Foot & Ankle International - September 2020 - 1057

Eble et al
according to 1 retrospective study.9 Cases that fail to
improve with nonoperative management often require operative intervention, with a range of methods used depending
on the severity of symptoms.
Most often in grade II and III hallux rigidus, a standard
cheilectomy has been used to improve dorsiflexion movement and reduce pain while preserving the MTP joint.13
Generally, however, cheilectomy is most effective for less
severe cases of hallux rigidus, and subsequent procedures
may be required in certain cases. Particularly for patients
presenting with more severe hallux rigidus, standard
cheilectomy has been shown to result in persistent symptoms for about 10% to 15% of patients at intermediate- to
long-term follow-up.5,6 Further, failure rates for an isolated cheilectomy have been reported as high as 37.5%
for patients with grade III hallux rigidus.10 O'Malley et
al13 have reported favorable clinical and patient-reported
outcomes for grade III hallux rigidus patients following
cheilectomy with the addition of a Moberg osteotomy.
The Moberg osteotomy has been found to increase dorsiflexion and shift the center of pressure on the proximal
phalanx more plantarly.12,13 Cheilectomy with Moberg
osteotomy is routinely used at our institution as a jointpreserving procedure to address hallux ridigus.
As an alternative to standard joint-preserving procedures,
a synthetic cartilage implant (SCI) (Cartiva Inc, Alpharetta,
GA) was approved by the US Food and Drug Administration
(FDA) in 2016 for use in hemiarthroplasty of the first MTP
joint. The goal of this polyvinyl alcohol (PVA) implant is to
provide pain relief while maintaining motion of the joint. A
randomized clinical trial sponsored by the manufacturer of
the implant showed equivalent pain relief and functional
outcome scores at 2-year follow-up when comparing patients
undergoing hemiarthroplasty with patients undergoing first
MTP fusion.3 However, a recent non-industry- sponsored
study demonstrated less promising results with this implant.
These authors report that 33 out of 64 patients (52%) in their
cohort required therapeutic steroid injection at an average of
7.6 months after initial implantation, and 13 out of 64 (20%)
required reoperation at an average of 12.3 months postoperatively. Subsequent procedures included implant removal
and conversion to arthrodesis for 5 out of 64 patients (8%).4
In addition to relatively high rates of complication and
revision surgery, these authors present validated PatientReported Outcomes Measurement Information System
(PROMIS) scores for the Pain Interference and Physical
Function domains, as well as patient satisfaction measures.

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For their cohort of 60 patients with 64 implants, mild pain
symptoms, mild physical dysfunction, and neutral levels of
satisfaction were reported.4 However, PROMIS scores were
not collected preoperatively, so postoperative scores could
not be compared with baseline scores.
The current study aimed to evaluate outcomes following
first MTP hemiarthroplasty with PVA hydrogel implant at
an academic, multisurgeon center. In addition to retrospective review of clinical outcomes, we prospectively collected baseline PROMIS scores through our institution's
foot and ankle registry and compared them with scores collected postoperatively. We performed a subgroup analysis
to evaluate outcomes for patients undergoing prior procedure of the first MTP compared with patients who did not
undergo a prior procedure. We also compared outcomes for
patients undergoing concurrent Moberg osteotomy versus
those who did not undergo a Moberg. We hypothesized that
outcomes would generally improve and would not be
affected by prior procedures, but that patients undergoing a
concurrent Moberg osteotomy would report significantly
better outcomes compared with those who did not undergo
a Moberg.

Methods
Approval was obtained from the institutional review board
steering committee, which oversees our institution's foot
and ankle registry. One hundred three hallux rigidus patients
who underwent first MTP hemiarthroplasty with PVA hydrogel implant between January 2017 and October 2018 were
identified. Patients treated with or without concurrent
Moberg osteotomy were eligible for inclusion. Patients
undergoing PVA hydrogel implant for a condition other than
hallux rigidus were excluded. Eight fellowship-trained
orthopedic foot and ankle surgeons at a single academic
institution were represented.

Study Population and Design
Retrospective chart review was performed to assess for
prior procedures, operative procedure performed, postoperative events, and clinical outcomes. Demographic data
including age at time of surgery, gender, and body mass
index (BMI) were also collected. The average age of this
cohort was 57.7 (range, 26-76) years, and 74 out of 103
patients (71.84%) were female. The average BMI was 25.9

Hospital for Special Surgery, New York, NY, USA

*Matthew M. Roberts, MD, Martin J. O'Malley, MD, Andrew J. Elliott, MD, Jonathan T. Deland, MD, David S. Levine, MD, Constantine A. Demetracopoulos,
MD, and Scott J. Ellis, MD
Corresponding Author:
Stephanie K. Eble, BA, Hospital for Special Surgery, 523 East 72nd St, 5th Floor, New York, NY 10021, USA.
Email: Stephanieeble97@gmail.com

Foot & Ankle International - September 2020

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