Harold Schoenhaus, DPM reviews indications and goals for FMPJA (First Metatarso-Phalangeal Joint Arthrodesis) complications, methods of fixation and fusion versus implants. Dr Schoenhaus outlines various surgeries to correct this problem.
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Harold Schoenhaus, DPM
Surgical Editor for PRESENT e-Learning
Penn-Presbyterian Medical Center
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So we’re going to talk about first metatarsophalangeal joint arthrodesis. And I have always been a proponent of implant or joint arthroplasty procedure to retain motion. I've always felt motion is life, the great toe joint one of the most important joints within the forefoot, one of the most important joints in the foot itself certainly in the propulsive phase needs to retain a certain amount of motion fluidity and the propulsive capability. So if we can retain motion, that would be my goal.
Unfortunately there are times when things present that you can’t simply put an implant in the joint, and the controversy of whether implant versus fusion to determine which procedure you should perform and what is the outcome of this, which procedure does the patient do best with long-term, what is the lifespan of an implant that we put within a joint.
When we used silicone as a material many years ago, hemi-implants were abject failures because the compressive forces of the great toe joint are incredible and the material breaks down. The total double-stemmed implant of silicone still is in existence, is still being utilized, and the use of grommets on the implant have helped the lifestyle or the lifespan of the implant. But the body doesn’t necessarily like silicone. So the argument years ago was how long will an implant last or live before it needs to be replaced, and did you advise your patient that this implant may have to be replaced.
Interestingly, one of the longest implants out is cobalt-chrome as a material. It's been in use for close to 50 years. That has stood the test of time. Titanium as a material is able to withstand compressive forces, and is not a material that’s going to have to be replaced. So the concept of implant no good because it has to be changed, go to fusion, and fusion does great because you have fixed position. That argument will continue to go on based upon your ability, your technique, and patients’ demands.
Let’s take a look at some of these things. The goals of surgery of a fusion are simple. We want to maintain and restore length, and sometimes by restoration of length we may have to utilize bone grafting techniques. We want to correct deformity – whether you have an elevated first ray, the deformity within the joint; reduce or eliminate pain. I would tell you as residents and/or practitioners, I do not ever tell my patient I’m going to eliminate your pain.
That is a very profound statement, because the patient who has any type of pain postop is now in a position to say: you lied to you, you told me you were going to eliminate my pain. So I should even take that out; you’re reducing pain, improving forefoot weight distribution, and ultimately you’re going to allow heel height up to 2 inches when you’re doing the fusion.
I think one of the pitfalls of fusion or of one of the goals that must be shared with the patient is the fact that as a result of this fusion, when you stand with your foot flat on the ground, you’re big toe is going to stick up in the air a little bit, it’s going to be off the ground. That's to enable the patient to go into a propulsive phase and still come up onto a structure that is rigid, that will provide for the 2-inch heel; otherwise you can't get into that type of foot cure.
Method of fixation in fusion; you'll find what works best in your hands. External fixation – screws, locking plates, compression plates, wires, chewing gum, I don't care what you put in there, the end result is we need to get a fusion of the great toe joint. And certainly, industry has provided us with the armamentarium to enable that to happen. You’re going to need a certain amount of compression in that environment, [Indiscernible] [0:04:44] and quality of bone to enable that fusion to take place.
I do use a lot of interpositional grafting, I use, I don’t care what company it is, there's a bunch of companies that you should be familiar with that have products that allow proliferation of bone leading to the end product, which is ultimately an osteosynthesis to take place or a fusion. When one looks to your bone-to-bone fusion you're dealing with usually minimal resection at the site without necessarily utilizing any foreign materials to assist in this process. I go to orthobiologics when I deal with patients who are somewhat immunocompromised, the diabetic, and the patient that smokes.
In the Philadelphia area, a ton of my patient smoke, and as soon as I walk into the room you smell smoke on them. You’re still smoking, aren’t you? Yeah, well, I cut down to two or three a day. Two or three a day is catastrophic. And I explained to them the influence of smoking on bone healing. Now do I think my patients are going to stop smoking? You could answer as well as I. Smokers are smokers are smokers. The amount of smokers that will stop completely is just minimal. So these are the patients that I utilize other materials to assist in the process.
