Is First MTPJ Fusion Superior for Bunion Correction?

Yes.

As this author asserts, first MTPJ fusion can successfully correct the intermetatarsal angle, stabilize the medial column, and properly align the first digit when chosen in the proper patient scenarios.

By Danielle Butto, DPM, FACFAS

First metatarsophalangeal joint (MTPJ) fusion is widely recognized as the primary treatment for hallux rigidus. However, its effectiveness in addressing hallux valgus deformities often goes underestimated. Certainly, this procedure is not a one-size-fits-all solution for bunion correction. Opting for first MTPJ fusion must be a judicious decision, with clear selection criteria implemented.

The first MTPJ fusion’s ability to stabilize the medial column, correct the intermetatarsal angle, and align the first digit makes it a superior option for certain patients. In my experience, ideal candidates include those with severe hallux valgus deformities, significant osteoarthritic changes, or a history of failed bunion surgeries. The procedure can prove particularly beneficial for patients requiring a stable and permanent correction. Surgeons should assess factors such as patient age, activity level, and expectations to ensure alignment with the procedural outcomes, thereby enhancing satisfaction and surgical success.

Gait Function and Activity Postsurgery

Concerns about the loss of joint mobility post-fusion are common among patients and surgeons. A prospective gait analysis by Brodsky and colleagues of patients who had first MTPJ arthrodesis showed statistically significant improvements in propulsive power, weight-bearing function of the foot, and stability during gait after fusion.¹  

Additionally, there is concern over the patient’s ability to return to sports and activities after fusion. A study by Da Cunha and colleagues found patients returned to 44.6% of preoperative physical activities in less than 6 months and reached their maximal level of participation in 88.6% of physical activities.² Ninety-six percent of patients stated they were satisfied with the procedure regarding return to sports and physical activities.

Moreover, in a systematic review by Baumann and colleagues of 450 patients, while return to sport after first MTPJ fusion was variable depending on the patient and sport, researchers found that numerous different sporting activities have a high rate of return after first MTPJ fusion with a majority of patients reporting similar or increased ability to perform sporting activities after surgery.³

Surgical Considerations for First MTPJ Fusion

The debate persists over the necessity of additional osteotomies to correct the intermetatarsal angle. From a soft tissue perspective, the conjoined tendon of the adductor hallucis is also a factor in intermetatarsal angle reduction. The adductor hallucis pulls the first MTPJ toward the midline, which prevents lateral deviation of the hallux. Mann and Katcherian also observed that an osseous fusion/stabilization eliminated the bowstringing effect of the long flexor and extensor tendons, thereby reducing their deforming forces.⁴

A study by McKean and colleagues found a mean change of 8.3 degrees in the intermetatarsal angle in patients with severe bunion deformities after first MTPJ fusion.⁵ Cronin and colleagues found an average correction of 10 degrees when the preoperative intermetatarsal angle was 16 degrees or more.6 When the preoperative intermetatarsal angle was 15 degrees or fewer the average correction was 6 degrees. Both studies show that first MTPJ fusion alone can achieve significant corrections, negating the need for additional osteotomies in many cases.^5,6

Unfortunately, in the case of the revisional bunion, the intermetatarsal angle may be more rigid. In these cases surgeons can consider proximal fusion as well or a base osteotomy. This can lead to increased recovery time, rigidity through the medial column, and the possibility of additional complications. To address this, Boffeli and colleagues describe a technique to perform a transpositional first MTPJ fusion to again allow for the first MTPJ to adequately correct the bunion deformity.⁷

Joint Preparation, Positioning and Fixation

With any fusion, surgeons should spend adequate time on joint preparation. A review by Roukis on first MTPJ fusions noted an overall 5.4% nonunion rate, a 6.1% malunion rate, and an 8.5% hardware removal rate.⁸ The most common techniques for joint preparation include cup and cone reamers and flat cuts. With both methods it is critical to remove all cartilage and appropriately fenestrate the joint through the subchondral plate. A systematic review by Fussenich and colleagues reviewing 934 feet found an overall 7.7% nonunion rate.⁹ Flat cuts had a 22.2% nonunion rate while cup and cone reamers had a 6.3% nonunion rate. Hand instruments for joint preparation had a 12.2% nonunion rate.

