Foot & Ankle International - September 2020 - 1095

Chrea et al

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fracture around the base of the PVA implant (Figure 3). A
revision was planned. The second patient initially presented
with a 6-mm second MT OCL. She had failed nonoperative
management and was treated with second MT PVA implantation. The patient had persistent pain with an MRI demonstrating substantial bone marrow edema in the second MT,
and she subsequently underwent cortisone injection, 2
rounds of shockwave therapy, and ultimately a revision surgery at 1 year postoperatively requiring implant removal,
interpositional arthroplasty, and bone grafting of the second
MT. At the time of revision, it was noted that the implant
was loose and mobile within the MT head. The patient
recovered and has not had any postoperative complications
in the first 2 months postoperatively.

Patient-Reported Outcomes
On average, there was significant improvement in PROMIS
Pain Intensity and Pain Interference scores at an average of
21 months of follow-up. Average Pain Intensity improved by
11.5 points (P = .01) and average Pain Interference improved
by 8.2 points (P = .01). Improvement was reported for all
other PROMIS domains following surgery, but these did not
reach statistical significance (Table 2).

Figure 2. Postoperative radiograph demonstrating persistent
avascular necrosis and collapse of the second metatarsal head.
This patient remained asymptomatic at 2 years postoperatively.

Of the 5 patients who presented with Freiberg's infraction treated with PVA implant, 1 patient developed AVN
following surgery (Figure 2). She remained asymptomatic
at 2 years postoperatively and did not require any additional
procedures. She requested the procedure for her fourth toe
on the contralateral side. Two patients with Freiberg's
infraction reported persistent pain postoperatively, one
requiring ultrasound-guided injection, and the remaining 2
patients had no reported postoperative events.
Of the 6 patients who presented with second or third
MTP arthritis treated with PVA implant, 2 patients reported
persistent postoperative pain. One such patient required
ultrasound-guided injection at 7 months postoperatively,
with complete resolution of pain at 1 year postoperatively.
Of the 2 patients who presented with second MT OCL
treated with a PVA implant, both patients experienced a
postoperative complication. The first patient initially presented to our institution with a 4-mm second MT OCL with
arthritis and contracture of the second MTP joint 2 years
status post-microfracture of the second MT head and Weil
osteotomy performed at an outside institution. This patient
underwent hardware removal, second MTP joint release,
and PVA implantation. While pain initially improved, she
had recurrence of pain at 4 months postoperatively, with
both magnetic resonance imaging (MRI) and computed
tomography (CT) scans demonstrating a periprosthetic

Discussion
This is the largest case series to date evaluating clinical outcomes following PVA hydrogel implant in the lesser toes.
All 13 patients in our study underwent off-label PVA
implantation in the second or third MT head for lesser toe
pathologies, including Freiberg's infraction, severe arthritis, and osteochondral defect of the MT head. Other surgical
options for the treatment of these conditions have been
described in the literature and include core decompression,
open joint debridement, arthroscopic joint debridement,
perichondral grafting, MT osteotomies, and excisional or
interpositional arthroplasty.4 However, to date there has
been no consensus as to which operative treatment offers
the best clinical outcomes. While long-term follow-up studies have recently begun to demonstrate the efficacy of dorsal wedge closing osteotomies for the treatment of Freiberg's
disease, the best approach for failed operative management
of the disease remains in question.14 Five out of 13 patients
in our cohort failed not only conservative management but
also previous operative management for Freiberg's.
Therefore, it is important to note that a common use of PVA
implant in our study cohort was in the setting of a previously failed operative treatment.
Demographically, our cohort treated with PVA implant
for lesser toe pathologies is consistent with the existing literature with regard to age, sex, and clinical follow-up
times.3,9 Our cohort was 100% female, and 5 of 13 patients
presented with Freiberg's disease, which is consistent with
the current literature suggesting the prevalence of Freiberg's
disease predominantly in females.4,5

Foot & Ankle International - September 2020

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