First metatarsophalangeal joint (MTPJ) fusion is an effective surgical intervention for conditions such as hallux valgus and hallux rigidus. This systematic review and meta-analysis aims to compare the safety and efficacy of crossed screws versus plating supplemented with an interfragmentary screw. A literature search of the Scopus, Embase, Web of Science, and MEDLINE databases was performed to identify all studies directly comparing the two techniques. Meta-analysis was carried out using RevMan Web. Nine studies with 976 patients (1,035 toes in total, 512 toes in the crossed screws group, and 523 toes in the plate supplemented with screws group) were included. There was no significant difference in union rates (OR=0.75, CI 0.45 - 1.27, p = 0.29), overall complication rates (OR = 1.13, CI = 0.71 - 1.77, p = 0.61), superficial complications, (OR = 0.41, CI = 0.10 - 1.68, p = 0.22), revision surgery (OR = 1.92, CI 0.81 - 4.57, p = 0.14), hardware removal (OR = 1.07, CI = 0.55 - 2.08, p = 0.85), and malunion (OR = 1.63, CI 0.27 - 10.00, p = 0.60). Plate and screws had a significantly shorter time to fusion than crossed screws (MD = 0.51, CI = 0.10 - 0.92, p = 0.02). No significant difference was noted in patient-reported outcome measures or in postoperative hallux valgus, intermetatarsal, and lateral metatarsophalangeal angles. Other potential factors that should influence the decision to use one technique over the other include the indication for MTPJ fusion, the patient's bone quality, and the differing costs of surgery.

Arthrodesis of the first metatarsophalangeal joint is a common surgical procedure used to treat a variety of forefoot pathologies. The purpose of this study was to evaluate radiographic outcomes for hallux valgus and first tarsometatarsal joint alignment after first metatarsophalangeal joint arthrodesis. A retrospective radiographic analysis of the first intermetatarsal angle, hallux valgus angle, first metatarsal-cuneiform angle, and medial cuneiform-first metatarsal angle was performed preoperatively and postoperatively. One hundred eighty-eight procedures met inclusion criteria. Significant radiographic improvements were noted in first intermetatarsal angle (4.38°, P < 0.0001), hallux valgus angle (16.01°, P < 0.0001), first metatarsal-cuneiform angle (5.96°, P < 0.0001), and medial cuneiform-first metatarsal angle (5.68°, P < 0.0001). Significant radiographic improvements (P < 0.0001) were also noted when subjects were subdivided into first intermetatarsal angle ≤ 15° and > 15° for all measured angles. An isolated first metatarsophalangeal joint arthrodesis corrects both hallux valgus deformity and first tarsometatarsal alignment. These findings support that additional first ray procedures may not be required when performing a first metatarsophalangeal joint arthrodesis for hallux valgus.

This study evaluated the outcome of the Cartiva synthetic cartilage implant (SCI) in the treatment of hallux rigidus.

In the present retrospective matched case-control study, we compared 18 patients with Cartiva SCI (mean follow-up: 17.7 months) to 18 patients with metatarsophalangeal joint arthrodesis (mean follow-up: 20 months) using multiple function measures, along with four specified visual analog subscales for pain. Pre- and postoperative radiographs were compared, and radiographic abnormalities were documented.

We observed no significant differences in function measures between groups. While both groups experienced significant pain reduction, the arthrodesis group reported significantly lower exertion pain than the Cartiva SCI group (p = 0.004). Radiographic abnormalities, including implant site enlargement (6/18, 33.3%), erosive changes of the metatarsal bone (11/18, 61.1%) or articular surfaces (10/18, 55.6%), and bright sclerotic margins (12/18, 66.7%), occurred in the Cartiva SCI group.

The present study showed good functional results and a high satisfaction rate after MTP joint arthrodesis, which is considered the gold standard surgical treatment for higher grade hallux rigidus. While the Cartiva SCI group did not show significant differences from the arthrodesis in most aspects of function and clinical scores, the arthrodesis group tended to have better results in terms of satisfaction, residual pain, and revision rate. Even after the short follow-up period, there were some remarkable radiographic findings in the Cartiva SCI group, the long-term effects of which are not yet evident, but which may lead to implant loss. Cartiva SCI has advantages for patients who prioritize postoperative mobility, but the potential risks should be considered in the patient's informed consent. Therefore, the present study highlights the importance of MTP joint arthrodesis for the treatment of hallux rigidus.