So continued indications, unremitting pain, degenerative joint disease, rheumatoid arthritis, hallux varus, implant complications, AVN at the head of the first metatarsal. Complications of fusion, nonunion, delayed union, malunion infection, prominent hardware, sesamoid prominence.
So we’re going to look at some cases. Here is an example of an old silicone implant. This was a double stemmed implant with a grove in the middle to allow motion to take place. It does maintain the hallux usually somewhat straight; however the body does not like silicone, and you can see the bony absorption around the material, you can even see proliferative bone around the joint. So the body wants to wall off silicone and possibly engulf it.
When you go to take these out you usually find a fibrous membrane in the canal that act as a separating medium between the implant and the bone itself. You’re not looking for boney ingrowth in these type of implants. And when patients become symptomatic and painful, you got a dilemma on your hands because you're looking at an encasement that has taken place with shallow bone, and now what are you going to do to hope to replace it?
So here is an example of one that was taken out. You could see the implant on the clinical picture; that is going to be removed. There’s different materials [Indiscernible] [0:08:06] had one with a Dacron mesh so wouldn’t break; implants do break when you're using these total stems, and you're often left with a short digit. Take a look at that, shortness of that hallux. That is not cosmetically acceptable to the majority of people let alone the fact that your second toe sticks out way beyond what it normally would.
These are cases where I will go to iliac crest bone, and I do not like bone-bank bone in these compromised cases. I go to my friendly orthopedists and I have them harvest a piece of iliac crest which has a nice shape to it. I usually keep it loaded in blood, keep the sponges wet, and I want bleeding in this so that we maintain a viable graft that I'm going to put into this compromised bone.
So I shape it on the table. Here it is. It’s a little bit of challenge to get these implants into the site. Here it is, this is an interpositional graft, and there is an external fixture for maintaining the position of the graft. You can see that the toe is slightly dorsiflexed, we've increased the length. We’re giving the patient at least an acceptable amount of length, and that is the approach that I take on that type of case. The graft ultimately incorporates, the patient recognizes his own bone obviously, I don't want any foreign substances in there, and these patients want to do rather well.
The other advantage of this is the hip hurts hell of a lot more than the foot. The patient is complaining of postoperative pain, and I always blame my orthopedic friend on that. Here is another example. Certainly when we perform surgical procedures we don't anticipate or expect results that look like this, but I can guarantee you if you don't get results that sometimes look like this and you shake your head, you’re probably not doing enough surgery.
This is a little bit of an extreme. If I had a result like this, I'd probably jump out of the window and shoot myself on the way down, because this would now say, you know your skills as a surgeon are certainly in question. But here is an example of this. You can see the cockup position, it’s a disaster.
Here is a different approach. We actually resected a portion of the diseased component of the joint, and I'm actually going to place an interpositional graft into the site. You can see the strut graft placed in. My next talk today by the way dealing with orthobiologics talking about osteoconductive and inductive activities, but here is an example of a strut graft being placed in. It once again has a curvilinear shape. This is bone-bank bone. I don't worry about that it does not fill the defect completely, because I will use orthobiologics in that site, and then utilize a bone plate over it to hold everything in position for final incorporation of the graft itself.
Here is an example of autologous platelet gel being utilized. If you PRP bone marrow aspirate in addition to any of the orthobiologics. So this one fusion probably costs about $15,000 of materials alone, where somebody could come back to me and say, why don’t you take the damn hallux off, and that would have been a lot cheaper and we all be finished.
Here is an example of hallux varus and what I do for this. Hallux varus is more times than [Indiscernible] [0:12:06] deformity. You’ve done a beautiful bunion correction, you’ve taken out the fibular sesamoid, and I put a big question mark over that. And then patient comes back and see the hallux start to go in a medial direction. It could have been because you’ve overcorrected the IM angle.
