Simon Mest, DPM discusses treatment options for first metatarsal phalangeal joint arthritis. Dr Mest outlines the evaluation and diagnostic workups of the first metatarsal phalangeal joint, and then presents information on Hallux Rigidus and surgical options, including hemiarthroplasty.
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Simon Mest, DPM
Assistant Professor, Dept. of Orthorpedics
VCU-MCV Medical Center
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Simon Mest Discloses that he is a consultant to MMI, Vilex and Trimeds
Dr. Kalish: Our next speaker is Simon Mest who is a graduate of the Pennsylvania College of Podiatric Medicine and he is a professor at VCU Medical Center in Richmond, Virginia. He is past president of the Virginia Podiatric Medical Association and he's very active in Virginia politics and speaking for podiatry in Virginia and it's a great pleasure to meet him and let him speak to us about his unique techniques using hemi implants for first MP joint arthritis. So let’s give him a big welcome in Vegas for Dr. Mest.
Dr. Mest: Dr. Kalish thank you. Thank you for allowing me to come and speak to all of you today. To get some housekeeping out of the way I am a consultant for MMI, Vilex and for Trimed and those are my disclosures for this morning.
There's a couple of things that I hope you’d be able to take away from the talk this morning, one is what I am actually lecturing about which is on the first MPJ and Hallux rigidus. The second is on politics. My area of expertise is actually more in dealing with politicians than that is in podiatry. I am past president of the VPMA but also we are very active in Virginia when it comes to dealing with our legislature and I probably know every single legislator in Virginia more than I know most of the podiatrist that practice in the states.
As an aside we recently put through a law in Virginia that gives podiatry the opportunity to treat lower extremity wounds, and when I say lower extremity we are talking below the inguinal ligament and we can treat them medically and surgically and this was a big thing for us to be able to push through, as all of you know in your states, we have foot laws, we have ankle laws but we came very close to getting a leg law and we were limited a little bit but for the most part it's a wound law. And when I spoke to the head of Medicare for our area, she goes, “Does that mean that you can do bypasses to the lower extremity?” And actually – by the way the law is written, the answer is yes.
So what I would like you take away this morning is if you, when you are out there in practice get involved on the state level and it's really very, very important, all of you guys are younger than I am and except for Dr. Schoenhaus.
And for the most part Dr. Schoenhaus was actually one of my teachers so -- . Actually basically male -- he is old. So take that away that it’s very important you guys are going to be much better trained than all of us that have been in practice for years, the laws need to be updated, the laws need to be changed and you are the guys that are out there to be able to change this.
What we are going to talk about is first MPJ hemi-arthroplasty. And it says I am an Assistant Professor in Department of orthopedics at MCV Medical Center, I've been there for almost 25 years and I've been in Department of Orthopedics for 10. My area in podiatry that I am actually very good at is in wounds and vascular problems and I went to work for the orthopedic department about 10 years ago. And my chairman who is the foot and ankle specialist for the hospital sat me down and said, you know it's time you do surgery of the foot and not do vascular problems but he still wants me to do all the wounds for the department.
So I've gotten very good over the last few years of doing a lot of the stuff and my area is primarily forefoot surgery, I don't do any rearfoot or ankle. And being on practice for 30 years I like to keep things simple. I don't like complex problems and so I think that you’ll enjoy the talk this morning.
Hallux rigidus is basically arthritis of the first MP joint, it's a progressive disease, the joint deteriorates and the patient when they come in, their symptoms don't really correlate that much with the progression of the disease. The disease can be absolutely so far along and they don’t come in to see you until it’s just absolutely horrible.
Etiology is either primary osteoarthritis, systemic inflammatory arthritis or septic arthritis. It can be posttraumatic, you can get an intra-articular fracture or turf toe injury, particularly in a lot of the athletes that we see they do eventually go on to get some type of a hallux rigidus.
And for whatever reason in my practice we see a lot of firemen, and I don't know what the deal is but these guys that go and treat fires they end up with hallux rigidus by the time they're in their late 20s or early 30s. By mechanical factors you can get a hypermobile first metatarsal, long first metatarsal or basically or an elevated first metatarsal. The amount of [phonetic] [0:05:08] arthritis can be focal areas of cartilaginous injury, you can get an osteophyte formation without the joint narrowing or you can get ankylosing with complete loss of the joint space.
