Stevens Jasper, de Bot Robin T A L, Hermus Joris P S, van Rhijn Lodewijk W, Witlox Adhiambo M
Department of Orthopaedics, Maastricht University Medical Centre, Maastricht, the Netherlands.
JBJS Rev. 2017 Nov;5(11):e2. doi: 10.2106/JBJS.RVW.17.00032.
Hallux rigidus is a common cause of foot pain in the elderly and has a negative impact on quality of life. Several operative treatment options are available for feet that are refractory to conservative treatment. Of these, total joint replacement and arthrodesis of the first metatarsophalangeal joint are the most commonly performed interventions. Nevertheless, it is still not known which intervention results in the best clinical outcome and the fewest complications.
PubMed/MEDLINE, Embase, and the Cochrane Library were systematically searched for studies assessing outcome with the American Orthopaedic Foot & Ankle Society-Hallux Metatarsophalangeal Interphalangeal (AOFAS-HMI) score, Foot Function Index (FFI), visual analog scale (VAS) for pain, or Short Form-36 (SF-36) in patients who underwent an arthrodesis or total joint replacement for the treatment of symptomatic hallux rigidus. Secondary outcomes were complications and revision rates. The screening of titles and abstracts, data collection, data extraction, and study quality assessment were performed independently by 2 reviewers. Study quality was determined with use of risk-of-bias tools. Results of included studies were presented in a qualitative manner, and the results of high-quality studies were pooled.
Thirty-three studies, describing a total of 741 arthrodeses and 555 total joint replacements, were included in the qualitative analysis. Six different prostheses were used for total joint replacement, and various fixation techniques were used for arthrodesis. The results of 6 arthrodesis studies and 7 total joint replacement studies were pooled in the quantitative analysis. Pooled results showed superiority of arthrodesis compared with total joint replacement for improving clinical outcome (by 43.8 versus 37.7 points on the AOFAS-HMI score) and reducing pain (a decrease of 6.56 versus 4.65 points on the VAS pain score). Because of the rare reporting of the FFI and SF-36, no comparison could be made for these outcomes. Fewer intervention-related complications (23.1% versus 26.3%) and revisions (3.9% versus 11%) were reported after arthrodesis as compared with total joint replacement, with pain and nonunion and prosthetic loosening being the most commonly reported complications after arthrodesis and total joint replacement, respectively.
The present systematic review of the literature indicated that arthrodesis is superior for improving clinical outcome and reducing pain, and is less often accompanied by intervention-related complications and revisions, compared with total joint replacement in patients with symptomatic hallux rigidus. Prospective, randomized controlled trials will need to be conducted to verify this conclusion.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
僵硬性拇趾炎是老年人足部疼痛的常见原因，对生活质量有负面影响。对于保守治疗无效的足部，有几种手术治疗方案可供选择。其中，第一跖趾关节全关节置换术和关节融合术是最常用的干预措施。然而，仍不清楚哪种干预措施能带来最佳的临床效果和最少的并发症。
系统检索PubMed/MEDLINE、Embase和Cochrane图书馆，查找评估采用美国矫形足踝协会拇趾跖趾间关节（AOFAS-HMI）评分、足部功能指数（FFI）、疼痛视觉模拟量表（VAS）或简短健康调查问卷36项版本（SF-36）对有症状的僵硬性拇趾炎患者行关节融合术或全关节置换术治疗效果的研究。次要结局指标为并发症和翻修率。标题和摘要筛选、数据收集、数据提取以及研究质量评估由2名评审员独立进行。采用偏倚风险工具确定研究质量。纳入研究的结果以定性方式呈现，高质量研究的结果进行汇总。
定性分析纳入了33项研究，共描述了741例关节融合术和555例全关节置换术。全关节置换术使用了6种不同的假体，关节融合术采用了多种固定技术。定量分析汇总了6项关节融合术研究和7项全关节置换术研究的结果。汇总结果显示，与全关节置换术相比，关节融合术在改善临床效果（AOFAS-HMI评分提高43.8分对37.7分）和减轻疼痛（VAS疼痛评分降低6.56分对4.65分）方面更具优势。由于FFI和SF-36的报告较少，无法对这些结局指标进行比较。与全关节置换术相比，关节融合术后报告的干预相关并发症（23.1%对26.3%）和翻修率（3.9%对11%）更低，关节融合术和全关节置换术后最常报告的并发症分别为疼痛、骨不连和假体松动。
本系统文献综述表明，对于有症状的僵硬性拇趾炎患者，与全关节置换术相比，关节融合术在改善临床效果和减轻疼痛方面更具优势，且干预相关并发症和翻修较少。需要进行前瞻性随机对照试验来验证这一结论。
治疗性IV级。有关证据水平的完整描述，请参阅作者指南。