Once hallux varus begins you must surgically intervene ASAP with any of the soft-tissue approaches, because once it continues to grow, abductor hallucis now becomes a deforming force, maintains the position of the hallux, and you ultimately go on to need a fusion of the great toe joint; implants do not work. Even the double stems will not overcome the force of the abductor.
In those cases, an end-to-end fusion is easy to accomplish. I use these instruments that really create a ball and socket environment. The big toe joint is what I consider a ball and socket joint similar to the TN joint. So if I can create a ball and socket shape, I can put that great toe into the direct position I want in the transverse sagittal and frontal plane. So here we are denuding the cartilage from the head of the first metatarsal. When you do this, my recommendation is to go through the subchondral plate. If you don't, you better shingle it, you better fenestrate it with multiple holes, because the subchondral plate acts as a barrier against osteogenesis.
So you must finish grates through it, create multiple holes, or debride right through the entire plate itself, get into cancellous spongy bone on both sides which will lead you to a beautiful fusion. And here we are; you could see the head of that metatarsal is now a beautiful cancellous appearance to it. Here is the other component which will create the cup and bowl concept. Here is a nice case of hallux varus; you could see where the tibial sesamoid has now moved to the medial side of the first metatarsal head, the IM angle is zero to maybe even a little minus; there is no way to bring that hallux back into position.
These patients are very very unhappy. This is the patient that says to you, can you please give me my bunion back, because where my big toe is, over and up is a disaster. It’s painful, it like hell, and it is problematic and gets worse. So here it is back into position, you see minimal shortening even though I’ve done the aggressive approach on the bone. There is your plate for fixation; you can use an interpositional compression screw as well, I do recommend that. I don't care how you fix this; whatever gives you the best stability is what I want.
So you determine how much dorsiflexion you want to place on the proximal phalanx, recognizing you will still be able to get some gripping capability from the distal phalanx of the hallux even though you've gone on to fuse the great toe joint. My experience with hardware in this area is more times than not, [Indiscernible] [0:15:46] the patient because the shoe rubs on the hardware. Once all the soft tissue swelling goes away, you will now feel the plate even though you use screws that go directly into the plate. They screw in very nicely, you still have prominence, and I could tell you I tell my patients in advance, there’s a good chance I'll have to take the plate out.
Here is an example of a position of a hallux, this was shortly postop, and you could see how a patient can wear a shoe with a slight heel raised to it. Here is an example of a straight cut that’s going down through the bone for an end-to-end fusion, and here I’m drilling throwing the bone that's left to still create vascular channels for the angiogenesis that will convert into an osteogenesis.
I do not like using K-wire, some people use these to create these holes. I think most physicians or surgeons are going to use 2.0 drill bits so that you don't polish the vascular channel that you're creating, but you're creating an environment of roughing the bone that will proliferate through and end up in a fusion of the site. I don’t care what plates you use, every company has fabulous materials for us; we’ve really have no excuse to say that we don't have what we need to perform the surgical procedures that we do.
The only thing you got to be careful of as a resident is where you're going to practice ultimately, what the hospital has available for you, and what you're most comfortable in using to do these surgical procedures.
Here is an example of one of my own patients. Look at that hallux valgus on the left; severe deformity of the toe. And what did I do? I did a great job, I reduced the IM angle, I even left the fibular sesamoid in, I did a Lapidus on this patient with plates fixation. If you just didn't look at the toes and just looked at the metatarsal, you said hey, you did a great job. Look where that great toe is? Disaster! This patient obviously was not a happy camper. And here we are completely remodeling the forefoot. I used an interpositional graft, plated the great toe joint, and remodeled the second and third digits as well.
So here we’ve got multiple plates to correct deformity. So what I try to share with you in these few minutes that I had available to me, was a concept of introduction of the fusion of the great toe joint; how you could make it a successful procedure, and why it can be a benefit to the patient. It’s certainly the alternative to implant arthroplasty or even Keller type bunionectomies. Fusion is the direction you been trained and are most comfortable with. I thank you.