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Effect of co-morbidities on outcomes of first metatarsophalangeal joint fusion: A systematic review
, Sumedh Sridharb, Matt Harrisonc, Linzy Houchen-Wolloffc, Pip Divalld, Jitendra Mangwanic
⁎Corresponding author: Somen Agrawal. somen.agrawal@nhs.net
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
The pre-existing co-morbidities have a major impact on the outcomes of Orthopaedic procedures as shown by the several studied in various contexts. However, the specific influence of these co-morbidities on first metatarsophalangeal joint fusion remains relatively underexplored. This study aims to address this gap by examining the association between co-morbidities such as obesity, smoking, diabetes, advancing age, and rheumatoid arthritis, and the outcomes of first metatarsophalangeal joint fusion.
A comprehensive search was conducted across multiple databases, including MEDLINE, EMBASE, and CINAHL. Relevant articles were identified and processed using Covidence, with independent assessment conducted to ensure inclusion criteria were met. The focus of the review was on analysing the effects of specific co-morbidities on fusion outcomes.
Seven qualifying studies were identified for full-text extraction, revealing significant heterogeneity across the literature, which hindered direct statistical comparisons. The findings presented inconclusive effects of obesity on fusion outcomes, with ambiguous impacts observed for diabetes mellitus and smoking. Additionally, no discernible variance was observed in functional outcomes across different age groups. Furthermore, steroid usage in rheumatoid arthritis cases demonstrated delayed fusion in revision procedures, while primary outcomes remained uncertain.
This systematic review highlights the need for further research with standardised methodologies to better understand the correlation between pre-existing co-morbidities and outcomes in first metatarsophalangeal joint fusion. By elucidating these relationships, clinicians can better tailor treatment approaches and optimise patient care in this specific Orthopaedic context.
Level III.
Abstract
Highlights
•To establish the effects of obesity, smoking, diabetes, advancing age, and inflammatory arthritis on First metatarsophalangeal joint (MTPJ) fusion.
Keywords
Metatarsophalangeal joint (MTPJ)
Comorbidities
Obesity
Diabetes
Smoking
Rheumatoid arthritis
1 Introduction
First metatarsophalangeal joint (MTPJ) fusion is one of the commonly performed foot and ankle procedure for various disorders of the first metatarsophalangeal joint and this includes osteoarthritis, severe hallux valgus, and failed hallux valgus correction surgery.1 Additionally, while dealing with inflammatory arthropathies like Rheumatoid arthritis, it can play an integral part in the forefoot reconstructions for these2,3 as the results are predictable and patient satisfaction rate is high. The reported fusion rates for this procedure range from 90 to 100 %.4
The profile of the patients with comorbidities is evolving, and there has been an increasing prevalence of individuals suffering from various comorbidities.5–7 Obesity, smoking, diabetes, advancing age and inflammatory arthritis are a few of the common conditions identified as important factors influencing outcomes in orthopaedic surgery.8–12 Strong evidence has suggested a clear linkage between these comorbidities and the outcomes of trauma and orthopaedic procedures. Significant correlation has been found between prolonged hospital stay and an increased readmission rates following Hip and Knee arthroplasty in the patients who suffer from one or more of these conditions.12–15
There have been reported increase in the surgical complications following ankle surgery in the patients who suffer from conditions such as Diabetes and Obesity, as well as Advancing age.16–19 Impact of comorbidities has been extensively studied in the patients undergoing foot and ankle surgery and has been known to affect their outcomes.10,20–23
There is a notable scarcity of evidence on the influence of these conditions on the outcomes of first MTPJ fusion extensive research on other conditions. This systematic review seeks to scrutinise the existing body of evidence, shedding light on the potential effects of comorbidities and their implications on complication rates in the context of first MTPJ fusion.
2 Methods
This systematic review was undertaken and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines24 and registered on PROSPERO (Reference: CRD42024459989).
2.1 Search strategy
Three electronic databases (MEDLINE, EMBASE, and CINAHL) were initially searched on 17/05/2023. An updated search was conducted on 25/01/2024 due to the length of time since the initial search. The following key terms ‘metatarsal phalangeal joint’, ‘arthrodesis’, and ‘co-morbidities’ were expanded and explored. See appendix 1 for full search strategy.
2.2 Inclusion
•Inclusion was restricted to studies that directly assessed the impact of pre-operative co-morbidities on the outcomes following first MTPJ arthrodesis.•Cohort studies, case series of more than 20 cases, and randomised controlled trials (RCTs).•Age >18 years, males and females undergoing arthrodesis of the first MTPJ.•No geographical restriction.•The pre-operative comorbidities which were included comprise of Obesity, Rheumatoid Arthritis, Diabetes Mellitus, Advancing Age and Smoking.•All included articles were required to be written or translatable in English.