While the literature varies on the recommended position for first MTPJ fusion, in my review and observation, 10 to 15 degrees of abduction and 10 to 25 degrees of dorsiflexion appear to be the consensus.

Advancements in orthopedic implants have allowed for a variety of fixation techniques. Surgeons have the ability to use both metallic and non-metallic options to fixate the fusion site along with varying combinations of plate, screws and staples. With all of the varying combinations for fixation it is difficult to say which is superior. Fussenich and colleagues found a 2.8% nonunion rate for joint fixation with a plate combined with a lag screw vs 6.5% for plate fixation and 11.1% for crossed screw fixation.⁹ Dening and van Erve compared fusion rates for 4 types of fixation: single screw fixation, cross screw fixation, dorsal plate fixation, and dorsal plate with lag screw finding superior fusion rates for the dorsal plate and plantar lag screw group.¹⁰

A Closer Look at Long-term Fusion Outcomes

Long-term follow-up studies, such as that by Coughlin and colleagues, which tracked patients for 8 years post-fusion, report high satisfaction rates and successful fusion in the majority of cases.¹¹ The authors found 18 of the 21 patients successfully achieved fusion. Of the 3 nonunions, 2 were symptomatic and 1 required revision. The patients rated the procedure 80% excellent and 20% good with no patients stating they were unsatisfied.

Similarly, Grimes and Coughlin’s review of patients undergoing fusion for failed hallux valgus surgery showed significant improvements in pain and functionality.¹² The visual analog scale for pain improved from 7 to 3. The final AOFAS score was 73. Overall, 72% of the patients rated the procedure either excellent or good.¹²

Dayton and colleagues surveyed 60 patients who underwent a first MTPJ fusion for a hallux valgus deformity at a mean of 28.4 months postsurgery.¹³ The results found overall satisfaction with the procedure with 93% responding they felt better after the surgery. Eighty-eight percent felt their foot looked better after surgery. Ninety-eight percent did not require medication or other treatments for symptoms after surgery with 92% of patients stating that pain never limits their postoperative activity. When surveyed if the loss of motion of their big toe affected their ability to do normal activity, 95% responded “no.” When asked if the patients considered their foot surgery successful 93% responded “yes.”¹³

In Conclusion

First MTPJ fusion stands out as a robust method for correcting hallux valgus deformities, providing stability and substantial correction of the intermetatarsal angle. Its ability to improve functional outcomes, even in complex cases, underscores its utility as a primary and revisional procedure for bunion correction. The surgical approach for first MTPJ fusion can significantly influence patient outcomes. Techniques and fixation options vary with each technique having implications for postoperative recovery, complication rates, and the precision of deformity correction. The position of the fusion is by far the most crucial in terms of patient outcome. When performed correctly, the first MTPJ fusion can be superior for hallux valgus correction.

Dr. Butto is a Fellow of the American College of Foot and Ankle Surgeons and practices at Advanced Foot and Ankle Specialists in Avon, CT.
 
