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David Davidson, DPM
Center for Wound Care & Hyperbaric Medicine
Erie County Medical Center
Buffalo, New York
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Male Speaker 1: We invite back one of our speakers from last several years, David Davidson from SUNY State of Upper New York, I believe. And he’s going to be speaking about arthrodesis versus implants. Is there really a controversy? So let’s welcome David Davidson for you.
David Davidson: Thank you, sir.
Thank you. I know you’re hungry. I just want to go on record saying that I did asked Dr. Laporta to lecture for me and he refused.
And I know it’s not snowing and you’re in Buffalo, New York yet. Just a disclaimer. I have no financial relationship to disclose other than being on a speakers bureau. And these are the learning objectives of this short talk to understand. And most of this is going to be a review for you. And I think at the end maybe we can talk a little bit of more about if is there or is there not a controversy. So basically, to be complete, we need to talk about the ideology of first MP joint pathology being the hyper mobile first tray, which will cause the wear and tear arthritis traumatic injury, osteochondritis, metatarsus elevatus, long first metatarsal and there are others. When we talk about hallux rigidus, we really need to complete this to talk about functional hallux limitus. And I thank Paul Share for this great animation, which clearly shows you the cause of the metatarsus elevatus causing functional hallux limitus. And if that won’t go, it would obviously cause hallus rigidus. I think it’s a great animation of the abnormal subtalar, midtarsal pronation. There are several classifications for hallux limitus or hallux rigidus, grade one, two and three, mostly involving the joint space. The range of most classifications we all know. This is probably one of the Coughlin and Shumas in 1999. I talk about range of motion in making that definition. In 2002, there was analysis. I haven’t seen anything more recent than this of almost 800 patients with hallux limitus. And Grady basically said that most of his patients as can be treated successfully conservatively. And the conclusion of their study is that only 45% of those patients required surgery. And when they talked about those patients that did require surgery, there’s the whole flatter of choices that we all have. So how do we make those decisions? You can see arthrodesis and implant arthroplasty right up there but pretty small percentage. So how do we make the decision of what type of procedure we’re going to do on this particular patient? How severe is the deformity? Is there pain? Where is the pain? Is there a desire? And is there a need for motion, the joint status? What’s the complication potential? And what’s your own ability and what’s your experience doing these procedures? We’ll about implants in a few minutes. But I will tell you that there was a very large successful malpractice case in California where the surgeon put in bilateral hemi-implants in a 33-year old aerobics instructor that taught 30 hours a week. I suspect that there should be no challenge as to the use of the implant itself. But was that the right procedure for the right patient that particular time? And I suggest not. So there’s lots of choices. We have osteotomies and people have talked about that whether they’re opening or closing. We talked about Keller arthroplasty, implants and fusion. And so, the goals of any type of surgery, first MP joint or whatever other foot surgery we’re doing, obviously we want the patient to be pain free. We need to have a congruous joint. The joint needs to have some weight-bearing. We would love it to be cosmetically pleasing. We would love the foot to be functional. And it would be nice to have a nice x-ray to show people. So as we said, there’s lots of choices. And the most simplest approach is a cheilectomy. We use that for the younger people with a significant grade three or grade four hallux limitus or hallus rigidus where it’s just simply remodeling of the joint.
[04:59] Sub contour trailing is with questions marks. I do that all the time. The importance here is early range of motion. But cheilectomy is certainly a time limited procedure, which means that we’re still solely been bone against bone, so that if we don’t do anything to improve the function to the motion through that joint, the patient will require a second procedure. Metatarsal osteotomy, we’re not going to talk about but there are several. So let’s talk a little bit about what we call joint-destructive procedures, the arthroplasty total implant, hemi-implant or arthrodesis. This is a great article in 2003 in KFAS. And I suggest each one of you should have this in your library. It’s really a great review of first MP joint arthritic problems. Stage one, two, three and four talks about the simpler procedures for the early stages and the more destructive procedures in the later stages of hallux rigidus. So we can see here this is a typical first MP joint arthritic joint. And the choice is arthrodesis or hemi-implant, that kind of a joint. I said hemi, but it could be total. In my own practice, I’ve used all of these. In the ’70s, the Swanson silastic hemi-implant was used. And that’s pretty much out of favor. There are people that still use the Swanson double stemmed implant with grommets. Viropro, Integra, Vilex and there’s multiple companies that have held different types of implants available. In my own experience by the way, I don’t use totals. I don’t do both sides of the joint, because I found that one side sufficient. In the choices, which side is more destroyed whether it would be the phalanx side or the metatarsal site? I like to do things simple. So the simpler procedures within my hands there’s really the phalangeal side. I’ve used the Viropro. I’ve used the Integra. I really like the Vilex hemi-implant because I like things easy. This is the only implant that is actually screwed into the bone. Just very briefly we’ll show you a couple of slides here about open joint in seeing the severe arthritis, remodeling the joint, the first metatarsal both medially and dorsally. Removing the base of the proximal phalanx, using an appropriate size or putting the K-wire through the phalanx. And this is really the only important part of this procedure is to make sure that that K-wire is driven to the longitudinal axis of the proximal phalanx. Once that’s on, you can confirm the size and take that implant and screw it into the bone, excuse me. And you’re left with that. Again, this is a procedure that I like because it’s pretty safe and really pretty simple to do. And you end up with excellent range of motion. And it should be a permanent forever type procedure. Of course nothing is forever. Arthrodesis, of course, there’s lots of just different choices there also. Strict, just like there is an implant procedure. You can use a dorsal plate with screws. You can use crossing cancel screws, you can use the crossing Kirschner wires and there’s other choices or combination about all of those. The indications are many, advance hallux rigidus, severe hallux valgus even, hallux varus, rheumatoid arthritis, the neuromuscular disease, the muscle imbalance. Arthrodesis is really almost a procedure of choice because I find that in those patients with neuromuscular diseases, it’s difficult to predict a permanent result with those patients that have neuromuscular disease. So arthrodesis, you got a very predictable long standing result. Post septic joint, post trauma, AVN and failed first MP joint surgery. And there’s a ton of companies that have the appropriate, they’re pretty similar techniques of doing the arthrodesis. The re-immerse are my favorite choice to play with because it gives you really a nice fitting joint. And then the simplest part of this procedure is that the more difficult part of the procedure is putting the plate on in leaving the toe in appropriate position. And I’m just going to skip through that. But what are the functional implications? So let’s compare these. And I think John Laborvitz from Los Angeles can give me some of this information. What are the functional implications of doing one procedure over another?
