Progressive First Metatarsal Shortening Is Observed Following Allograft Interpositional Arthroplasty in Hallux Rigidus
Authors: Fayed Aly , Carvalho Kepler A.M. , Jones Matthew T. , Schmidt Eli , Acker Antoine , Luo Emily Joan , Talaski Grayson M. , Anastasio Albert O. , Mansur Nacime Salomao Barbachan , de Cesar Netto Cesar 
Published: April 2024

Introduction/Purpose: Interpositional arthroplasty (IPA) is a motion-preserving surgery in patients with advanced hallux rigidus. Literature displays several complications after the procedure including transfer metatarsalgia, cock-updeformity and infection. In a finite element model, shortening of the first metatarsal was associated with increased plantar pressure on lateral rays during gait. Additionally, there are reports of a positive correlation between first metatarsal shortening after hallux valgus surgery and transfer metatarsalgia of the second,third and fourth metatarsophalangeal joints. The goals of this study were to report the outcomes and complications of IPA using acellular dermal allograft (IPA-ADA) as well as study the changes in the length of the proximal phalanx of the hallux (P1) and the first metatarsal (M1) following the procedure. Methods: In this IRB-approved retrospective study, we assessed patients who underwent IPA-ADA in a single academic institute from 2019-2022. All patients’ demographic data, surgical details, complications, and patient-reported outcomes (PROs) were extracted. On standing conventional anteroposterior (AP) foot views, we measured the lengths of the first metatarsal (M1), the second metatarsal (M2), the proximal phalanx of the big toe (P1), and the entire length of the hallux (HX). The ratio of M1/M2 and P1/HX were calculated. The first metatarsophalangeal joint space was measured at the medial and lateral aspects of the joint on the APview. All measurements were recorded pre-operatively, at six weeks follow-up, and at the final follow-up. Descriptive statistics were performed, and comparison between groups was performed using analysis of variance(ANOVA) or Kruskal Wallis test according to data normality. The Dunn-Bonferroni test was then performed for pairwise group comparisons. A p-value < 0.05 was considered significant. Results: Eleven patients were included, 9 being females (81.81%). Six were hallux rigidus Coughlin grade III (54.55%), and 5 were grade IV (45.45%). The average age was 59 years (SD±6.78), and the body mass index (BMI) was 26 (SD±4.79). At the final follow- up, there was significant shortening of the first ray in comparison to the pre-operative length evidenced by lower M1/M2 (82.63 SD±2.29 versus 75.42 SD±5.1; p=0.001) and P1/HX ratio53.38 ± 2.29 versus 48.98 SD ± 7.92; p=0.001). Although there was no significant difference between M1/M2 at 6 weeks and at the final follow-up (p=0.716), there was a significant negative correlation between follow-up length and M1/M2 (r= -0.76, p=0.003). Follow-up was (19.95 months; range 3-39). Complications and PROs are listed in Figure 1. Conclusion: Interposition arthroplasty using dermal allograft for HR is associated with progressive shortening of the first ray at the level of the first metatarsal as well as the proximal phalanx. Although the study did show shortening of the first ray, the small sample size didn't allow for a correlation between this shortening and complications such as transfer metatarsalgia and cock-up toe deformity. The potential shortening should be considered in the selection of patients, particularly in the setting of an already short first metatarsal or when simultaneous Akin/Moberg osteotomy is planned. Interposition arthroplasty using dermal allograft for HR is associated with progressive shortening of the first ray at the level of the first metatarsal as well as the proximal phalanx. Although the study did show shortening of the first ray, the small sample size didn't allow for a correlation between this shortening and complications such as transfer metatarsalgia and cock-up toe deformity. The potential shortening should be considered in the selection of patients, particularly in the setting of an already short first metatarsal or when simultaneous Akin/Moberg osteotomy is planned.