Abstract
Background:
Minimally invasive cheilectomy is becoming a more prominent surgical approach in the management of mild to moderate hallux rigidus. This systematic review aims to analyze and present the current literature on patient-reported outcomes following minimally invasive (MIS) cheilectomy for mild to moderate hallux rigidus.
Methods:
PubMed, Cochrane Central Register of Controlled Trials, and Scopus databases were searched in April 2024. Inclusion criteria consisted of articles evaluating patients undergoing cheilectomy through an MIS approach either using fluoroscopy or arthroscopy, studies that reported patient-reported outcomes, and studies written in English. The primary outcome measure was scored patient-reported outcomes. The secondary outcome measures included complications, secondary surgeries, surgical techniques, return to activity, patient satisfaction, and grades of hallux rigidus.
Results:
Eight studies met the inclusion criteria, and a total of 296 patients were evaluated. Overall, 36 of 296 (12.2%) underwent arthroscopy with a shaver, 130 of 296 (43.9%) underwent an MIS percutaneous approach with burr, and 130 of 296 (43.9%) had a combination of both techniques. The mean reported range of motion (dorsiflexion) improved from 32.4 degrees (range, 6.3-50.0 degrees) to 61.2 degrees (range, 47.6-89.6 degrees). All studies that reported patient outcomes scores demonstrated improved outcomes regardless of surgical technique. Overall combined reported complication rate was 18 of 296 (6.1%), with the most common complication being dorsomedial cutaneous nerve problems, affecting 6 of 296 patients (2.0%).
Conclusion:
Minimally invasive cheilectomy results in positive patient outcomes, patient satisfaction, preserves range of motion, and has low complication rates for the treatment of mild to moderate hallux rigidus.
This is a visual representation of the abstract.
Introduction
Hallux rigidus is a degenerative disorder of the first metatarsophalangeal (MTP) joint. Patients with this condition experience symptoms including pain, stiffness, discomfort, reduced range of motion of the first MTP joint, and functional limitation. 1 Hallux rigidus is the second most common condition affecting the first MTP joint following hallux valgus, affecting 2.5% of people aged ≥50 years, with higher prevalence in females.13,16 Initially patients are treated with conservative measures including the use of rigid sole shoes or a carbon fiber orthotic, an anti-inflammatory medication, or an intraarticular steroid injection. Surgery is indicated in patients who fail conservative intervention, and surgical treatment typically consists of either a cheilectomy procedure or an arthrodesis procedure.
Minimally invasive techniques for cheilectomy have become increasingly popular, with studies demonstrating positive outcomes and low complication rates among patients with mild to intermediate-grade hallux rigidus. 8 These techniques include using burr or shaver instrumentation through small stab incisions aided by fluoroscopic visualization and/or small-joint arthroscopy to remove osteophytes and painful loose bodies within the MTP joint.5,7 -9,11,14,18,22 This systematic review aims to analyze and present the current literature on patient-reported outcomes (PROs) following minimally invasive cheilectomy for mild to moderate hallux rigidus.
Methods
Search Strategy and Article Inclusion
This systematic review was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search of PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus databases was conducted on April 6, 2024, for clinical studies published from 1973 to April 5, 2024, evaluating MIS cheilectomy procedures. Minimally invasive cheilectomy was defined as a cheilectomy procedure that used either an arthroscopic or percutaneous approach. The initial search term used was “cheilectomy.” A combination of keywords and Medical Subject Headings (MeSH) terms were used in the final search strategy “minimally invasive cheilectomy” OR “MIS cheilectomy” OR “arthroscopy AND cheilectomy.” The search strategy used for this study is summarized in a PRISMA flowchart (Figure 1). Inclusion criteria consisted of articles evaluating patients undergoing cheilectomy through a minimally invasive cheilectomy (MIS) approach either using fluoroscopy or arthroscopy, studies that reported patient-reported outcomes, and studies written in English. Exclusion criteria included studies that used a metatarsal osteotomy as part of the surgical procedure, studies through which the procedure was performed through an open approach, animal studies, biomechanical studies, case reports, opinion articles, review articles, and surgical technique articles. All articles were initially reviewed based on title and abstract. Articles with titles and abstracts that initially met inclusion criteria underwent full-text review to determine eligibility. Two independent authors conducted the title or abstract and full-text screening. A fellowship-trained orthopaedic foot and ankle surgeon resolved all disputes in the screening process.