Level IV - Retrospective matched case-control study.

Painful degenerative joint disease (DJD) of the first metatarsophalangeal joint (MTP I), or hallux rigidus, mainly occurs in later stages of life. For end-stage hallux rigidus, MTP I arthrodesis is considered the gold standard. As young and active patients are affected considerably less frequently, it currently remains unclear, whether they benefit to the same extent. We hypothesized that MTP I arthrodesis in younger patients would lead to an inferior outcome with decreased rates of overall with lower rates of patient postoperative pain and function compared to an older cohort.

All patients aged <50 years who underwent MTP I arthrodesis at our institution between 1995 and 2012 were included in this study. This group was then matched and compared with a group of patients aged >60 years. Minimum follow-up was 10 years. Outcome measures were Tegner activity score (TAS), a "Virtual Tegner activity score" (VTAS), the visual analog scale (VAS), and the Foot Function index (FFI).

Sixty-one MTP I fusions (n = 28 young, n = 33 old) in 46 patients were included in our study at an average of 14 years after surgery. Younger patients experienced significantly more pain relief as reflected by changes in VAS and FFI Pain subscale scores. No difference in functional outcomes was found with change in the FFI function subscale or in the ability to have desired functional outcomes using the ratio of TAS to VTAS. Revision rate did not differ between the two groups apart from hardware removal, which was significantly more likely in the younger group.

In patients below the age of 50 years with end-stage DJD of the first metatarsal joint, MTP I arthrodesis not only yielded highly satisfactory postoperative results at least equal outcome compared to an older cohort of patients aged >60 years at an average 14 years' follow-up. Based on these findings, we consider first metatarsal joint fusion even for young patients is a valid option to treat end-stage hallux rigidus.

Level III, a case-control study.

Patients frequently turn to the internet to learn about their orthopedic procedures. This study evaluates the readability and quality of first metatarsophalangeal (MTP) joint fusion information found online. We evaluated websites based on classification, search term, readability, HON code, DISCERN score, Journal of the American Medical Association benchmark criteria, and an author-created MTP fusion index (MFI). The average readability of websites was 8.48 ± 1.99, above the recommended sixth- or eighth-grade reading level. Almost half of all websites (48.98%) provided "poor" information. Keywords had no significant impact on the readability or quality of information. Academic/governmental websites had the highest quality of information, with the highest DISCERN and second highest MFI. Most websites (52.04%) were commercial and were the easiest to read, but had the second lowest DISCERN and MFI scores. Our results suggest that inappropriate information on the MTP joint fusion procedure is abundant online. Academic/governmental websites have the highest quality of information, but may be difficult for patients to comprehend. Many websites do have readable and relevant information. We recommend that physicians create a list of websites with accurate, relevant information for patients to circumvent the misinformation they may find while navigating and reading online.

Lateral subtalar dislocations are rare injuries with the potential for misdiagnosis and for poor patient outcomes if missed. Prompt reduction and surgical intervention is the consensus and is key to improved patient outcomes.We present a case of a male patient in his 70s who was brought in by ambulance to the emergency department late one afternoon with a lateral subtalar dislocation associated with calcaneal and lateral malleolar fractures. He was operated on that evening, involving cannulated screw fixation of the calcaneus and buttress plating of the lateral malleolus. Non-weight-bearing mobilisation was permitted at 2 weeks and weight-bearing was commenced at 6 weeks postoperatively.The authors could not find any precedent in the literature for same-day definitive fixation and early mobilisation of this rare but significant injury, the combination of which resulted in excellent functional outcomes for the patient.

Although hammertoe (HT) is a common complaint among foot patients, there is little consensus on the best surgical approach for correction. These authors hypothesized that the use of a headless intramedullary screw across both the proximal interphalangeal joint (PIPJ) and distal interphalangeal joint (DIPJ) would decrease many post-surgical complications, such as infection, pain, and mallet toe deformity, found in traditional HT corrective surgical techniques. In this retrospective cohort study, N = 163 adult patients who had undergone DIPJ/PIPJ arthrodesis for HT correction at least 1 year prior to the study were identified. One hundred fifty-nine patients were contacted through REDCap to complete Patient-Reported Outcome Measurement Information System (PROMIS) physical function (PF) and pain interference (PI). Demographic, radiographic, and follow-up data were taken from the electronic medical record (EMR). Analysis was completed with Microsoft Excel; PROMIS PF and PI measures for the 32-person cohort were 45.65 ± 8.26 and 51.65 ± 9.01, respectively. The PF and PI measures had a statistically significant correlation (R2 = 0.71). The 163-person cohort had an overall revision rate of 6.75%, or 11 patients, and an infection rate of 1.23%. This procedure had lower rates of residual pain, infection, mallet toe deformity, and reoperation when compared with current techniques. This study supports the safety and viability of PIPJ/DIPJ arthrodesis using a headless screw for HT correction.Levels of Evidence: Level III Retrospective Cohort Study.