References
1.    Brodsky JW, Baum BS, Pollo FE, Mehta H. Prospective gait analysis in patients with first metatarsophalangeal joint arthrodesis for hallux rigidus. Foot Ankle Int. 2007;28(2):162-165. doi: 10.1177/107110070702800206.
2.    Da Cunha RJ, MacMahon A, Jones MT, et al. Return to sports and physical activities after first metatarsophalangeal joint arthrodesis in young patients. Foot Ankle Int. 2019;40(7):745-752. doi: 10.1177/1071100719842799.
3.    Baumann AN, Walley KC, Kermanshahi N, et al. Return to sport after first metatarsophalangeal arthrodesis: a systematic review. Foot Ankle Int. 2023;44(12):1319-1327. doi: 10.1177/10711007231198817.
4.    Mann RA, Katcherian DA. Relationship of metatarsophalangeal joint fusion on the intermetatarsal angle. Foot Ankle Int. 1989;10(1):8–11
5.    McKean RM, Bergin PF, Watson G, et al. Radiographic evaluation of intermetatarsal angle correction following first MTP joint arthrodesis for severe hallux valgus. Foot Ankle Int. 2016;37(11):1183-1186. doi: 10.1177/1071100716656442.
6.    Cronin JJ, Limbers JP, Kutty S, Stephens MM. Intermetatarsal angle after first metatarsophalangeal joint arthrodesis for hallux valgus. Foot Ankle Int. 2006;27(2):104-109. doi: 10.1177/107110070602700206.
7.    Boffeli T, Brett KM, Lubeck ZJ. Transpositional 1st metatarsophalangeal joint fusion for an arthritic or recurrent bunion complicated by rigid intermetatarsal angle deformity. J Foot Ankle Surg Case Rep Ser. 2022; 2(2):100230.
8.    Roukis TS. Nonunion after arthrodesis of the first metatarsal-phalangeal joint: a systematic review. J Foot Ankle Surg. 2011;50(6):710-713. doi:10.1053/j.jfas.2011.06.012
9.    Füssenich W, Seeber GH, Zwoferink JR, Somford MP, Stevens M. Non-union incidence of different joint preparation types, joint fixation techniques, and postoperative weightbearing protocols for arthrodesis of the first metatarsophalangeal joint in moderate-to-severe hallux valgus: a systematic review. EFORT Open Rev. 2023;8(3):101-109. Published 2023 Mar 14. doi:10.1530/EOR-22-0134
10.    Dening J, van Erve RH. Arthrodesis of the first metatarsophalangeal joint: a retrospective analysis of plate versus screw fixation. J Foot Ankle Surg. 2012; 51(2):172-175.
11.    Coughlin MJ, Grebing BR, Jones CP. Arthrodesis of the first metatarsophalangeal joint for idiopathic hallux valgus: intermediate results. Foot Ankle Int. 2005;26(10):783-792. doi: 10.1177/107110070502601001.
12.    Grimes JS, Coughlin MJ. First metatarsophalangeal joint arthrodesis as a treatment for failed hallux valgus surgery. Foot Ankle Int. 2006;27(11):887-893. doi: 10.1177/107110070602701104.
13.    Dayton M, Dayton P, Togher CJ, Thompson JM. What do patients report regarding their real-world function following triplane metatarsophalangeal joint arthrodesis for hallux valgus?. J Foot Ankle Surg. 2023;62(5):905-911. doi:10.1053/j.jfas.2023.04.015

No.

Emphasizing the importance of considering individual patient needs, these authors argue that traditional bunion correction methods can provide excellent outcomes.

By Michael Radcliffe, DPM; Ramez Sakkab, DPM, AACFAS; and Jeffrey E. McAlister, DPM, FACFAS

Bunion deformities—hallux valgus or metatarsus primus varus—are characterized by a prominent first metatarsal head medial eminence with lateral deviation of the hallux and rotation of the first metatarsal. Surgical correction ultimately depends on balancing the bony deformity and soft tissue influences around the first metatarsophalangeal joint (MTPJ) and proximally.

Among the surgical treatments available for first MTPJ pathology, joint fusion has increased in popularity in recent years.^1-3 First MTPJ fusion is a predictable and reliable option for arthritic conditions of the first MTPJ. Researchers still consider fusion the gold standard treatment of end-stage hallux rigidus with positive outcomes.⁴ First MTPJ fusion is also indicated for failed primary bunion correction salvage, hallux varus, severe deformity, avascular necrosis, neuromuscular disorders, rheumatoid arthritis, and failed implant arthroplasties.^5-8

First MTPJ fusion for primary management of bunion correction is not a new concept, dating back to the 1950s.⁸ The typical population in these reports were elderly patients with severe deformity. It is well known that surgeons can achieve powerful correction with first MTPJ fusion with the added benefit of low recurrence risk.^5,9-10 However, research shows an increased risk of nonunion with greater deformity and these must be perioperative considerations.¹⁴ While a few recent studies describe outcomes of first MTPJ fusion for bunion correction in the absence of a degenerative joint, more studies are warranted.^8,15-18

Advocates of  first MTPJ fusion for primary bunion correction tout permanent correction of severe deformities, pain alleviation, and lower recurrence risk. But a critical literature evaluation demonstrates that this procedure may not be superior to other surgical options, especially when considering individual patient demands, needs, and goals.

Why Fuse a Joint That Is Not Arthritic?

A significant downside of any fusion is perhaps the permanent loss of motion. The first MTPJ plays a crucial role in balance, gait, and physical activity. Following joint fusion, patients experience a permanent limitation in toe dorsiflexion, which can impact these mechanics. Normal gait requires at least 65 degrees of dorsiflexion at the first MTPJ. This motion can significantly decrease in bunion pathology depending on key factors such as severity, joint malalignment, soft tissue imbalance, and associated deformity. Surgically correcting this pathology via joint-sparing bunion methods can potentially re-establish these mechanics and allow for normal gait and function.

