearing CT scan assessment of foot alignment in patients with hallux rigidus

Foot Ankle Int

The Green-Watermann procedure: geometric analysis and preoperative radiographic template technique

J Foot Surg