The Journal of Foot & Ankle Surgery xxx (2015) 1–6
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Original Research
Comparison of Hallux Interphalangeal Joint Arthrodesis Fixation Techniques: A Retrospective Multicenter Study Jakob C. Thorud, DPM, MS, AACFAS 1, Tyler Jolley, DPM, MHA 2, Naohiro Shibuya, DPM, MS, FACFAS 3, Eric Lew, DPM, AACFAS 4, Matthew Britt, DPM 5, Ted Butterfield, DPM 6, Alan Boike, DPM, FACFAS 7, Mark Hardy, DPM, FACFAS 8, Steve Brancheau, DPM, FACFAS 9, Travis Motley, DPM, MS, FACFAS 10, Daniel C. Jupiter, PhD 11 1
Staff, Central Texas Veterans Affairs Health Care System; and Staff, Baylor Scott and White Health, Temple, TX Third Year Resident, Baylor Scott and White Health, Central Texas Veterans Affairs Health Care System, Texas A&M Health Science Center, Temple, TX 3 Associate Professor, Department of Surgery, Texas A&M Health Science Center College of Medicine; Chief, Section of Podiatry, Central Texas Veterans Affairs Health Care System; and Staff, Baylor Scott and White Health, Temple, TX 4 Fellow, University of Arizona College of Medicine, Southern Arizona Limb Salvage Alliance, Tuscan, AZ 5 Physician, Private Practice, Mesquite, TX 6 Third-Year Resident, University of North Texas Health Science Center/John Peter Smith Hospital, Fort Worth, TX 7 Dean, Kent State University College of Podiatric Medicine, Independence, OH 8 Chief, Foot and Ankle Services, Mercy Health Foot and Ankle/HealthSpan Physicians, Cleveland Heights, OH 9 Director, Hunt Regional Healthcare Podiatry Residency Program, Hunt Regional Healthcare, Greenville, TX 10 Associate Professor, University of North Texas Health Science Center/John Peter Smith Hospital, Fort Worth, TX 11 Assistant Professor, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 3
Few studies have investigated the complications that occur after hallux interphalangeal joint arthrodesis. The present study evaluated complications in 152 patients aged 18 to 80 years from 2005 to 2012 from 4 different academic institutions after hallux interphalangeal joint arthrodesis. Overall, 65.8% of the patients had 1 complication. Infections occurred in 16.5%, dehiscence in 12.5%, and reoperations in 27.0%. The clinical nonunion rate was 17.8%, and the radiographic nonunion rate was 13.8%. After logistic regression analysis, only the study site and peripheral neuropathy were associated with having 1 complication (p < .01 and p < .05, respectively). Single screw fixation compared with other fixation did not have a statistically significant influence on the postoperative complications. However, when fixation was expanded to 4 categories, single screw fixation had lower infection and reoperation rates than either crossed Kirschner wires or other fixation category but not compared with crossed screws on multivariate logistic regression analysis. Although additional studies are warranted, the findings from the present study might aid in both the prognosis of complications and the support of the use of a single screw over crossed Kirchner wire fixation in hallux interphalangeal joint arthrodesis. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: fusion great toe intramedullary screw
Hallux interphalangeal joint (HIPJ) arthrodesis procedures have been used for many different pathologic entities, including neuromuscular disorders, arthritic conditions, congenital deformities, and iatrogenic conditions (1). However, very few studies have been conducted to guide surgeons regarding the best method of fixation. In 1943, O’Donoghue and Stauffer (2) described Kirschner wire
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Jakob C. Thorud, DPM, MS, AACFAS, Central Texas Veterans Affairs Health Care System, 1901 Veterans Memorial Drive, Temple, TX 76504. E-mail address:
[email protected] (J.C. Thorud).
fixation for the stabilization of the HIPJ arthrodesis site; however, others have reported high rates of pseudoarthrosis (44%) using this technique (3). A single intramedullary screw technique was introduced to improve this failure rate (3,4). Other modifications of Kirschner wire and screw fixation have also been described, including V-osteotomy with an obliquely placed screw, a bucket handle technique, and a combination of a single screw and Kirschner wire (1,2,5). External fixation has also been described as a method for HIPJ arthrodesis (6). Other methods include tenodesis of extensor halluces longus to the extensor digitorum brevis, stabilization with smooth and threaded Kirschner wires, and intramedullary screw fixation (7).
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.04.007
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J.C. Thorud et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
To the best of our knowledge, no reports of nonunion rates with the use of crossed screws for HIPJ arthrodesis have been published. Furthermore, only 1 study has reported the results from crossed Kirschner wires, and no study has compared the 2 most common techniques, single intramedullary screw and crossed Kirschner wire fixation (Fig. 1). The present study compared the postoperative complications occurring with different fixation techniques for HIPJ arthrodesis. A retrospective evaluation of patients who had undergone hallux interphalangeal joint arthrodesis at 4 academic institutions from January 1, 2005 to August 1, 2012 was performed. The present study specifically investigated the complications of infection, dehiscence, deep venous thrombus (DVT) or pulmonary embolism (PE), reoperation, clinical union, radiographic union, and any complications. The most popular fixation techniques of a single intramedullary screw, crossed Kirschner wire, and crossed screws were of clinical interest, and all other fixation techniques were combined into 1 group. Owing to the small sample sizes, for analysis we combined the crossed screws, crossed wires, and others into 1 group and compared these with the single screw technique. Patients and Methods This was a retrospective study. Patients who had undergone HIPJ arthrodesis at 4 institutions (Scott and White Healthcare, John Peter Smith Hospital, Cleveland Clinic, and Hunt Regional Healthcare) from January 1, 2005 to August 1, 2012 were included. The patients were identified using the Common Procedural Terminology code (code 28755) for HIPJ arthrodesis. Patients were included for the medical record review if they had undergone an HIPJ arthrodesis procedure and were 18 to 80 years old. The patients were excluded if the procedure had been revision arthrodesis. Only 1 side was included for patients who had undergone bilateral procedures. The side was chosen by random selection. The smoking history was defined as follows. The patient was considered an active smoker if documentation was present of smoking within the 2 weeks before surgery or the patient had returned to smoking in the postoperative period. Patients who had quit smoking >2 weeks before surgery and had not restarted during the postoperative period were categorized as having quit smoking. Infection was defined as the documented suspicion of infection and prescription of an antibiotic within the postoperative period as determined by the treating physician. Wound dehiscence was defined as documented delay of healing by the treating physician, the need for adjunctive wound healing measures, or the failure of sutures to maintain well-approximated skin
margins. DVT or PE was recorded if the patient was diagnosed within 3 months after the procedure. Clinical union was defined as the absence of motion or pain with attempted range of motion of the HIPJ with 6 weeks of follow-up. The patient was considered to have clinical nonunion if the criteria for clinical union had not been met at the last follow-up examination and that follow-up examination occurred >6 weeks postoperatively, or if the patient had a undergone reoperation
