Harold Schoenhaus, DPM discusses the etiology of hallux rigidus, complications of implants and important considerations for surgical intervention. Dr Schoenhaus supports his discussion with multiple case examples.
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Harold Schoenhaus, DPM
Surgical Editor for PRESENT e-Learning
Penn-Presbyterian Medical Center
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Male Speaker: Very interesting terms that we utilize and things that we apply to our everyday lives. In practice, as an educator and teaching students for 43 years at the college, I’ve always lived by an adage that said, “To be the best, you must continually strive to be better.” That sums it all up for me and everybody in our profession. So it’s continuous learning curve to make us that much better. What I’m going to do over the next 20 minutes I hope is share some of my experiences implants of the great toe joint, and the evolution that I have experienced and the complications that I have seen, some of which I have certainly created. Learning objectives, identify etiology of Hallux ridigus, understand avoidable complications, understand the structures involved with deformity because there’s been an evolution in my thinking as to how to go about Hallux ridigus and why we fail. There’s my disclaimers. You’ve seen this a number of times. Certainly the concept of implant versus arthrodesis, there’s articles constantly written on this. There was just recently an article in foot and ankle. Identifying implant versus arthrodesis. It seems to point to the fact that patients do relatively well depending upon how good you are, your patient’s selection. So arthrodesis does not necessarily have an advantage over implantation but certainly has its place. Let’s look at Hallux ridigus. Degenerative joint disease, grade three, four, pain with activity in motion, range of motion markedly diminished, age predominantly greater than 50 but primarily dependent on x-ray findings and clinical evaluation, and the expectation of mild to moderate activity post op, Degenerative joint disease, narrowing of the joint space, absence of the space, squaring of the metatarsal head, proliferative disease, sesamoidisus which is something I will stress shortly, and marked decrease in range of motion with crepitation and good bone stock. These are things we typically see in the development of degenerative joint disease of the great toe joint. It’s a common affliction in an active population. I’ve always been a proponent to say emotion is life. Great toe joint is the most important joint in the front of the foot. It’s the propulsive organ that pushed you forward the final step. You need motion to be able to accomplish that. My goal has always been retain motion. You don’t fuse a knee joint. You don’t fuse a hip joint. You may fuse an ankle. The great toe joint in my opinion, if it can be maintained with restoration of function, that’s my goal. Early on we would use implants with silicones. Silicone is a material that was recommended. We found out rather quickly that your initial post-operative x-rays look great and then you watch the implant undergo a degradation and then eventually it took out this cataract from the space because it failed. Implant could not withstand the compressive forces in the joint. Silicone, not a good material between bone and the material itself. Double stemmed implants to help prevent deviation. With a hinge in it thinking that going to allow for motion of the great toe joint. You watch the breakdown not only of the implant itself but actually resolution and osteolysis around the implant itself with very poor bone stock that is left. Silicone implant failure often led to fusion which was challenging at best. Also the loss of bone in what you had to debride prior to doing any interpositional grafting to replace what you’ve just taken out. Sometimes the implant looked good when they took it out but it was an absolute disaster. In cases where I have to take implants out of that type, I do go to the iliac crest bone bank, and actually not the bone bank. I want fresh bone when I’m doing these type of remodeling procedures for fusion. You could see you remodel it into a beautiful-shaped implant as you can see on this side. Plenty of bone and blood is maintained when my orthopedic friend harvest this and I said, “Be sure there’s plenty of blood and keep that bone as viable as possible.”