The literature regarding a first MTPJ fusion’s impact on gait and function is variable. A prospective gait analysis of patients who underwent first MTPJ fusion demonstrated improvements in propulsive power, weight-bearing function of the foot, and stability during gait.¹⁹ Another study showed abnormal biomechanical alterations after first MTPJ fusion including but not limited to: loss of ankle plantarflexion, decreased step length, and altered gait.²⁰

Eliminating motion in an “essential joint” can lead to compensation through the foot and the entire lower extremity.²¹ This can cause discomfort or secondary issues such as transfer metatarsalgia, hammertoes, or increased proximal joint stress from the ankle to the hip. Moreover, any malpositioning of the fusion can exacerbate similar symptomatology. One may claim comparable pathology can arise from a first tarsometatarsal joint (TMTJ) arthrodesis as it relates to bunion correction. However, this joint motion is considered nonessential and patients tolerate its fusion well, without significant functional limitations.²² Additionally, fusion of the first TMTJ obtains compensation from the MTPJ and hallux interphalangeal joint (IPJ) whereas a MTPJ fusion almost exclusively forces distal first ray motion through the IPJ.

Another challenge in first MTPJ fusion is patient buy-in. In general, patients want to improve or at least preserve what joint motion they have while also decreasing pain. Telling patients they should have their nonarthritic joint fused often meets with their confusion and hesitation. If patients engage in activities requiring significant first MTPJ dorsiflexion or wear high heels, a lengthy discussion is often required to explain the need to eliminate such recreational activities status post–MTPJ fusion, despite its “one-and-done” nature in hallux valgus correction. In addition, recommending a first MTPJ fusion under the premise of a near zero recurrence rate or no need for further surgery in the future is, at best, dubious.

When surgeons appropriately address bunions with triplanar deformity correction and holistically treat concomitant pathology as necessary (metatarsus adductus or pes plano valgus) they can achieve long-term patient satisfaction with low recurrence rates.^23-24 First MTPJ fusion requires precision and is unforgiving to malpositioning. Excessive plantarflexion or dorsiflexion can cause permanent increases in plantar first ray pressures or lesser metatarsalgia if bunions are over-shortened, leading to need for secondary revision.

If the condition is unilateral, asymmetry with a fusion on one side but not the other may be poorly tolerated, causing decreased patient satisfaction. Shoe gear limitation is another prudent part of preop discussions. Particularly with female patients, shoe gear flexibility is an important factor. Knowing that only a small heel lift will be tolerable after a fusion may lead to patients opting against it. As care becomes more focused on patient satisfaction, a mutual understanding of all appropriate surgical treatment options between provider and patient is more important than ever.

Additional Key Considerations

When counseling patients and deciding on appropriate surgical procedures for bunion correction, there are a few additional considerations to keep in mind. If one can correct the bunion by means other than fusion of an essential joint, the preference should be to maintain a foot with near anatomic alignment. Patient functional demands should be a key factor in surgical decision making, and one should discuss realistic postop expectations in detail.

Bunions often have a hereditary component and understanding family history bears utility.^23-24 If a patient’s family member underwent bunion correction with either good or bad results, they may be hesitant about certain procedures. In the setting of a bad surgical outcome of a patient’s family member, this should raise curiosity as to why the outcome was unsatisfactory. Do not overlook congenital variations in first ray length as these can influence procedure selection. A short first ray can create functional limitations and cosmetic dissatisfaction with a first MTPJ fusion. A long first ray would support fusion due to well-tolerated acute shortening and working to “harmonize” the forefoot. However, this shortening is not unique to fusion and surgeons can achieve this through several other methods.