This case report illustrates the outcome of a deep infection following internal fixation of a fracture of the big toe. Hallux amputation could be avoided through staged salvage procedure. This paper can assist readers on how to effectively and safely recognize and treat this type of injury.

Nonunion and adjacent joint osteoarthritis (OA) are known complications after a fusion procedure, and foot and ankle surgeons are commonly exposed to such disabling complications. Determining who is at risk of developing nonunion is essential to reducing nonunion rates and improving patient outcomes. Several evidenced-based modifiable risk factors related to adverse outcomes after foot and ankle arthrodesis have been identified. Patient-related risk factors that can be improved before surgery include smoking cessation, good diabetic control (HbAc1 <7%) and vitamin D supplementation. Intraoperatively, using less invasive techniques, avoiding joint preparation with power tools, using bone grafts or orthobiologics in more complex cases, high-risk patients, nonunion revision surgeries, and filling in bone voids at the arthrodesis site should be considered. Postoperatively, pain management with NSAIDs should be limited to a short period (<2 weeks) and avoided in high-risk patients. Furthermore, early postoperative weight-bearing has shown to be beneficial, and it does not seem to increase postoperative complications. The incidence of surrounding joint OA after foot and ankle fusion seems to increase progressively with time. Owing to its progression and high probability of being symptomatic, patients must be informed consequently, as they may require additional joint fusions, resulting in further loss of ankle/foot motion. In patients with symptomatic adjacent joint OA and unsatisfactory results after an ankle arthrodesis, conversion to total ankle arthroplasty (TAA) has become a potential option in managing these complex and challenging situations.

The Cartiva implant (CI) is being increasingly used in the surgical therapy of hallux rigidus. Despite a growing number of studies, numerous questions regarding patient selection remain unanswered.

As part of a retrospective case series with prospective follow-up (average follow-up period: 12 months), a total of 44 patients (male/female = 16/28; mean age at the time of surgery: 55.4 years) with 44 CI were analysed (VAS, EFAS-, AOFAS-score). Using a correlation analysis and a machine learning algorithm, risk factors for therapy failure were investigated.

The overall survival rate of the CI was 93% at 12 months. The VAS, EFAS and AOFAS scores showed a significant improvement in comparison to the preoperative condition. The mobility of the metatarsophalangeal joint showed no increase. Patients with a medium osteoarthritis grade and a medium level of clinical restraint showed the greatest improvement in relation to their preoperative condition.

The CI can be seen as an effective therapy for hallux rigidus. Nonetheless, realistic patient expectations must be communicated.

Fusion of the first metatarsophalangeal joint has been used by foot and ankle surgeons as a reproducible and useful means of treating end-stage arthritis of the great toe. However, the overall utility and successful outcomes of this procedure have led to its incorporation into the treatment of more significant bunion deformities, reconstruction forefoot, and salvage procedures. The authors review surgical fixation methods, offer insightful technical pearls for challenging cases and share examples of complex reconstructive and salvage procedures.

Swefoot is a Swedish national registry, that covers surgery in the foot and ankle. Surgical treatment of hallux rigidus (HR) vary within and between countries. The aim of this study was to report baseline variables for patients with HR.

We extracted baseline characteristics, surgical procedures and patient-reported data for patients with HR entered in the registry during the period January 2014 to August 2019.

By August 2019, 1818 patients were reported in the registry. 68.9% of the patients were women, the average age was 58 years, the mean BMI was 26.4kg/m². 41.9% of the patients underwent a cheilectomy,19.8% a metatarsal osteotomy, 34.3% a fusion, 0.2% an arthroplasty, 0.3% Keller's procedure and 3.5% other methods. The preoperative summary score for SEFAS (Self-reported Foot and Ankle Score) was 26 and for EQ-5D (Euroqol-5 Dimension) 0.60.