There’s the shape. I place it into the great toe joint. As Stanley said, “You need to have available armamentarium of material to be able to maintain position.” Foresight, insight, as to what you’re going to do. Here’s an example of an external fixator being utilized to maintain the position while eventual incorporation of graft occurs. You’re going to even see slight dorsiflexion which I was able to obtain because the iliac crest had a slight curvature to it. You should take advantage of that. Then overtime the graft incorporates and becomes a rigid unit. Your x-rays don’t necessarily look picture perfect. But you don’t treat x-rays, you treat patients. Another example of the silicone implant. It’s interesting how the body rolls off silicone. When you go in and take these out, there’s a fibrous band surrounding the implant from its entirety. That has to be removed if you expect to establish an interpositional bone graft with ultimate fusion. Some of them look real good overtime. I will tell you that the double stemmed implant, when grommets were introduced, it’s still available and it’s still used today. Here’s an example of a patient that came into emergency room, of a hospital and said, “There’s something shiny sticking out the side of my foot.” I said yeah, you’re absolutely right about that. That’s what this was. Somebody had put a double stemmed implant, a non-constrained double stemmed implant into a great toe joint. You could see the angulation. The position was poor and it actually had to be removed from the great toe joint. Interesting you can also see the poly wear on the surface of this diaper implant. Again, the challenging component of what to do, I like external fixed that maintain a space. If there’s potential infection, you can maintain the space. You could pack it antibiotic beads. Take out the beads and then go on to your final fusion. Let’s look at some of other type of complications we see with implants. Any implants, I love them. There’s many different types on the market. I will not stress one versus the other, but I utilize many of them. Here’s an example. What happens with complications from implants? Poor range of motion, painful range of motion, lesser metatarsalgia, lack of hallux purchase, implant bulldozing, and implant stem plantar flexion. Here’s an example. One has to recognize the anatomy of the proximal phalanx to realize you need to be down the shaft centrally. You need to make your cut on the base appropriate so that the shat of that implant can go down the stem or the stem down the canal. Otherwise you can actually penetrate through the plantar cortex and create problems of the flexor mechanism. Cockup hallux, a propulsive hallux, transfer metatarsalgia, stiff painful joint, these are all good reasons not to do an implant. Elevatus. You must recognize that if there’s a structural deformity that led to limitation of motion and degradation of the joint, it’s still going to exist postoperatively. So if I’m going to put an implant in this joint, I’m going to have to deal with the elevated first ray. I’m going to have to consider a planter flexed osteotomy or a cotton procedure or something that’s going to drop down that ray so that I don’t jam the great toe joint because I don’t care what material you put in there. It’s not going to work. What are the goals of implant surgery? Alleviate pain, improve range of motion, improve quality, reduce deformity, and ability to wear varying heel heights up to two inches. I always try to set goals for the patient that are suboptimal. This is not a new joint. This is not a perfect joint. It’s not going to restore the motion that you had when you first began walking. We’re trying to reduce symptomatology. Motion is life. First metatarsal phalangeal joint, I consider a ball and socket joint. When you look at the confines and the motion that occurs, there’s rotation, there’s sagittal plane component, transvers plane component.
Consider it a ball and socket joint. What are the joints involved in Hallux ridigus? Obviously the metatarsal phalangeal joint. But I am just as concerned about the sesamoid metatarsal joint. So when one looks at the first MPTJ, consider base proximal phalanx, head of first metatarsal sesamoid apparatus. They all work in conjunction. When you enter the propulsive phase gate, the first ray actually rotates up on the sesamoids and is pushed back somewhat. That’s normal gate, normal propulsive. If you have degenerative joint disease involving the sesamoid metatarsal apparatus, there is no rotation capable. You will not get your range of motion back. So the failures of implants that I’ve seen are selection of material, lack of decompression of the joint, poor position of the implant, inappropriate size, one piece total. I never liked connecting the base of the proximal phalanx to the metatarsal head or the total implant. You need rotation. You just eliminated it. That puts a strain on the implant and the confines of the joint. Severing of the flexor hallucis brevis or abductor hallucis, that whole combination. It’s a membrane expansion which you must maintain when you decompress these joints. The sesamoiditis, if you haven’t noted it, it’s there in certain elevation of the first ray. Materials that have stood the test of time. Cobalt chrome. Probably one of the longest standing implants. That is probably 50 years that has been utilized, and titanium. Those are the two that I like to use on a regular basis. Angled implants, shapes stems, all of the whistles and the bells, to me give me the implant that is of material that’s going to last, be biocompatible, and allow for a range of motion. There’s all kind of systems out there to make our lives easy, sizes to be sure everything is perfect when we go in with our surgical approach. I like an open incision that’s pretty large. I’ve always said big surgeons make big incisions. Take the tension off tissue. Open it up. Go right down to bone. Clean off all the ectopic bone. Whatever needs to be done to remodel. The base of the proximal phalanx should be removed with care. I even angulate my cut somewhat. Show that it will force to stem the implant that I’m going to put to go right down the canal. Avoid cutting the mechanism plantarly. When you remove the base of the proximal phalanx, you should be able to look into the void and see the aponeurotic sheet coming from sesamoid apparatus on to the phalanx. If you see the long flexor tendon, you made a bad mistake. So there it is. You look down into the void and all you see is that membrane. Now I know the flexor hallucis brevis is intact. Then you get ready for your implant. Complications. Biomechanics to the great toe joint and propulsive activity require freedom of motion. First at the metatarsal relative to the sesamoids and the base of the proximal phalanx. I’m going to show you some more things because one of the things that I’ve identified is the sesamoid problem. What do you do when you do an implant procedure at Hallux ridigus? You take the magic shovel, the McGlamry scooper, and you put it underneath the metatarsal head and you free up the sesamoid. You watch the range of motion dramatically increase and you say okay, I’ve got it. Now the implant’s in. Everything’s going to look good. The problem is that arthritic joint is going to do what? It’s going to arthrodese once again. So what I have come up with over the past seven years that I’ve been doing this procedure, is actually dealing with the sesamoid apparatus which becomes part and parcel of my procedure when necessary. It’s not everyone. I’ve selected a material that I’m going to use to resurface the metatarsal head and to act as an interpositional graft between the sesamoid apparatus and the inferior aspect of the metatarsal head. Here’s a good example of a patient with a hemi implant. It’s completely flat. There’s no motion taking place. The compressor forces along the great toe joint are incredible. So I remove the implant. I then take the first metatarsal head and turn it into a sphere.