Preferred Reporting Systems for Systematic Reviews and Meta Analyses (PRISMA) Diagram.
Article Quality Assessment
The Methodological Index of Non-Randomized Studies (MINORS) score was used to qualitatively assess the risk of bias for all articles included in the review (Supplemental Table S1). 21 Potential biases, such as adequate follow-up period, study endpoints, and prospective data collection, were assessed for each article using the MINORS scoring methodology. Case series were graded on a score of 0-16. Two independent authors scored all articles. Conflicts in score were resolved by a third author.
Data Extraction
Two authors independently extracted all data. Discrepancies were resolved by a third author. The following information was recorded from each article: author, year of publication, study design, surgical indication, demographics, range of motion, complications, patient-reported outcomes, return to activity, patient satisfaction, surgical techniques, and grade of hallux rigidus.
Results
Search and Literature Selection
The initial literature search yielded 462 total articles. Once duplicates were removed and the articles were screened for inclusion and exclusion criteria, 63 studies were included, and full texts were assessed for eligibility. After screening, there were 55 additional articles excluded because they either did not evaluate patient-reported outcomes of minimally invasive cheilectomy or were systematic reviews or review articles. Figure 1 depicts the literature search procedure.
Study Characteristics
A total of 8 articles met the inclusion criteria, evaluating a total of 296 patients. Study characteristics and demographic information are exhibited in Table 1.
Summary.
Abbreviations: AOFAS, American Orthopaedic Foot & Ankle Society; EQ-VAS, EuroQol–visual analog scale; EQ-5D, EuroQol–5 dimensions; HMI, hallux metatarsophalangeal-interphalangeal; MIS, minimally invasive surgery; MOxFQ, Manchester-Oxford Foot Questionnaire; ROM, range of motion; VAS, visual analog scale.
Surgical Technique
The surgical technique used in each of the studies is noted in Table 1. One study performed arthroscopy and debridement using a shaver. 14 Two studies reported cheilectomy using a percutaneous incision with an MIS burr.18,22 Five studies combined percutaneous MIS burr followed by arthroscopic debridement with a shaver.5,7 -9,11 Overall, 36 of 296 (12.2%) underwent arthroscopy with a shaver, 130 of 296 (43.9%) underwent an MIS percutaneous approach with burr, and 130/296 (43.9%) had a combination of both as described above.
Coughlin-Shurnas Grade
Four articles reported Coughlin-Shurnas preoperative grade hallux rigidus (Supplemental Table S2).5,14,18,22 Most patients (168 of 211; 79.6%) had Coughlin-Shurnas grade 1 or 2 hallux rigidus (range: 1-3); grade 1: 63 of 211 (29.9%), grade 2: 105 of 211 (49.8%), and grade 3: 43 of 211 (20.4%). All studies excluded grade 4 patients.
Patient-Reported Surgical Outcomes
All 8 studies evaluated PROs (Table 2). Patient-reported outcome scores and metrics included AOFAS, ROM, VAS, MOxFQ, and ED-5D index. The most common patient-reported outcome scale/metric was range of motion and the Visual Analog Scale (VAS).5,7 -9,11,22 The mean range of motion (dorsiflexion) improved from 32.4 degrees (range, 6.3-50 degrees) to 61.2 degrees (range, 47.6-89.6 degrees). Regardless of technique, all studies that reported VAS demonstrated improved scores.
Patient Reported Outcomes.
Abbreviations: AOFAS, American Orthopaedic Foot & Ankle Society; DF, dorsiflexion; EQ-VAS, EuroQol–visual analog scale; EQ-5D, EuroQol–5 dimensions; HMI, hallux metatarsophalangeal-interphalangeal; MIS, minimally invasive surgery; MOxFQ, Manchester-Oxford Foot Questionnaire; PF, plantarflexion; ROM, range of motion; VAS, visual analog scale.