2.3 Exclusion criteria
•Studies which discussed non-arthrodesis procedures were excluded, as were studies which discussed procedures on joints other than the first MTPJ.•Studies which did not report on pre-operative baselines and patient co-morbidities were also excluded.•Results which did not mention post-operative patient outcomes were excluded.•Studies which consisted of revision surgery cases were excluded.
2.4 Study identification and selection
The articles across all three databases identified as relevant according to the inclusion criteria were exported to the COVIDENCE systematic review software (Veritas Health Innovation Ltd). Duplicate results were removed. The abstracts of the remaining results underwent independent assessment by two teams of reviewers, with each team consisting of two reviewers: team 1 (authors SS, SA) and team 2 (authors MH, LHW), following the predefined inclusion criteria. Any conflicts were discussed and resolved by the senior author (JM). Results deemed to meet the inclusion criteria by all reviewers were then subject to full-text analysis.
2.5 Quality checking
To ensure a high standard of abstract assessment, all independent reviewers (SS, SA, MH, LH) utilised the appropriate critical appraisal skills programme (CASP) checklist for.-Systematic reviews - https://casp-uk.net/checklists/casp-systematic-review-checklist.pdf-Cohort studies - https://casp-uk.net/checklists/casp-cohort-studies-checklist.pdf-RCTs - https://casp-uk.net/checklists/casp-rct-randomised-controlled-trial-checklist.pdf
2.6 Data extraction
Appropriate studies identified through the above processes were then subject to data extraction based on pre-operative co-morbidities, and post-operative outcomes (union rates and complications). Extracted data was exported to Microsoft Excel and reviewed for accuracy by two independent reviewers (SS and SA).
3 Results
The updated search yielded 807 articles. Following removal of 309 duplicates, 498 studies were identified and screened in the initial search. Of these studies, 489 were excluded following review of the abstract/papers and seven studies were identified to be relevant for full text data extraction. See Fig. 1: Prisma flowchart.
Table 1 shows the demographics of the study population within the included studies.
| Study | Sample Size | Average Age (years) | Female | Male | BMI |
| Webb et al., 2022 | 94 | 63.2 | 81 (86.2 %) | 13 (13.8 %) | 27.5 (SD 17–39) |
| Anderson et al., 2014 | 76 | 62.3 | 44 (57.9 %) | 32 (42.1 %) | 29.01 (range 16.8–51.8) |
| Weber et al., 2021 | 153 | 61.1 | 105 (68.6 %) | 48 (31.4 %) | N/A |
| Lunati et al., 2020 | 143 | 64.2 | 122 (85.3 %) | 21 (14.7 %) | OA Group 28.7 ± 5.79 |
| RA group 27.6 ± 6.09 | |||||
| Ellington et al., 2010 | 107 | 61.4 | 77 (71.2 %) | 30 (28.0 %) | Union 29.3 ± 5.6 |
| Non-union 28.4 ± 5.0 | |||||
| Hyer and Morrow, 2014 | 155 | 60.3 (OA group) | 110 (71.0 %) | 45 (29.0 %) | 27.6 kg/m2 |
| 62.9 (RA group) | |||||
| Weigelt et al., 2021 | 165 | 60.4 | 137 (83.0 %) | 28 (17.0 %) | N/A |
A wide range of comorbidities were identified. However, the following comorbidities Obesity, Diabetes, Smoking, Rheumatoid Arthritis and Advancing Age have been selected as they as pivotal factors influencing outcomes in orthopaedic surgery.8–11Table 2 summarises the results of data extraction.
