Arthrodesis of the First Metatarsophalangeal Joint: A Robotic Cadaver Study of the Dorsiflexion Angle

Background: Arthrodesis of the first metatarsophalangeal joint is indicated for severe osteoarthritis or as a revision of failed treatment for hallux valgus. The literature suggests that an optimum fused dorsiflexion angle is between 20 degrees and 25 degrees from the axis of the first metatarsal. The purpose of this study was to investigate the relationship between dorsiflexion angle and plantar pressure in the postoperative gait. We assumed that there is a fused dorsiflexion angle at which pressures are minimized under the hallux and the first metatarsal head. Methods: Six cadaver foot specimens underwent incremental changes in simulated fused metatarsophalangeal joint dorsiflexion angle followed by dynamic gait simulation. A robotic gait simulator performed at 50% of body weight and one-fifteenth of physiologic velocity. In vitro tibial kinematics and tendon forces were based on normative in vivo gait and electromyographic data and were manually tuned to match the in vitro ground reaction force and tendon force behavior. Regression lines were calculated for peak pressure and pressure-time integral under the hallux and the metatarsal head by dorsiflexion angle. Results: Peak pressure and pressure-time integral under the hallux were negatively correlated with dorsiflexion angle (p < 0.004), while peak pressure and pressure-time integral under the metatarsal head were positively correlated with dorsiflexion angle (p < 0.004). The intersection of the regression lines that represented the angle at which peak pressure and pressure-time integral were minimized was 24.7 degrees for peak pressure and 21.3 degrees for pressure-time integral. Conclusions: Our findings support the hypothesis that an angle-pressure relationship exists following arthrodesis of the first metatarsophalangeal joint and that it is inversely related for the hallux and the metatarsal head. Our results encompass the suggested range of 20 degrees to 25 degrees. Clinical Relevance: This investigation provides a basis for assessing clinical decisions surrounding operative technique and hardware utilization that may improve gait, quality of life, and functional performance in patients undergoing operative treatment of osteoarthritis of the first metatarsophalangeal joint.