Two studies evaluated isolated percutaneous MIS with burr outcomes. Pastides et al 18 reported an AOFAS-HMI improvement score of 71.1 preoperatively to 88.2 at 2-6 weeks postoperatively and a final score of 87.1 at 17 months (P < .001). Teoh et al 22 shows that the mean improvement in the MOxFQ summary index decreased from 58.6 (range, 30-94) to 30.5 (range, 0-92) after percutaneous MIS with burr (all 3 domains improved but were statistically insignificant). Furthermore, VAS scores decreased from 8 (range, 6-10) to 3 (range, 0-10). 22
Five studies evaluated PROs of combined percutaneous MIS with burr and arthroscopy with a shaver. Di Nallo et al 5 reported AOFAS mean improvement of 59 ± 8 (range, 51-67) to 88 ± 6 at 1 year and 84 ± 4 (range, 80-88 ) at 4 years postoperation (P < .001). Gauthier et al 7 demonstrated a mean decrease in VAS scores from 6.5 ± 2.7 to 2.1 ± 1.9 at follow-up (P < .001). Furthermore, mean improvement in MOxFQ summary index decreased from 54.7 ± 18.9 to 22.4 ± 23.5 (P < .001). 7 ED-5D index increased from 0.64 ± 0.2 to 0.76 ± 0.21 but was not statistically significant (P < .069). 7 Glenn et al 8 reported a mean decrease in VAS scores from 7.05 (range, 5-10) to 0.75 at follow-up (P < .05). Hickey et al 9 demonstrated a mean preoperative AOFAS score of 66.64 ± 5.55 (range, 55.00-85.00) and used a survey for postoperative outcomes. The mean patient-reported pain out of 10 was 2.67 ± 2.50 (range, 0-9) at follow-up with percentage pain relief 74.22 ± 32.24 (range, 0-100). 9 Iqbal and Chana 11 reported that 10 of their 15 patients (66.6%) had complete relief in pain and 5 of the 15 patients (33.3%) had partial relief in pain following the procedure.
Levaj et al 14 reported that 24 of their 27 patients (88.9%) were satisfied or very satisfied with their arthroscopic cheilectomy procedure. Furthermore, 25 of the 27 patients (92.6%) reported they would undergo the same procedure again. 14
Patient Satisfaction and Return to Activity
Five studies broadly evaluated patient satisfaction following the procedure (Table 3). Overall, 107 of 118 patients (90.7%) would recommend the procedure and 59 of 62 patients (95.2%) were either satisfied or very satisfied with the results following the procedure.8,9,11,14,18 Patient satisfaction results are detailed in Table 3.
Patient Satisfaction and Return to Activity.
Three studies evaluated return to activity following MIS cheilectomy (Table 3). Using percutaneous MIS with burr, Pastides et al 18 reported that 30 of their 41 patients (73%) returned to some sporting activity at 6 weeks postop whereas 24 of the 41 (59%) returned to nonimpact sports such as swimming and 6 of 41 patients (14%) returned to impact-intensive activities such as tennis. Hickey et al 9 reported 73% of patients (73.03% ± 33.65%, range, 0%-100%) returned to “function” (including work and exercise) after combined percutaneous MIS with burr and arthroscopy with a shaver. Furthermore, Iqbal and Chana 11 reported mean return to normal activity was 3.7 weeks (range, 3-4.5 weeks).
Complications and Secondary Surgeries
All 8 articles reported complication data and secondary surgeries (Table 4). The calculated complication rate across the 8 studies was 18 of 296 patients (6.1%), with numbness of the hallux and in the dorsomedial cutaneous nerve distribution being the most common, affecting 6 of 296 patients (2.0%).9,14,22 One study used arthroscopy and debridement solely with shaver, reporting complications in 4 of 36 patients (11.1%), with transient sensory disturbances being the most common, affecting 3 of 36 patients (8.3%). 14 Complications occurred in 8 of 130 patients (6.2%) from the 2 studies that used percutaneous incision with an MIS burr.18,22 The reported complications were from Teoh et al 22 only. Two patients (2.2%) developed wound infections, 2 (2.2%) had delayed wound healing, 2 (2.2%) transient nerve paresthesia, and 2 (2.2%) permanent numbness of the dorsomedial cutaneous nerve distribution. The 5 studies that combined percutaneous MIS burr and arthroscopic debridement with a shaver reported complications affecting 6 of 130 patients (4.6%), with numbness of the hallux being the most common complication, 3 of 130 patients (2.3%).5,7 -9,11 Gauthier et al 7 and Hickey et al 9 both report 1 patient in each of their studies having an extensor hallucis longus tendon complication.
Complications and Secondary Surgeries.
Abbreviations: DMCN, dorsomedial cutaneous nerve; EHL, extensor hallucis longus; MTP, metatarsophalangeal.