When you grade hallux rigidus using the Hattrup and Johnson grading system, grade one will give you osteophyte formation without joint narrowing, grade two will get you narrowing of the joint space, grade three you can't see the joint space at all. And the other big grading system for hallux rigidus and the residents might be interested in this is the Coughlin and Shurnas grading of hallux rigidus, a grade zero greater than 40 degrees of dorsiflexion, there's really no pain, just stiffness with decreased range of motion.
A Grade 1A dorsiflexion limited to 30 to 40 degrees, painful limited dorsiflexion and pain less plantar flexion and you get a little bit of osteophyte formation with a little bit of joint space narrowing. In Grade 1B you get occasional dorsal pain when they try to dorsiflex and there is pain at extreme dorsiflexion or plantar flexion. Grade 2A 10 to 30 degrees dorsal, lateral, medial osteophytes, moderate pain dorsally just before maxim dorsiflexion or plantar flexion and in Grade 2B you get the positive grind test and you can hear it.
Grade 3, dorsiflexion less than 10 degrees, you get cyst formation and you can actually see this on x-ray, you get significant joint space narrowing, stiffness, thing hurts all the time, extreme pain at the end of dorsiflexion or plantarflexion. You sit there and you try to put that joint through a range of motion the patient will just either, they usually just jump off the chair.
And Grade 4 pain through the entire range of motion.
They present stiffness, pain, exacerbated by shoes, you can see they’ve got usually large dorsal eminence, medial eminence and that first MPJ is very swollen.
Differential diagnosis; and you really need to be able to know all this because when you're sitting there and you're doing your charting you just can’t put in their hallux rigidus you want to know if there is osteochondral lesion. Is there a vascular necrosis, is there possibly an occult fracture.
Conservative management: Always offer the patient the opportunity for conservative management. Now I don't. When a patient by the time they come in to see me most of the time they've been to other docs in town and they have been through, they’ve been told that they need to use shoes, forefoot -- put a rocker bottom sole on it, orthotics put a turf toe plate, put a Morton’s extension on it.
You can pad it, you can inject it, you can put them on all kinds of medications. I won't give narcotic analgesics for painful bunion or for hallux rigidus or hallux limitus. I don't even inject them anymore to be honest with you. When a patient comes in to see me I look at them, I am going to tell them all this stuff but for the most part my attitude is, if you're coming to my department you're not coming there for conservative management.
I work with 18 orthopedic surgeons and to be quite honest none of them do really conservative care for any of the problems that they treat. They feel that conservative care should be left up to either a general orthopedist or the primary care physician. In our case or in my case anyway, I leave conservative care up to podiatrist that don't do surgery and I'll refer them back out to a lot of these guys to say, you know if you want conservative management that's fine, this is who you can go see in town.
Most patients know if they are coming to see me they are expecting to get surgery. When I was a student at PCPM and I did a rotation. I went out and spent time with an oncology surgeon and these patients would come in to see him and basically everybody got surgery and the med student that was with me asked the surgeon, he goes, “Why do you not offer them conservative management?” And he said, “I'm surgeon, all I do is surgery I'm not going…” when a patient comes to me and they know I am a surgeon they are not expecting conservative management, they are expecting to hear surgery is the way they are going to get treated and that's how I practice. And basically for 30 years I’ve managed to feel that way that if a patient comes to see me, will tell them where they can get conservative management from but for the most part they know when they are coming in that they are looking at some kind of surgical intervention.
Consideration: Patient’s age, occupation, their lifestyle, how severe the deformity is? Are there any other biomechanical deformities, metabolic diseases? There is a question as to whether or not you're going to do -- what kind of procedure due to the patient. The biggest issue I’ve got with my older patients is you’ve got to evaluate the vascular status of the patient and you want to know what their neurologic status is.
Surgical options: The orthopedic community loves colectomy's, there's no question. You do a dorsal eminence at cystectomy and for the most part that's what they are going to leave it at. They might do a metatarsal osteotomy, proximal pylangial osteotomy, distraction arthroplasty, tissue interposition arthroplasty, arthrodesis or implants. Most of the ortho guys I know do colectomy's. They are even trying to do them by scoping the adjoints, they would rather not even open it.
If you read the orthopedic literature it discusses colectomy very strongly and there are studies that are out there in the literature that go on that with the colectomy they get just as good results and get the patient back to functionality than any other procedure. Proximal pylangial osteotomy basically use shoes, forefoot a Keller, and you know put a rocker bottom sole on it. Growing up in Philadelphia and going to school in Philadelphia Dr. Ganley was one of my teachers and Dr. Ganley felt that a Keller was the ultimate procedure, he didn't believe in Keller with implants, he just felt that Keller was the way to go because he goes, the most things to make orthotics put a turf toe plate, put a Morton’s extension on it, the patient happy and he felt in his practice Keller's were the best procedure, pad it, you can inject it, you can put them on all kinds of medications.