This study is the first report from Swefoot regarding HR.

First metatarsophalangeal joint (MTPJ) arthrodesis is an index procedure for orthopedic trainees in the United Kingdom. There is an absence of evidence as to the outcome of surgery when performed by supervised trainees. The aim of this study is to compare the incidence of fusion, complication rate and radiographic outcomes in first MTPJ arthrodesis performed by supervised orthopedic trainees with consultants. This is a retrospective cohort study of 117 patients undergoing first MTPJ arthrodesis from August 2015 to December 2017 in our institute for hallux valgus (HV) deformity with first MPTJ arthrosis or for hallux rigidus. Patients were followed to a minimum of 1-year postsurgery and were given an open appointment thereafter. In the hallux rigidus group, there was no significant difference between the complication rate (p = .477), incidence of fusion (p = .663), postoperatively HVA (p = .763), and postoperative intermetatarsal angle (p = .539) between trainees and consultants. There was a significant difference in mean tourniquet time (p = .563) between trainees and consultants. In the hallux valgus group, there was no significant difference in the complication rate (p = .519), incidence of fusion (p = .786), tourniquet time (p = .075), postoperative HVA (p = .423), and postoperative intermetatarsal angle (p = .143) between the trainees and consultants. This is the first MTPJ fusion series that demonstrates good results can be achieved by supervised trainees performing the procedure. This would suggest that first MTPJ arthrodesis remains an opportunity for trainees to continue learning to perform under supervision whilst ensuring no change in outcome for the patient.

First metatarsophalangeal (MTP) joint arthrodesis is a surgical procedure in which the first metatarsal head is fused to the proximal phalanx of the great toe in order to permanently stiffen the first MTP joint. It was originally proposed as a treatment for severe cases of hallux valgus deformity, but the procedure's indications and utilization have expanded since its initial development. Despite a wide variety of indications, first MTP arthrodesis has been shown to have reliable, satisfactory outcomes. As a result, the development of a wide array of surgical approaches, joint preparation techniques, and fixation devices used in the procedure has occurred. In this narrative review, we highlight the evolution of fixation constructs used in first MTP arthrodesis in order to provide a frame of reference for the various types of fixation constructs available.

The goal of this study was to analyze trends in Foot and Ankle surgery in Germany during the past ten years.

Data of the German Federal Statistical Office from 2008 until 2018 were screened. We focused on the analysis of fusions and total joint replacements.

The total amount of the surgeries increased (+39.5%). Especially fusions like arthrodesis of the ankle (+31%) and of the MTP-1 joint (+77%) were on the rise. In 2017 60% of ankle arthrodesis were conducted in men, while 69% of MTP-1 arthrodesis were performed in women. The amount of joint replacements showed a decline during the last decade, in TAR (-39%) and in the MTP-1 (-48%). Regarding the patients age while undergoing a TAR, we observed a shift of the peak age group from 65 to 70 years in 2008 towards 55-60 years in 2017.

Our study represents actual health care reality in Germany and shows a constant increase of ankle arthritis surgeries in the last decade, while there was a massive shift regarding the ratio of TAR in favour of fusion procedures.

Mini implants are increasingly used in foot and ankle surgery. They preserve the joints' functions, are easy to insert and easy to convert to an alternative treatment. Early surgical attempts using silastic implants did not bring the expected success. First achievements where reached with modern metallic mini implants in the first metatarsophalangeal (MTP) joint and the ankle joint. For a few years now, a polyvinyl alcohol implant has been used to treat the arthritic first MTP joint. Even severe arthritic joints can be treated with an implant made of polylactide. This implant can also be used in the treatment of Lisfranc joint pathologies. To address severe osteochondral defects of the talus, an innovative hemiarthroplasty implant has been suggested. This article gives a summary of currently used mini implants. Their application as possible alternatives to total joint replacement or joint fusion are critically reviewed in the light of the current literature.

Minimally invasive surgery has several advantages: minor pain, smaller incisions and less tissue damage than traditional open surgery. Hallux arthrodesis with an endomedullary screw fixation provides compression and axial stability. The aim of this study was to describe the procedure and evaluate our first results of the minimally invasive first metatarsophalangeal arthrodesis with an endomedullary screw combined with a crossed screw fixation.

