Percutaneous vs Open First Metatarsophalangeal Joint Arthrodesis: A Proportional Meta-Analysis and Systematic Review

Research Type: Level 4 – Case series Introduction/Purpose: First metatarsophalangeal joint (MTPJ-1) arthrodesis (MTPJA-1) is the gold standard to treat end-stage osteoarthritis of this joint. The purpose of this study was to determine whether percutaneous techniques to perform MTPJA-1 might reduce the nonunion, complication and reoperation rate as compared to the traditional open approach. Methods: Following the PRISMA checklist, the Medline, Scopus, Web of Science and Cochrane databases were searched, including studies reporting patients affected by MTPJ-1 osteoarthritis and undergone MTPJA-1 stabilized using crossed screws as exclusive fixation method. Data were harvested regarding the cohort (sample size, age, sex, aetiology), the study design (type of study, level of evidence), the surgical technique (open/percutaneous procedure, the number of screws, technique of preparation of the joint) and the final outcome (nonunion, complication and reoperation rate) at the longest follow-up. The methodological index for nonrandomized studies (MINORS) was used to assess the methodological quality of studies. The percutaneous (PERC) and the open (OPEN) techniques were compared in terms of nonunion, complication and reoperation rate. Results: Nine studies (225 MTPJA-1 in 211 patients) were selected (PERC=130 cases, OPEN=95). In the two groups, the mean (±standard deviation) sample size (26.6±5.1 cases in PERC, 23.7±10.2 cases in OPEN; p=0.33), mean age of patients (62±5.4 and 59.5±5.4 years, respectively; p=0.26), sex distribution (81%±0.6 vs 57%±0.2 females, respectively; p=0.17) and length of follow-up (20.8±11.6 months vs 29.5±16.8 months, p=0.19) were comparable. The pooled nonunion rate (5% in PERC vs 6% in OPEN; p=0.93), complication rate (4% vs 17%; p=0.24) and reoperation rate (3% vs 5%; p=0.74) were not significantly different. The quality of studies was moderate and comparable in the two groups (MINORS at 9±1.3 points in PERC vs,11.7±3.7 in OPEN; p=0.19). Conclusion: The nonunion, complication and reoperation rate after percutaneous or open MTPJ-1 arthrodesis stabilized using two screws are not significantly different. The evidence provided so far is based on retrospective and short-term follow-up studies of moderate methodological quality. Further comparative and prospective analyses with a robust design are warranted to define which strategy allows to achieve the best outcome after MTPJ-1 arthrodesis.