| Study | Comorbidities and Complication Rate | |||
| Diabetes | Smoker | Rheumatoid Arthritis | Complication Rate | |
| Webb et al., 2022(25) | 8 (8.5 %) | 25 (26.6 %)- Smoker | 8 (8.5 %) | 7 (7.4 %) |
| 3 (3.2 %)- current smoker | Not statistically significantly increased risk in BMI >30 compared to BMI <30 | |||
| Anderson et al., 2014(26) | 76 (100 %) | 5 patients continued to smoke during time of surgery (2 out of 5 (40 %) had at least one complication) | 4 (50 %) had at least one complication | 27 (35.5 %) |
| Higher incidence of complications in diabetic patients with pre-operative neuropathy | ||||
| Ellington et al., 2010(27) | 0 (0 %) | N/A | • Present in 35 (32.7 %)• Complication rate- RA (37.1 %) compared to without RA (25 %), not significant.• Non-union without RA- 6.9 % (5/72)• Non-union with RA- 22.9 % (8/25) Significant | 31 (28.9 %) |
| Overall, no statistically significant difference between RA and non-RA in terms of complication rate. | ||||
| Hyer and Morrow, 2014(28) | OA Group 8 (6.9 %) | OA Group 14 (12.1 %) | 39 (25.2 %) | OA – 22 (19.0 %) |
| RA Group 6 (15.4 %) | RA Group 4 (10.3 %) | RA – 7 (18.0 %) | ||
| No statistically significant difference apart from delayed wound healing which was more delayed in the RA group. | ||||
| Weigelt et al., 2021(29) | Union 11 (6.6 %) | Union 34 (20.4 %) | Union 27 (16.2 %) | 6.2 % |
| Non-union 4 (36.4 %) | Non-union 1 (9.1 %) | Non-union 2 (18.2 %) | Diabetes was associated with a statistically significant risk of non-union. | |
| Weber et al., 2021(30) | N/A | 63 (41.2 %) | 5 in non-union group | 14 (9.1 %) |
| Non-union is statistically significant for the following: gender – higher risk for males. | ||||
| Smoking, BMI, etc were not significant. | ||||
| Lunati et al., 2020(11) | 14 (9.8 %) | 37- Smoker (25.6 %) | 9 (6.3 %) | 25.6 % for <65 and 21.9 % for >65 but difference is not significant. |
| 6 - Current smokers (4.2 %) | ||||
4 Discussion
The systematic review presented here explores the impact of comorbidities specifically on the outcomes for first MTPJ fusion surgery. The major comorbidities explored include Obesity, Smoking, Diabetes, Advancing age, and Rheumatoid arthritis. In all the studies reviewed, there were a higher proportion of females undergoing first MTPJ arthrodesis in comparison to men. The female cohort also displayed a higher revision rate when compared to males.
4.1 Obesity
Approximately a quarter of adults in the United Kingdom are classified as obese, and there exists a complex relationship between obesity and surgical outcomes.25 Obesity induces relative hypoperfusion, thereby presenting significant surgical challenges. This is further complicated by reduced delivery of oxygen and antibiotics to the tissues..26 Several studies have investigated the impact of obesity on surgical outcomes in foot and ankle surgery,21 and have shown increased complications and poorer results in fracture surgery, total ankle arthroplasty, hallux valgus correction, and surgical repair of Achilles tendon ruptures.27–30
A study by Althoff et al. has highlighted obesity as a significant risk factor for both primary and revision first MTPJ arthroplasties in Ref. 31. Although, another study by Weber et al.32 did not show any significant impact of high BMI on fusion. Furthermore, Webb et al.33 found no significant difference in the outcomes between people who are obese and those who are not. Another notable finding was that among non-obese patient groups, there was a higher prevalence of rheumatoid arthritis, whereas obese patients showed significantly higher rates of hypertension and diabetes. Similar findings were suggested by Weigelt et al.,34 where they found no difference in the non-union rates after first MTPJ arthrodesis when considering age and BMI as a risk factor, compared with patients who reached union.
4.2 Smoking
In the United Kingdom, approximately 6.4 million individuals smoke, constituting approximately 12.9 % of the population.35 A retrospective review conducted by Bettin et al. showed 4.3-fold increased likelihood of experiencing post-operative complications, with an increased relative risk of nearly seven times for non-union and delayed union in smokers when compared to their non-smoking counterparts after elective forefoot surgery.22 Similarly, another study identified a statistically significant association between smoking and increased postoperative pain, as well as persistent use of analgesics up to three months following major ankle or hindfoot reconstructive surgery.36 Regarding postoperative infection, an analysis of 906 patients undergoing ankle fracture surgery revealed a sixfold higher incidence of developing deep infections in smokers compared to non-smokers..37
Looking at the patients with first MTPJ fusion, Prat et al. 38 concluded that not only active smokers but also those with a history of smoking, were at higher risk of complications. Patients with a history of smoking had higher complication rates as well as significantly higher non-union rates.
In contrast, Weber et al., reported smoking to have no impact on fusion rate.32
4.3 Diabetes
Approximately 8.6 % of individuals aged 16 years and older in England are affected by Diabetes Mellitus, totaling nearly 3.8 million people.39 This presents an issue because diabetes introduces a diverse range of challenges that impede achieving surgical success.