We retrospectively studied 15feet, with a minimum 1year follow-up. Patients were evaluated with full-load radiographs and AOFAS score preoperatively and at last follow-up.

Consolidation rate was 93.3%, radiological consolidation time was 18 weeks (14-60). Radiographic alignment was achieved with satisfactory results. The preoperative AOFAS score improved from a mean 49 to 90 (p=0.001). There was one postoperative superficial site infection, which healed and a patient developed a pseudarthrosis but it was asymptomatic.

The minimally invasive metatarsophalangeal arthrodesis with an intramedullary screw is a secure procedure with comparable results to open techniques.

4.

Purpose This study compares the amount of joint preparation and first ray shortening following first metatarsophalangeal (MTP) joint fusion utilizing open conical reaming versus arthroscopic technique. Methods Ten below-knee cadaver specimens were randomly assigned to undergo either open or arthroscopic first MTP fusion. Following fixation, first ray length measurements were obtained from pre-operative and post-operative radiographs and were used to determine first ray shortening. Additionally, the ratio of first ray length to second ray length was calculated both pre-operatively and post-operatively and compared between the two approaches. All ankles were then completely dissected, and prepared surface areas were demarcated. ImageJ photo analysis software (National Institutes of Health, Bethesda, MD, USA) was used to calculate the percentage of prepared and unprepared cartilage of each articular surface of each specimen.  Results Overall, the open approach resulted in 99.3% ± 1.6% joint surface preparation, whereas the arthroscopic approach yielded 92.9% ± 7.2% (p = 0.089). On average, the head of the first metatarsal was significantly more prepared with the use of the open approach (99.5% ± 1.1%) than with the arthroscopic approach (96.6% ± 1.5%) (p = 0.008). However, with respect to the base of the phalanx, the average difference in preparation between the arthroscopic approach and the open approach was not statistically significant (90.0% ± 12.8% vs. 99.0% ± 2.2%; p = 0.160). The average amount of first ray shortening in the arthroscopic approach was 2.2 ± 1.8 mm compared to 2.1 ± 3.2 mm in the open approach (p = 0.934). The average change in the first to second ray length ratio was 0.02 for both approaches (p = 0.891). Conclusion Arthroscopic first MTP fusion can be used to achieve joint preparation comparable to open technique while maintaining first ray length.

The aim of this study was to determine the early outcomes and complications following the implantation of a hydrogel synthetic cartilage implant (SCI, Cartiva) for the treatment of hallux rigidus by a single surgeon.

A retrospective chart review was performed of consecutive patients who underwent treatment for hallux rigidus with an SCI between August 2016 and April 2018 by a single surgeon. Demographic information, radiographic assessment, and concomitant operative procedures performed were evaluated for all patients. Postoperatively, PROMIS physical function (PF) and pain interference (PI) scores, patient satisfaction, reoperation, conversion to arthrodesis, and need for further clinical treatment were collected. Sixty-four SCIs were implanted in 60 patients. Follow-up averaged 18.5 months (range 12-30 months).

14% (9/64) of patients were very satisfied, 28% (18/64) satisfied, 20% (13/64) neutral, 11% (7/64) unsatisfied, and 27% (17/64) very unsatisfied with their outcome. In addition, 45% of patients underwent additional procedures at the time of SCI, and 23% had a history of surgery on the hallux before implantation. PROMIS PF scores averaged 42 and PROMIS PI scores averaged 60. Overall, 63% completed PROMIS PI, 66% completed PROMIS PF, and 100% completed a satisfaction survey. In addition, 30% (19/64) underwent magnetic resonance imaging (MRI) postoperatively due to pain. There was a 20% reoperation rate, which included an 8% rate of conversion to arthrodesis.

Synthetic cartilage implantation yielded neutral patient satisfaction, mild pain, and physical dysfunction at early follow-up. We believe patient selection and counseling regarding early postoperative limitations are important before proceeding with SCI.

Level IV, case series.

A prospective, randomized, noninferiority clinical trial of synthetic cartilage implant hemiarthroplasty for hallux rigidus demonstrated functional outcomes and safety equivalent to first metatarsophalangeal (MTP) joint arthrodesis at 24 months. We prospectively assessed safety and efficacy outcomes for synthetic cartilage implant hemiarthroplasty at a minimum of 5 years.