In my practice they are consented for almost every procedure except the straight Keller or total art or total arthroplasty. Patients are advised that depending on what the joint looks like surgery will determine the appropriate procedure. Up until a few years ago I never [indiscernible] [0:12:30] arthrodesis joints and it got to the point where the joints would come in so bad that a Keller wouldn't work and I was doing, I was actually fusing the joint and I grew up -- and in my education it was, nobody fuse joints.
And if you look around the podiatry world these days you can go to workshops where they are actually teaching podiatrists now how to do an arthrodesis. It’s not a new procedure and it is the orthopedic procedure of choice for a bad joint. Implant, a total implant I've never really been very happy with and when insurance decided that a few years ago in Virginia we had a problem getting reimbursed for total implants, they felt it was experimental so we didn't bother with that anymore.
As a result of that basically we do there aren’t that many total implants that are done in Virginia. Hemis were the way to go from our perspective and we did a lot of Grade toe Hemi and with a variety of different companies depending on how it worked. Hemi-arthroplasty: First metatarsal head implant the problem you are going to have is bone, history of bone infection if there's not enough vascular supply down to the bone and the biggest issue that we have with doing any type of surgery, let alone just the first metatarsal head implants is unreal patient expectations. They’ve had a stiff joint, they’ve had problems with it, they are not going to out running a marathon within six weeks of doing the surgery.
Now when unrealistic patient expectations, usually they require revision surgery because they are just going on that there is just issues, they’ve got problems and we will go back in there and we will do something else with them. One of the reasons that I do first metatarsal head implants is I’ve done a lot of great toe hemis, we are using Keller with an implant but the problem is when you look at the joints the base of the proximal phalanx looks good.
There is hardly any cartilaginous issues with this, it's always the head of the first metatarsal and so we would look in -- well there’s got to be something else we can do because you would go in there, you do the Keller you put the implant in there they still have problems with it because they were having problems with that cartilage and with that head of the first metatarsal.
Now the impant is available and we’ve gone through a bunch of different implants. I personally have like Vilex cannulated hemi implant. The reason I like it is when I looked around the implants I needed a procedure that was not going to be time-consuming and what I thought would be relatively simple implant to be able to put in. There is an elliptical and a concave implant to replace the base of the proximal phalanx if you want to do that and there is a spherical and convex implant to replace the head of the first metatarsal. That's what the tray looks like.
For the MPJ procedure, basically it's a longitudinal incision dorsally go down to the capsule I do a longitudinal capsulotomy, get rid of all the hypertrophic bone. And at this point figure out whether or not we are going to be doing base procedure on the proximal phalanx, a head procedure or whether or not the joint just looks like it's just really bad and we may have to just do an arthrodesis.
We resect the head of the first metatarsal, the width of the bone is about 45 millimeters off the distal aspect of the first metatarsal that I end up resecting. If you resect too little you are going to end up with a problem, if you resect too much, the issue is going to be, you are not going to get really good apposition of the implants.
After the met heads resected we put trial sizes placed into the exposed surface to determine the correct size of the implant. This is what their sizes look like. As you can see, on the right you are looking at what the size it would be for a first metatarsal, on the left basically the sizer -- that's going to tell you what kind of an implants you are going to place into the joints for the base of the proximal phalanx.
The sizer needs to cover the entire surface without protruding beyond the bone. The sizer in place we can insert a K-wire or mark the center of the bone, remove the sizer, drive the wire into the metatarsal shaft and the K-wire needs to be in the center and parallel to the axis of the metatarsal. We insert the implant over the K-wire put the implant into the medullary canal. This is the instrument that’s used for actually inserting the implants.
As you can see here you open it up, basically the head of the first metatarsal you can tell where there's a lot of just bony overgrowth. Actually there is a lot of cartilaginous damage to it. A better view of that particular joint. And this is when you are lining it up that's what a ZI scan is going to look like afterwards. And that’s what it is going to look like at the end of the procedure.
Basically when you're driving the implants in, you are using the K-wire as a guide. Now complications with the procedure: Infection; the implant can loosen. So far and all the ones that we put in I've been lucky and I have not had any of the Vilex ones loosen up. Vilex has recently come out with a longer stem to place into the first metatarsal which makes it easier to -- which keeps that from happening.
