Anatomic Reconstruction Versus Traditional Rebalancing in Lesser Metatarsophalangeal Joint Reconstruction

https://doi.org/10.1053/j.jfas.2017.11.023Get rights and content

Abstract

Traditional rebalancing techniques, such as capsulotomies and capsulorrhaphies, are commonly performed during complex hammertoe and lesser metatarsal osteotomy procedures involving metatarsophalangeal joint (MTPJ) contractures; however, floating toes, digital instability, and malalignment are concerns. We critically analyzed the outcomes after anatomic reconstruction of the plantar plate and collateral ligaments compared with those after traditional rebalancing techniques. A case-control study was conducted of 54 patients who had undergone surgical correction of lesser MTPJ imbalances due to complex hammertoe deformities (power 80%, type I error = 0.05). Cases were defined as consecutive patients treated with anatomic plantar plate and collateral ligament reconstruction. Controls had undergone traditional lesser MTPJ rebalancing and were matched to cases by age, gender, follow-up duration (minimum 12 months), and concomitant procedures of the same lesser ray. Multivariate logistic regression demonstrated that patients treated with anatomic reconstruction had greater digital stability (negative dorsal drawer and negative paper pull-out test findings) at final follow-up examination compared with the controls. American College of Foot and Ankle Surgeons (ACFAS) forefoot module scores were greater in the anatomic group in all domains (p ≤ .05). Controls had greater postoperative radiographic MTPJ angles than the cases, with no differences detected between the 2 groups in visual analog scale scores or proximal interphalangeal joint angles. The importance of restoration of the plantar plate and collateral ligament integrity as a digital stabilizer is generally accepted but has not been well studied. We found that anatomic reconstruction yielded greater digital stability, greater ACFAS Forefoot module scores, and better radiographic MTPJ alignment than controls. Additional studies are warranted to assess the long-term viability of anatomic lesser MTPJ reconstruction.

Section snippets

Patients and Methods

A case-control study was conducted of consecutive adult patients who had undergone surgical correction of lesser MTPJ imbalances. These patients were from the surgical medical records from January 2013 to December 2014. The institutional review board approved the present study (protocol no. 045-2014). The cases were defined as consecutive patients who had undergone anatomic plantar plate and collateral ligament reconstruction. The control group was defined as patients who had undergone

Results

The analysis demonstrated that the propensity matching was successful in balancing the cases (n = 18) and controls (n = 36). The groups were comparable (Table 1), with no statistically significant differences in age, gender, body mass index, laterality, MTPJ location, baseline deformity, baseline pain, preoperative ACFAS score, comorbidities, incidence of smoking, use of immunosuppressant agents, and concomitant procedures (Fig. 4). The data from 54 patients were analyzed, and multivariate

Discussion

The importance of the restoration of the plantar plate and collateral ligament integrity as a digital stabilizer is generally accepted but has not been well studied. The results of the present his study (Table 2) favor anatomic reconstruction of the lesser MTPJ over those using traditional techniques, such as MTPJ releases, capsulotomies, capsulorrhaphies, and tendon transfers. Of the cases undergoing the MTPJ reconstructive technique shown in Fig. 3, 94% achieved greater digital stability than

Acknowledgments

We would like to thank Drs. N. Jake Summers, Jill Ashcraft, Brandon Barrett, Michael Sganga, Michael Matthews, and Timothy Karthas for their valuable contributions related to portions of the data collection for this report.

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    Financial Disclosure: This was an investigator-initiated study in which E.A. Cook and J.J. Cook applied for funding. This was not considered a grant, and we are both consultants for Smith & Nephew. The total amount provided in connection with our time for completing this study totaled $13,420; although we received this compensation, Smith & Nephew did not maintain rights to the data and did not have any input to the content or data analysis. We performed and interpreted our own data, and Smith & Nephew made no edits to the content of the report.

    Conflict of Interest: J.J. Cook is a consultant to Smith & Nephew. E.A. Cook is a consultant to Smith & Nephew.

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