[0:10:00] Is there IM reduction? Yeah, there is. And probably because of the removal of the muscle attachments of the joint when you’re doing a resection arthroplasty or an implant or an arthrodesis. Could there be a recurrence of the deformity? I guess even with arthrodesis there could be recurrence. Well, there won’t be a recurrence but there still could be complications. There are definitely could be a recurrence of that especially if you do the procedure improperly. The cosmetic appearance will almost all of us will agree that there’s a poor cosmetic appearance with amputation and many times there’s a poor cosmetic appearance with a Keller procedure. Usually with implant and arthrodesis, if the procedure is done correctly, the appearance is fine. So you really want patients to be happy. Could there be a hallux hammertoe? Certainly there could be if you remove too much bone at the base of the proximal phalanx. There won’t be a hallux malleus deformity with arthrodesis obviously not with amputation. There could be a floppy toe if you do take too much bone off. And certainly there could be transfer pain after these procedures. If the joint is fused in a proper position, there is rarely lesser MP joint pain after an arthrodesis. Weight-bearing propulsion, certainly there’ll be a decrease in most of the procedures, but there seems to be an increase in propulsive, weight-bearing and after first MP joint fusion. And basically there’s pretty much long term stability in all those procedures. But again, the most important part when you’re talking about first MP joint arthrodesis is doing the fusion with the toe in correct position. And usually we tell that very simply on the operating table using the cover from the implant tray or the joint fusion tray. We can see if that holding up against that joint and just slightly dorsiflexing the great toe to see if we can have some motion there. Our colleague, Rich Moushey in Seattle probably about 15 years ago asked a question, do you really need more first MP joint range of motion? When I first started in practice, doing an arthrodesis of the first MP joint, I felt was doing the patient’s rocking chairs. So Rich actually started, so I have a pretty small study back then. I think he’s developed a much greater population of I think 22 people, min age of 54 years, all different types of weight-bearing activities. And almost 90% of those patients were able to resume their previous activities without any trouble following arthrodesis. So a summary that basically of his small study back then. And so far his increased patient study has proven this again, is that after first MP joint arthrodesis, there’s significant potential for high level sports activity, but further research certainly is needed. And in 2005, another study from the orthopedic literature in Foot & Ankle International had an article functional outcomes of arthrodesis using parallel screw fixation. And his conclusion was, with an appropriate technique, I just had to underline that, correct fusion angle and appropriate post-op care patients functioned extremely well. And most athletes were able to continue participation in their sports with the advantage of greatly diminished discomfort. So we did a little literature review here. And in this article just this past year, evidence-based analysis of the efficacy of the operative treatment of hallux rigidus, there’s a lot of words here, but basically the conclusion was there are no consistent findings that are properly powered with validated and appropriate outcome measures to allow any definitive conclusions. However, there is grade B evidence that arthrodesis may make it a logic leading candidate. And this is really a good study, but basically said that both arthrodesis and implants sufficiently improve patient score, arthrodesis probably scored a little bit better. Another study and earlier this year also, no significant difference was found between hemiarthroplasty or total joint or arthrodesis.
[14:59] And I think lastly 2012, the best surgical treatment for end stage arthrosis continues to be controversial. Arthrodesis is recommended as this procedure is definitive and produces predictable results. And one last study here in 2012, again, the conclusion was pretty similar that all three surgical procedures are certainly viable options. So is there a controversy? I don’t think so, but I think what separates the podiatric community with orthopedic community is that we really try and attempt to restore function. And that’s what I try to do with my private practice. So if we can catch this early similar to wound care, if we could see every patient when they were grade one and not a grade three or four, life would be wonderful. And then we could do those 10 procedures and keep them out of our wound centers. Same thing, if we can catch all these people when they are grade one or a functional hallux limitus get them and proper orthotics, we won’t be even talking about this stuff. But in acts of adult attempt to restore motion. I’m a big fan of hemi-implants, I am. If their attempt fails and there is a small percentage of implants that do fail, arthrodesis has become the standard of care. These are some references you can check. And thank you for your attention.