Here’s the McGlamry elevator going in to be sure the apparatus is separated. I actually take acellular dermis and I wrap the metatarsal head. That grafts it between the sesamoid apparatus and the metatarsal head inferiorly and now is a new surface. When you look at that metatarsal head and you say man, there’s a lot of destruction there, here’s one of the approaches that I have utilized. We’ve written the articles about this. Watch the change that develops at the great toe joint with the implant on the other side. This is what it looks like when it’s completed. The implant is in place. We have a beautiful smooth surface on a denuded metatarsal head and you need to get to the calculus component of the bone. Here’s the space. The implant went right back here it was. Was it ideal? No, but there was no reason to change that. Here’s one of my early cases where I had denuded the metatarsal head, covered it with acellular dermis. A couple of years later had the opportunity to go back into the joint. This is a case where one of my residents said, “Sure. Now we’re going to see what that acellular dermis turns into.” They thought it was going to turn into whatever, mush, garbage. We opened the joint up and you’re now looking at what appeared to be hyaline cartilage sitting right over the metatarsal head. There it is. Open that joint. We now have a regenerative cartilage because of the stem cells that exist in the bone. The acellular dermis is recognized by the body, can undergo a differentiation, and I have now resurfaced with cartilage. We actually did some photomicographic studies and evaluations to see the chondrocytes that were in that material. So this to me has been a promising approach to deal with the sesamoid problem and remodeling of the head that we didn’t use before. There’s just some more cases that I’ve done. Here’s an example of a nice case. Look. The stem of an implant was taken out. Look at that garbage that’s in there. There’s a canal. What are you going to do with it? Here’s our orthobiologics going into. Then I can press fit an implant back into the canal. It can remodel ahead. There are many things you can do that are going to lead to a success of hemi implantation. If a tendon is bound down, do something to cover it after you free it up, whether it’s amniotic membrane, whatever you do to make that better. This is an example of a case, elevated great toe not where I want that to be. Perfect position of implant. You could see actually on the metatarsal head as that toe comes up it actually digs right in somewhat into the metatarsal. That’s pretty good range of motion post op with an implant in place. Transfer metatarsalgia can occur when you’re taking bone off and decompressing joints. So osteotomies of the west metatarsals is sometimes utilized. I’m not going to bore you. Here’s a good example of bulldozing. If you use an implant that is too small and doesn’t use the cortical margins of the phalanx as a support base, the compressive forces in that joint will drive the implant right down into the toe. Another example of a stem being placed too plantar. Comes right out the bottom of the phalanx. Not a happy camper. This is one of my oldest cases. I just saw this gentleman in the office the other day. Seven year follow up of hemi implantation and resurfacing of the first metatarsal. Interesting. Doesn’t have a lot of plantar flexion in the great toe joint. The IPJ is fine. Motion at the MPJ. Happy camper seven years later with resurfacing and hemi implantation of the great toe joint, and good ability by the way purchase the ground without excessive shortening. There it is. There’s the implant in place. This is what it looks like seven years following hemi implantation with resurfacing of the metatarsal head. So I’m not going to bother you with anymore of this. I think what I’ve always felt is use your head. Consider biomechanics. Consider why things fail. I can’t say it any planer than get your head out of your backside and utilize the skills and develop a though process to improve our patient outcomes. I thank you very much for your time.