Considering cases of adjacent joint arthritis or deformity at the hallux IPJ or TMTJ, multiple fusions including the first MTPJ would create a very stiff first ray with more severe gait changes. Although Dayton and colleagues reported a small series on polyfusion involving the first TMTJ and MTPJ with positive results, consider multiple first ray joint fusion a relative contraindication until larger and longer-term studies are available.²⁵

Minimally invasive surgical (MIS) approaches have invigorated a renewed interest in contemporary generations of MIS bunion systems. MIS techniques may come with a steep learning curve, but short-term results have been promising. The aesthetic postop appearance is the first eye-catching benefit to many patients. Various papers tout decreased postoperative edema, less pain, and quicker healing times since more native tissue is undisturbed.^26-28 Bunion correction has been a much bigger focus in the MIS world than first MTPJ fusion, but as surgeons grow in their confidence and skill with MIS procedures, we may see the boundaries of what can be done expand rapidly in the coming years. Figure 1 demonstrates a patient who underwent bilateral staged bunion correction with an MIS procedure on one foot after a TMTJ fusion on the other.

In Summary

Surgeons regularly employ traditional methods of bunion correction in any foot and ankle surgical practice. There is a plethora of ways to address bunions to fit the skill set and preferences of the surgeon as well as individual patient needs. For most patients with bunion deformities but without significant arthritis, traditional methods such as distal or, proximal metatarsal osteotomies and first TMTJ fusion remain reliable options with excellent outcomes.^29-32

Tailoring surgical decisions to patient needs, lifestyle, and preferences is crucial. By doing so, clinicians can ensure the most appropriate and effective treatment, ultimately leading to better outcomes and quality of life. Thus, while first MTPJ fusion undeniably holds value, we contend that surgeons should not view fusion as the unequivocal best option for all bunion corrections. Asserting that fusion is categorically superior to other bunion correction methods is flawed. The motion limitations, potential for compensatory issues, and variable patient satisfaction underscore the necessity for a more nuanced approach. Studies directly comparing outcomes for traditional osteotomies versus primary first MTPJ fusion would provide valuable insight into their differences.

Michael Radcliffe, DPM, is a third-year podiatric surgery resident at University of Florida College of Medicine Jacksonville.

Ramez Sakkab, DPM, AACFAS, is the current fellow at Phoenix Foot & Ankle Institute in Scottsdale, AZ.

Jeffrey McAlister, DPM, FACFAS, is the fellowship director and CEO at the Phoenix Foot & Ankle Institute in Scottsdale, AZ.