Of 135 eligible patients from the original trial, 112 (83.0%) were enrolled (mean age, 58.2 ± 8.8 years; 87 females). Pain visual analog scale (VAS), Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL), and FAAM Sports subscales were completed preoperatively and 2 and 5 years postoperatively. Great toe active dorsiflexion, weightbearing radiographs, secondary procedures, and safety parameters were also evaluated.

At 24 months, 14/152 (9.2%) patients had undergone implant removal and conversion to arthrodesis. In years 2 to 5, 9/119 (7.6%) patients underwent implant removal and conversion to arthrodesis. At mean 5.8 ± 0.7 (range, 4.4-8.0) years' follow-up, pain VAS, FAAM ADL, and FAAM Sports scores improved by 57.9 ± 18.6 points, 33.0 ± 17.6 points, and 47.9 ± 27.1 points, respectively, from baseline. Clinically significant changes in VAS pain, FAAM ADL, and FAAM Sports were reported by 103/106 (97.2%), 95/105 (90.5%), and 97/104 (93.3%) patients, respectively. Patient-reported outcomes at 24 months were maintained at 5.8 years in patients who were not revised. Active MTP joint peak dorsiflexion was maintained. Ninety-nine of 106 (93.4%) patients would have the procedure again.

Clinical and safety outcomes for synthetic cartilage implant hemiarthroplasty observed at 2 years were maintained at 5.8 years. The implant remains a viable treatment option to decrease pain, improve function, and maintain motion for advanced hallux rigidus.

Level IV, case series.

Arthrodesis of the first metatarsal-phalangeal joint is a reliable procedure for correction of both hallux limitus/rigidus and severe hallux abducto valgus deformities. However, 1 potential contraindication to the procedure is the extended period of non-weight-bearing immobilization that is typically associated with the postoperative course. The objective of this investigation was to perform a systematic review of the incidence of non-union after early weight bearing in patients who underwent arthrodesis of the first metatarsal-phalangeal joint. We performed a review of electronic databases with the inclusion criteria of retrospective case series, retrospective clinical cohort analyses, and prospective clinical trials with n ≥ 15 feet, a mean follow-up of ≥12 months, a defined postoperative early weight-bearing protocol (defined as ≤2 weeks), a clear description of the fixation construct, a reported incidence rate of non-union, and patients who underwent primary surgery for hallux abducto valgus or hallux limitus/rigidus deformities. Seventeen studies met our inclusion criteria, with a total of 898 feet analyzed. Of these, 57 (6.35%) were described as developing a non-union. This would likely be considered an acceptable crude, heterogeneous incidence of non-union when considering this procedure. It might also indicate that arthrodesis of the first metatarsal-phalangeal joint does not always require an extended period of non-weight-bearing postoperative immobilization.

To examine the safety and efficacy of Masquelet's technique as a surgical method for treating the first metatarsophalangeal joint in cases of gout accompanied by a massive bone defect.

From January 2010 to January 2016, eleven patients (7 males and 4 females; mean age 33.1 years; range, 23-43 years) received surgical treatment for a first metatarsophalangeal joint tophus which caused a serious bone defect. The first metatarsophalangeal bone defects ranged from 3-6cm, or nearly 50% of the length of normal bone. During the first stage of Masquelet's technique, we removed the tophus and infused that area with bone cement that contained antibiotics. Two months later, we performed the second stage, in which the prosthesis was replaced with iliac cancellous bone, and the operated area was stabilized via locking plate fixation.

All of the surgeries were successful, and the 11 patients were followed up for an average of 10.9 months. Postoperative evaluations showed that 10 of the 11 patients healed between 9 and 14 days after the initial surgery. Bone fusion occurred between 2.3 and 3.6 months after the operation, and the average healing time was 3.0 months. One foot wound became infected, but healed after vacuum aspiration. When the American Association of Foot and Ankle Surgery Maryland Foot scoring system was used to evaluate the foot function of the 11 patients prior to surgery, all 11 patients were graded as "failures." Following surgery, 2 patients were graded excellent, 5 were good, 3 were fair, and only 1 patient failed. The total combined excellent and good rate was 63.6%. The total mean Maryland scores pre- and post-surgery were 27.8 points and 74.1 points, respectively; thus the average patient score increased by 46.3 points.

Joints with advanced tophus nodules develop segmental bone defects. Masquelet's technique is an effective method for treating such nodules and their associated bone defects.

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.