Overall, 23 of 296 patients (7.8%) underwent a revision or secondary surgery (Table 4). First MTP arthrodesis/fusion was the most common secondary surgery, affecting 12 of 296 patients (4.1%). In the arthroscopy and debridement solely with shaver group, 1 of 36 patients (2.8%) underwent open revision at 6 months for pain and joint stiffness. 14 Revisions or secondary surgeries occurred in 14 of 130 patients (10.8%) from the 2 studies that used percutaneous incision with an MIS burr. Conversion to arthrodesis was the most common revision procedure performed between 8 months and 2.5 years following the initial surgery, with 9 of 130 patients (6.9%) undergoing secondary surgery.18,22 The 5 studies that combined percutaneous MIS burr and arthroscopic debridement with a shaver reported that 8 of 130 patients (6.2%) underwent revision or secondary surgery.5,7 -9,11 Arthrodesis was the most common secondary surgery performed on 4 of 130 patients (3.1%) between 6 months and 3 years. Hickey et al 9 reported that 3 of 36 patients (8.3%) experienced postoperative stiffness. These patients subsequently received a steroid injection and manipulation of the first MTP joint at 3 months, 7 months, and 1 year after the procedure, respectively. 9
Discussion
Minimally invasive strategies for first MTP cheilectomy are garnering increased attention as an alternative to open surgery for mild to moderate hallux rigidus. This study demonstrates advantageous clinical outcomes with low complication rates following MIS cheilectomy regardless of percutaneous vs arthroscopic vs combined surgical technique. Although use of either a fluoroscopy with a burr or arthroscopy with a shaver has been the traditional minimally invasive approach for first MTP cheilectomy, newer studies have demonstrated favorable outcomes with potential benefits with combined fluoroscopic and arthroscopic approaches.
The rise in popularity of MIS approaches is notable as it is a favorable alternative for younger patients to preserve range of motion and alleviate symptoms caused by mild to moderate hallux rigidus of the first MTP joint. 18 Compared to the traditional open dorsal cheilectomy approach, MIS approaches offer advantages such as decreased operative time, rapid rehabilitation, reduced postoperative risk of infection, minimal soft tissue disturbance, cosmetic benefits, and strong patient satisfaction.8,10,12,15,18,19 A small dorsomedial incision can be used for the MIS cheilectomy as well as one of the portal incisions for the arthroscopy (Figures 2 and 3). MIS cheilectomy under fluoroscopic visualization can be performed using a high-torque low-speed burr to excise osteophytes of the first MTP joint and to assess postresection range of motion (Figure 4). Furthermore, high-torque low-speed burrs preserve tendons and limit soft tissue damage, contributing to shorter recovery times and reducing the risk of complication secondary to tendon injury. 12 MIS cheilectomy performed with arthroscopy and a shaver renders direct visualization of the dorsal spurs and the joint with a small arthroscopic camera affording advantages of identification and treatment of concomitant pathology including synovitis, loose bodies, and osteochondral lesions (Figure 5). 8
Clinical images before and after MIS cheilectomy: (A) preoperative; (B) postoperative. MIS, minimally invasive surgery.
Clinical images demonstrating the incision for MIS vs open cheilectomy: (A) MIS incision, (B) open incision. MIS, minimally invasive surgery.
Intraoperative fluoroscopic images: (A) resection of dorsal osteophyte under fluoroscopic guidance; (B, C) fluoroscopy demonstrating range of motion following osteophyte resection.
(A) Intraoperative image of first MTP arthroscopy chondral injury. (B) Intraoperative image of first MTP arthroscopy using a probe to assess the chondral surface. MTP, metatarsophalangeal.