You don't need to backfill the canal with any cements which is also an advantage to using this particular implant. You can get recurrent pain and loss of motion and I assume that Dr. Schoenhaus is going to be speaking today on complications, so I'm sure that he'll be telling me just what I’ve been doing wrong with some of these when I get the pain and loss of motion.
What you need to know when you are doing this procedure is, you got to take off enough bone dorsally. And as I said you need to remove enough bone from the head of the first metatarsal in order to decompress the joints.
Now Moberg osteotomy of the proximal phalanx may be needed in order to help with range of motion. When we operate on them weight-bearing is tolerated and basically within the first two days after motion we get them moving and I want range of motion going back into that joint as soon as possible, don't want them stiffening up. We get our patient's weight bearing after this procedure normally under a week, for a variety of reasons.
Number one, once I am operating on compliance is always an issue with that so no matter how much you tell your patients you don't want him walking on it they still walk on it so we figured we altered some of the closure with it and we’ve actually got them weight-bear twice about what you are going to be doing with it. The joint is basically destroyed, this is as close to a Grade 4 as you can get, you’ve got a problems with the first metatarsal, you’ve got problems with the proximal phalanx, you need to resect this joint. You can tell the cartilage is pretty much gone on the first metatarsal head – not a good slide sorry about that.
But what’s interesting is the base of the proximal phalanx is actually tolerable and if you’ve got -- for choosing the lesser of two evils, the first metatarsal needed to be resected in this particular case. You can see here we did the cut, originally I was going to do the cut a little bit more proximally, looked at it and said, no just way too much so still stuck with about resected about that much of bone.
Using the sizer, take the bone out and I will check – align it up actually with the bone that we’ve taken out and see what we're looking at. At this point you can see we are putting the K-wire in, it’s got to be centered both medial, lateral and dorsal plantar.
Taking out the K-wire here, you can see this, insert the K-wire back in there. We are taking ZI scans or mini C-arms to make sure that it’s being situated both dorsal laterally and medial plantar. And I don’t know how well this project, but what you can see here is the K-wire directly through the center of the canal of the first metatarsal.
We’ve lined the bone up, we’ve taken the bone off and what you can see here – what I was concerned about sizing. In this particular size that we are looking at here which is – actually I know them in sizes 1, 2, 3, 4, 5 to be honest with you, I don’t know what the millimeter structure is on this. And so we are looking at this versus this. This is going to be too big, this size implant is going to way too big to put into that joint, you are going to get restriction when you do that.
Picture the implant itself, you can see that where it’s cannulated and it is -- and this thing just screws right in very easily. You don't need to tap it that much. The bone normally if the bone is good you may need to ream it a little bit but for the most part I don't – I will be honest I haven’t ream the bone for putting a first metatarsal head in in probably over a year and a half to two years. We put this in there, you could see where the implant is going in.
Now the key at this point is making sure that the implant isn’t far enough and you remove the K-wire. As a result of not doing that and taking the K-wire out soon enough we ended up with a few complications and I'll show you what that is. In this particular case you can see the met head is in, it’s flush we’ve got it back as far as we want. It's butting up against the bone. Now I don't know if this is projecting well or not so.
The biggest problem that we've had with this is when you are putting the implant in and we had this both in the proximal phalanx and in to the first metatarsal of the K-wire actually breaking. There is enough heat built up when you are literally screwing this implant in over the K-wire that it will cause the K-wire to snap. And you can irrigate it from now until the cows come home it's not to make any difference.
When I’ve left K-wire in and screw the implant in all the way and I've removed the apparatus that we use to screw the K-wire in you take a look and there is no K-wire there anymore. It's actually going back into the handle and you realize that you’ve now got a K-wire stuck in the first metatarsal.
It's not a bad thing I’ve told the patients that it’s in there because it's having to support the implant. Now, we haven’t had an implant break off because of this so I really don't have that much of an issue with that. That's pretty much the end of the talk. When we travel it actually -- I have two dogs one is an English Springer and this is Lucy and this is Maggie. The Springer actually -- she will pose for you is a total ham for taking pictures.
Maggie if you try to take a picture of her she will not look at you whatsoever she will run and hide. She is basically the Frisbee dog and this is what she likes to do and she will play frisbee with you all day long. The two dogs and my wife are what actually keep me going. This is a woman that I owe a great deal to. We've been together for 23 years and let me tell you she puts up with a hell of a lot for me especially during legislative season when she does not see me for from starting from January through May and a dinner time every single night I'm on the phone with either a legislator or a lobbyist. So luckily I'm not on the phone with a hospital telling me the patient complications. I thank you. Are there any questions?