A Prospective Assessment of Great Toe Fusion Outcomes: The Effect of Concomitant Procedures

CATEGORY: Midfoot/Forefoot; Bunion INTRODUCTION/PURPOSE: Great toe fusion is the standard of care for severe hallux rigidus and other great toe pathology requiring definitive surgical management. Great toe fusion has proven an effective surgical treatment when correctly performed on appropriate patients. This study aimed to prospectively assess the clinical results of great toe fusion surgery in isolation compared to great toe fusion surgery combined with concomitant procedures. METHODS: All patients undergoing a 1st metatarsophalangeal joint fusion from January 1st 2017 through June 30th 2018 were prospectively studied. Patients completed the Foot and Ankle Outcome Score (FAOS) and Veterans RAND 12 (VR-12) patient- reported outcome measures (PROMs) on the day of surgery (T0) and 12 months post-surgery (T1). Surgeons were surveyed regarding surgical details and patient characteristics. 204 patients underwent a great toe fusion during the study period. There were 67 enrollment failures (2 patient refusals, 63 incomplete T0 patient surveys, 2 incomplete surgeon surveys). Of the 137 patients completing the initial PROMs at T0, 100 patients (73%) also completed the PROMs at T1. Within this study group, 54 patients underwent an isolated great toe fusion and 46 underwent one or more concomitant procedures including hammertoe correction (30); MTP joint capsulotomy (22); Weil osteotomy (19); bunionette (2); metatarsal head resection (3); and other (12). RESULTS: The study group consisted of 80 females and 20 males with age = 63.3 +/-8.5 and BMI = 28.3 +/-6.0. Indications for surgery included: hallux rigidus (26%), hallux valgus (35%), hallux varus (7%), arthritic bunions (30%) and other (2%). Fixation constructs included: a plate and a lag screw (82%), a plate alone (15%), and lag screws alone (3%). Patients undergoing isolated great toe fusions and those undergoing concomitant procedures both improved at one year (Table 1). Multivariable analysis demonstrated that after controlling for confounding variables, patients undergoing an isolated great toe fusion when compared to those also undergoing a concomitant procedure had higher odds for improvement in: FAOS pain (odds Ratio = 0.34, p=0.011); FAOS QoL (Odds Ratio=0.38, p=0.022); and VR-12 PCS (Odds Ratio=0.58, p=0.162). CONCLUSION: A great toe fusion can lead to substantial improvement in pain, quality of life, and overall physical function. However, this study demonstrates that the addition of a concomitant procedure such as a claw toe correction or a Weil osteotomy leads to an inferior outcome with respect to pain and quality of life when compared to an isolated great toe fusion.