Although this study demonstrates good outcomes with both MIS techniques, there has been an increase in the use of a combined MIS approach due to potential superior clinical outcomes.5,7 -9,11 Using this combined technique, authors report starting with the MIS burr to resect dorsal osteophytes on the metatarsal head and proximal phalanx under fluoroscopic guidance. The same dorsomedial incision can be used as one of the arthroscopic portal incisions. An arthroscopy using either a small arthroscope or needle arthroscope can then be performed to directly visualize the integrity of the first MTP joint. In addition, the surgeon may remove loose bodies or smoothen remaining osteophytes, adequately irrigate the joint under direct visualization, and note any abnormal pathologies. Notably, bone debris and loose bodies may be present following bone resection using an MIS burr, and therefore, arthroscopy affords the ability to irrigate the joint. On arthroscopic evaluation, Glenn et al 8 reported that 100% of their patients had bone debris, 100% intra-articular synovitis, 10% loose bodies, and 30% cartilage flaps following MIS cheilectomy with a burr. With the addition of arthroscopy, the surgeons were able to perform joint debridement, remove loose bodies, and resect any cartilage flaps. 8
This study also demonstrates that the combined approach had a low complication rate.5,7 -9,11 Overall, the complication rate across the 8 studies ranged from 4 to 8 of 296 patients (4.6%-11.1% per surgical technique). Specifically, 4 of 36 patients (11.1%) within the arthroscopy and debridement solely with shaver group, 8 of 130 patients (6.2%) from the 2 studies that used percutaneous incision with an MIS burr, and 6 of 130 (4.6%) for the 5 studies that combined percutaneous MIS burr and arthroscopic debridement with a shaver.5,7 -9,11,14,18,22 Previous studies have demonstrated comparable complication rates following open MIS procedures. An open cheilectomy case series of 75 feet by Easley et al 6 resulted in 6 of 75 complications (8%), including 4 transient paresthesias of the hallux and 2 superficial wound infections. Coughlin and Shurnas 2 reported 5 of 80 patients (6.3%) in their open cheilectomy group developed complications. In addition, our study demonstrates that 23 of 296 (7.8%) required either a revision or secondary surgery regardless of which MIS approach was used. First MTP arthrodesis was the most commonly reported secondary surgery (12/296; 4.1%). The remaining revisions include repeat cheilectomy (5/296; 1.7%), manipulation under anesthetic and steroid injection (3/296; 1.0%), open revision surgery (1/296; 0.3%), and open removal of loose bone (1/296, 0.3%). Cullen et al 3 examined the rate of revision in 341 open cheilectomies for early-stage hallux rigidus and demonstrated that 28 of 341 procedures (8.21%) required a secondary surgery. Their reoperation rate is on par with MIS cheilectomy reoperation rate, which is 7.8% for all patients in our study. Furthermore, Cullen et al 3 found fusion to be the most common secondary surgery, affecting 19 of 331 patients (5.74%). Fusion was also the most common secondary surgery in our study, with 12 of 296 patients (4.1%). Roukis 20 evaluated the reoperation rate of 706 cheilectomies in a review and found that 62 of those 706 (8.8%) underwent a secondary surgery, with arthrodesis being the most common (23/706; 3.3%). Therefore, the reoperation and secondary surgery rate seen in our study is comparable to open cheilectomy secondary surgery rates. Thus, this study demonstrates possible lower rate of complications and revision rates when using a combined MIS approach.
Furthermore, use of a combined MIS approach may also result in improved patient satisfaction scores and quicker return to activity. Minimally invasive procedures reduce incision size, soft tissue damage, and inflammation, contributing to a potentially quicker return to activity.8,10,12,15,18,19 Glenn et al 8 demonstrated that 20 of the 20 patients (100%) who underwent the combination of percutaneous MIS with burr and arthroscopy with shaver were very satisfied with the procedure. In addition, studies that performed a combined MIS approach reported the fastest return to normal activity at an average of 3.7 weeks (range: 3-4.5 weeks) compared with 6 weeks in the percutaneous MIS burr group.11,18 These findings are significant particularly when compared with open cheilectomy procedures. Mulier et al 17 demonstrated that athletes who underwent open cheilectomy had a return to activity of 11.5 weeks after the procedure. Although the literature examining return to activity after open cheilectomy is scarce, this study demonstrates that MIS cheilectomy may afford patients a faster return to activity with similar long-term results.
Although there are numerous benefits and advantages of minimally invasive cheilectomy, there are limitations to the approach. Cheilectomy is reserved for patients with mild to moderate hallux rigidus whereas arthrodesis better suits patients with end-state hallux rigidus.2,4,8,9,18,22,23 Although percutaneous MIS with burr benefits are attractive, significant disadvantages to the approach exist. First, direct visualization can only be achieved via arthroscopy, with visualization limitations and a technique-based learning curve existing when performing this procedure under fluoroscopy alone. This may increase the possibility of overresection due to lack of visualization, especially in the early stages of adopting a new surgical technique that uses an aggressive burr. Although arthroscopy with shaver is typically less aggressive, adequate resection may be difficult because of the osteophyte being located more dorsally extraarticularly. Therefore, a combination of both techniques may be most advantageous. Conservative percutaneous MIS with burr for initial removal of osteophytes followed by direct visualization with arthroscopy with shaver to inspect, smooth and debride the spurs, and irrigate the joint may reduce the limitations of each approach. Moreover, there is an associated learning curve. For example, Teoh et al 22 reported that 42% (5/12) of the reoperations in their study were due to technical issues such as incomplete cheilectomy (5 patients) or a loose bone (1 patient) for patients who underwent percutaneous MIS with burr.