References
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2.    Iselin LD, Munt J, Symeonidis PD, Klammer G, Chehade M, Stavrou P. Operative management of common forefoot deformities: a representative survey of Australian orthopaedic surgeons. Foot Ankle Specialist. 2012 Jun;5(3):188-94.
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6.    Grimes JS, Coughlin MJ. First metatarsophalangeal joint arthrodesis as a treatment for failed hallux valgus surgery. Foot Ankle Int. 2006 Nov;27(11):887-93.
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8.    Humbert JL, Bourbonniere C, Laurin CA. Metatarsophalangeal fusion for hallux valgus: indications and effect on the first metatarsal ray. Canadian Med Assoc J. 1979 Apr 4;120(8):937.
9.    Dusch T, Guareschi A, Moore A, Hoch C, Gross CE, Scott DJ. Changes in radiographic alignment following metatarsophalangeal fusion, distal metatarsal osteotomy, and Lapidus. Foot Ankle Spec. 2023 Oct 16:19386400231203114.
10.    McKean RM, Bergin PF, Watson G, Mehta SK, Tarquinio TA. Radiographic evaluation of intermetatarsal angle correction following first MTP joint arthrodesis for severe hallux valgus. Foot Ankle Int. 2016 Nov;37(11):1183-6.
11.    Korim MT, Allen PE. Effect of pathology on union of first metatarsophalangeal joint arthrodesis. Foot Ankle Int. 2015 Jan;36(1):51-4.
12.    Korim MT, Mahadevan D, Ghosh A, Mangwani J. Effect of joint pathology, surface preparation and fixation methods on union frequency after first metatarsophalangeal joint arthrodesis: a systematic review of the English literature. Foot Ankle Surg. 2017 Sep 1;23(3):189-94.
13.    Molloy A, Butcher C, Mason L. Risk factors for non-union in first MTPJ arthrodesis. Foot Ankle Orthop. 2018 Sep 14;3(3):2473011418S00356.
14.    Roukis TS. Nonunion after arthrodesis of the first metatarsal-phalangeal joint: a systematic review. J Foot Ankle Surg. 2011;50(6):710-713. doi:10.1053/j.jfas.2011.06.012
15.    Coughlin MJ, Grebing BR, Jones CP. Arthrodesis of the first metatarsophalangeal joint for idiopathic hallux valgus: intermediate results. Foot Ankle Int. 2005 Oct;26(10):783-92.
16.    Sung W, Kluesner AJ, Irrgang J, Burns P, Wukich DK. Radiographic outcomes following primary arthrodesis of the first metatarsophalangeal joint in hallux abductovalgus deformity. J Foot Ankle Surg. 2010 Sep 1;49(5):446-51.
17.    Raymakers R, Waugh W. The treatment of metatarsalgia with hallux valgus. J Bone Joint Surg. 1971; 53-B:684–687.
18.    Tourne Y, Saragaglia D, Zattara A, et al. Hallux valgus in the elderly: metatarsophalangeal arthrodesis of the first ray. Foot Ankle Int. 1997; 18:195–198.
19.    Brodsky JW, Baum BS, Pollo FE, Mehta H. Prospective gait analysis in patients with first metatarsophalangeal joint arthrodesis for hallux rigidus. Foot Ankle Int. 2007;28(2):162- 165.
20.    DeFrino PF, Brodsky JW, Pollo FE, Crenshaw SJ, Beischer AD. First metatarsophalangeal arthrodesis: a clinical, pedobarographic, and gait analysis study. Foot Ankle Int. 2002;23:496–502.
21.    Stevens J, Meijer K, Bijnens W, et al. Gait analysis of foot compensation after arthrodesis of the first metatarsophalangeal joint. Foot Ankle Int. 2017 Feb;38(2):181-91.
22.    Stødle AH, Hvaal KH, Brøgger HM, Madsen JE, Husebye EE. Temporary bridge plating vs primary arthrodesis of the first tarsometatarsal joint in Lisfranc injuries: randomized controlled trial. Foot Ankle Int. 2020 Aug;41(8):901-10.
23.    Mann RA. Decision-making in bunion surgery. Instr Course Lect. 1990;39:3-13.
24.    Coughlin MJ, Jones CP. Hallux valgus: demographics, etiology, and radiographic assessment. Foot Ankle Int. 2007 Jul;28(7):759-77.
25.    Dayton P, Dayton M, Hatch DJ, DeCarbo WT, McAleer JP. What do patients report regarding their real-world function following concurrent arthrodesis of the first tarsometatarsal and first metatarsophalangeal joints. J Foot Ankle Surg. 2024 Mar 1;63(2):187-93.
26.    Chan CX, Gan JZ, Chong HC, Singh IR, Ng SY, Koo K. Two year outcomes of minimally invasive hallux valgus surgery. Foot Ankle Surg. 2019 Apr 1;25(2):119-26.
27.    Neufeld SK, Dean D, Hussaini S. Outcomes and surgical strategies of minimally invasive chevron/Akin procedures. Foot Ankle Int. 2021 Jun;42(6):676-88.
28.    Knox AF, Studdert NJ, Knox NR. Radiographic outcomes from minimally invasive bunion surgery in Australia: a retrospective cohort analysis of 169 procedures using the minimally invasive chevron akin (MICA) Procedure. J Am Podiatr Med Assoc. 2022 Sep 1;1(aop):1-24.
29.    Faber FW, van Kampen PM, Bloembergen MW. Long-term results of the Hohmann and Lapidus procedure for the correction of hallux valgus: a prospective, randomised trial with eight- to 11-year follow-up involving 101 feet. Bone Joint J. 013;95-B(9):1222-1226.
30.    Lalevee M, de Cesar Netto C, Boublil D, Coillard JY. Recurrence rates with longer-term follow-up after hallux valgus surgical treatment with distal metatarsal osteotomies: A systematic review and meta-analysis. Foot Ankle Int. 2023 Mar;44(3):210-22.
31.    Singh MS, Khurana A, Kapoor D, Katekar S, Kumar A, Vishwakarma G. Minimally invasive vs open distal metatarsal osteotomy for hallux valgus-a systematic review and meta-analysis. J Clin Orthop Trauma. 2020 May 1;11(3):348-56.
32.    Jagadale VS, Thomas RL. A clinicoradiological and functional evaluation of Lapidus surgery for moderate to severe bunion deformity shows excellent stable correction and high long-term patient satisfaction. Foot Ankle Spec. 2020 Dec;13(6):488-93.