Perioperative assessment plays a crucial role, particularly in cases of complicated diabetes, as it is linked to higher infection rates and increased occurrences of non-union and mal union, particularly pronounced in diabetic patients with peripheral neuropathy. This is reflected in a large series of 57 183 patients undergoing ankle fracture internal fixation, where there was an overall infection rate of 1.44 %. The difference was notable when compared to an overall infection rate of 3.55 % in patients with uncomplicated diabetes and 7.71 % in those with complicated diabetes..17 Another study confirmed these findings, revealing a non-union and mal-union rate of 19.7 % in diabetic patients and 73 % in diabetic patients with peripheral neuropathy undergoing first MTPJ arthrodesis. Additionally, there was a 3.9 % incidence of superficial infection and a 5.3 % incidence of wound dehiscence.40
One of the studies has shown a higher prevalence of Type 2 diabetes compared to Type 1, reflecting the trend in the population..31 However, it did not identify Type 2 diabetes as a significant risk factor for revision in first MTPJ arthrodesis.
The occurrence of diabetes has been associated with higher complication rates, including non-union in first MTPJ arthrodesis, and an increased risk of revision, as demonstrated by other studies.32,38
Despite its prevalence in society, diabetes is not clearly identified as a significant risk factor for revision in first MTPJ arthrodesis. This underscores the complex relationship between diabetes and surgical outcomes.
4.4 Advancing age
Increasing age has been associated with frailty and various comorbidities due to changes in organ function. Therefore, it is a crucial factor to consider when deciding on operative interventions..41
However, a retrospective analysis of 53 patients comparing individuals younger than 60.5 years to those older than 60.5 years showed no significant differences in functional outcomes or satisfaction levels after first MTPJ arthrodesis.42 This finding was supported by another study involving 143 patients who were prospectively compared after undergoing MTP arthrodesis, where the comparison between those aged <65 years and those aged ≥65 years showed no significant differences in patient-reported functional outcomes and pain levels, despite a higher incidence of comorbid conditions in the older age group. Both cohorts exhibited comparable rates of postoperative complications, which contrasts with the assumption of age-related disparities in surgical outcomes.11
Current literature indicates no significant differences in functional outcomes, levels of satisfaction, or postoperative complications among various age groups undergoing first MTPJ arthrodesis.
4.5 Rheumatoid arthritis (RA)
Effective surgical planning is crucial for patients with rheumatoid arthritis, particularly considering the inflammatory nature of the disease and the implications of long-term steroid use. The latter was found to have a significant effect on revision MTPJ fusion, particularly in those with inflammatory disease such as RA.31 A study compared the union rates between the RA and OA groups following MTPJ fusion but did not find a statistically significant difference.43 However, there was a statistically significant difference in the interval to fusion between the two groups, with the RA group achieving faster healing (fusion). Although the OA group did not experience any delayed wound healing, the RA group had three cases with wound healing problems, which were both clinically and statistically significant. These findings highlight the critical need for meticulous surgical decision-making and planning in patients with RA.
5 Conclusion
The complexity of evaluating the influence of pre-operative co-morbidities on post-operative outcomes following first MTPJ arthrodesis is highlighted by this systematic review. Despite diligent efforts to clarify these associations, the observed results demonstrate considerable heterogeneity, presenting significant challenges for direct statistical comparison, particularly when considering the interplay of multiple comorbidities within individuals.
The influence of obesity on fusion outcomes remains inconclusive, despite established effects on post-operative infection and union rates in other Trauma and Orthopaedic procedures. Similarly, conflicting findings regarding the effects of Diabetes Mellitus and the uncertain impact of smoking on fusion results highlight the need for further investigation and standardisation of methodologies.
Contrary to anticipated age-related differentials, our review challenges presumptions, indicating a more nuanced understanding of surgical outcomes across age groups. Additionally, while steroid use in Rheumatoid Arthritis has demonstrated delayed fusion in revision procedures, its effect on primary fusion outcomes remains uncertain.
Despite these complexities, our analysis provides valuable insights into the roles of Obesity, Smoking, Diabetes, Advancing age, and Rheumatoid Arthritis in first MTPJ fusion surgery outcomes. Moving forward, future studies should prioritise standardised methodologies and larger sample sizes to enhance the validity of comparisons, ultimately optimising patient outcomes and guiding clinical decision-making in MTPJ fusion procedures.
Funding/sponsorship
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Informed consent
Irrelevant.
Consent to publish
All authors involved with this work authorise its publication.
Ethical approval
Irrelevant.
Guardian/patient's consent
I will like to declare on behalf of my co-authors that we did not need Guardian/Patient's consent for this study.
CRediT authorship contribution statement
Somen Agrawal: Data curation, Formal analysis, Writing – original draft. Sumedh Sridhar: Formal analysis, Writing – review & editing. Matt Harrison: Formal analysis, Writing – review & editing. Linzy Houchen-Wolloff: Formal analysis, Writing – review & editing. Pip Divall: Literature search. Jitendra Mangwani: Conceptualization, Methodology, Supervision.
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