Although this review indicates MIS cheilectomy results in satisfactory patient-reported outcomes and low complication rates, our study has several limitations. The primary limitation is that it is a review of case series with no open procedure comparative groups available. However, we compare across the case series based on technique. In addition, only 7 of the 8 studies included in the review report both preoperative and postoperative patient-reported outcomes. 14 Moreover, non–scale-based satisfaction rates are used in several studies that result in subjective outcome measures.9,11,14 In our study, 43.9% of patients underwent the combined approach, whereas another 43.9% underwent percutaneous MIS with burr only. However, only 12.2% of patients underwent cheilectomy via arthroscopy with a shaver. Furthermore, a limitation is the inclusion of all arthroscopic cheilectomies and those using a Shannon burr. Although both are minimally invasive, they differ in technical aspects and risks, which may introduce variability and affect the comparability of outcomes. Finally, one unified patient-reported outcome scoring/scaling method is not used, and many studies used AOFAS scores, which is not a validated outcome measure and should be interpreted with caution.
Conclusion
Overall, minimally invasive cheilectomy results in positive patient outcomes, patient satisfaction, preserves range of motion, and low complication rates for the treatment of mild to moderate hallux rigidus. A combined MIS approach initially using fluoroscopy with an MIS burr followed by arthroscopy with a shaver may be most advantageous to adequately excise osteophytes while maintaining the ability to assess, debride, and irrigate the first MTP joint after resection.
Supplemental Material
sj-pdf-1-fao-10.1177_24730114241303169 – Supplemental material for Modern Treatment of Hallux Rigidus by Cheilectomy: A Systematic Review of Patient-Reported Outcomes in Minimally Invasive Techniques
Supplemental material, sj-pdf-1-fao-10.1177_24730114241303169 for Modern Treatment of Hallux Rigidus by Cheilectomy: A Systematic Review of Patient-Reported Outcomes in Minimally Invasive Techniques by Scott D. Semelsberger, Michael S. Lee, Cale B. Dobson, Christopher P. Miller and Arianna L. Gianakos in Foot & Ankle Orthopaedics
Footnotes
Appendix
Coughlin-Shurnas Grade and Outcomes.
| Author, Year | Type of Radiographic Outcome | Reported Outcome | Coughlin-Shurnas Grade Related Outcomes |
|---|---|---|---|
| Di Nallo, 2023 | Coughlin-Shurnas grade | 10/30; 33% grade 1 20/30; 67% grade 2 |
1/28; 4% (grade 2) progressed to stage III during the follow-up period |
| Gauthier, 2024 | |||
| Glenn, 2021 | |||
| Hickey, 2020 | OA grade | 1.88 ± 0.42, range 1-3 | Reported no association between grade of chondral degeneration and need for secondary surgery |
| Iqbal, 1998 | Grade Hallux Rigidus | Mild to moderate arthritis of the first MTPJ in all cases | |
| Levaj, 2021 | Coughlin-Shurnas grade | 11/29; 38% grade 1 |
Satisfaction rates: |
| Pastides, 2014 | Coughlin-Shurnas grade | 9/54; 17% grade 1 |
|
| Teoh, 2019 | Coughlin-Shurnas grade | 33/98; 33% grade 1 |
0/98; 0% of grade 1 underwent arthrodesis |
Acknowledgements
Thank-you to Andrew Jimenez, MD, for providing the Covidence software during the review process.
Ethical Approval
Ethical approval was not sought for the present study.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Christopher P. Miller, MD, reports general disclosures as a consultant for Arthrex and Enovis and receives royalties from Enovis. Arianna L. Gianakos, DO, reports general disclosures as a consultant for Arthrex. The other authors report no conflicts. Disclosure forms for all authors are available online.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
References
Supplementary Material
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