Harold Schoenhaus, DPM, FACFAS discusses metatarsal phalangeal joint disease. Dr Schoenhaus also discusses how to diagnose degenerative joint disease and when surgery is indicated. Further, he presents the appropriate steps for a success hemiarthroplasty.
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Harold Schoenhaus, DPM,
Surgical Editor for PRESENT e-Learning
Penn-Presbyterian Medical Center
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Speaker needs no introduction, it’s me. And I’m going to be talking about the advances in MPJ Hemiarthroplasty and we just heard Dr. Solomon give us a little bit at the end about using certain type implants of the great toe giant. Let’s talk a little bit about degenerative joint disease of the first metatarsal phalangeal joint and the term hallux rigidus limitus. Criteria and indication for implant for hallux limitus are the following. Degenerative joint disease, pain with activity, range of motion which is markedly diminished, age which is predominantly greater than 50, and the expectation of mild to moderate activity postoperatively. So, one disease, the typical degenerative joint disease of the great toe joint with narrowing of the joint space, sclerosis of bone, irregular shape of the joint itself. When you look at a stress lateral dorsiflexion view you see the impingement occurring dorsally. We often see proliferative disease both at the dorsal aspect of the joint in medially and laterally. There’s often an evidence of elevatus, or an element of elevatus. And when one has to determine whether it’s functional or structural. Structural means it’s fixed in position. Functional is associated with hypermobility in the first ray. If I can control the hyperpronation syndrome, we should be able to see a reduction in the elevatus. And it’s interesting that Dr. Solomon pointed out that in the rheumatoid foot, if the rear foot is unstable, don’t do the fore foot. And here’s again an indication of the fact that if we can’t control hyperpronation, if it is the ideology of the elevated ray then you’ve got a problem. I do like to use stress lateral dorsiflexion views to determine how much dorsiflexion I can achieve at the first metatarsal phalangeal joint and if in fact the first ray can get back to a position of normalcy. Goals of surgery of implant surgery are simple. Alleviate pain, improve range of motion, improve the quality of motion and reduce deformity. Notice, I do not use terms of eliminate pain or give you range of motion that’s normal. Those things are not expectations with implants. Misconception, normal motion postop, I do not see normal postop. Your best motion is on the operating table. Anybody who’s done an implant, you put an implant in, you resected the joint, everybody is happy, you hive five, look at the range of motion. Six weeks later it’s half of what it was on the table. Good thing to do is take a picture intraoperatively to be able to how the patient just how much motion you did achieve, and then six weeks later you can blame them for the fact that the darn thing is not moving. Don’t tell the patients they’re going to wear shoes with hill heights greater than 2 inches. Don’t ever use the term I’m going to make it as good as new. Those are things that will get you into medical legal complications. Complications of implants, poor range of motion, painful range of motion, lesser metatarsalgia, lack of hallux perches, implant bulldozing and implant stem which is planter flex through the cortex. Each and every one of these complications can be avoided with proper technique. There are a number of different implants that I like to use. Here’s one that’s come to fit. A titanium variety, there’s another one that is cobalt chrome. I will tell you that the longest implant of the metal type that has been used is approximately 50 years out. So if anybody states that implants have not served the test of time, they’re absolutely mistaken. That’s the cobalt chrome implant. Incisional planning, very simple. I like to make a curvilinear incision over the great toe joint, straight incisions contract on the long axis, curvilinear ones don’t. So I don’t want an elevated potion because of my incisional approach. I’m also very simplistic in my dissection. I know I like to see my residents who go in and create tissue planes. Every tissue plane you create has to heal. It’s traumatic. It’s interrupting blood supply. My position is, make your cut get simple exposure and go right down dorsally over the joint, and expose the disease process.
[05:04] Clean up what has to be done, do your remodeling. I’m aggressive with remodeling, and then the determination of what you’re going to do when the joint complex. Here we’re determining a resection of an appropriate amount of baso proximal phalanx. And I use that term very carefully, appropriate amount. In implant joint resections, you are trying to decompress the joint. If you take out 3 millimeters and put 3 back in, you’ve accomplished nothing. You’ve just exchanged cartilage for metal. And you still will have limited range of motion. On the other hand, it’s critically important that you do not resect too much bone such that you will interfere with the planar mechanism. The ab/adductor and flexor hallucis brevis come together almost like an aponeurotic sheath extending from the sesamoid apparatus to the base of the proximal phalanx extending on to the shaft. If you do a resection and look into the space and see the long flexor tendon, you made a bad mistake. And I like the people who say, well, you could tie that back in with the holes in the proximal phalanx and it’ll be fine. Not so. Those are the patients postoperatively where you see an elevated great toe and then a propulsive gait leading to lesser metatarsalgia. Another important thing is the direction of the cut. I always recommend making cuts that come from dorsal or planar with a slight angulation. Sorry about that. The angulation of the cut should be dorsal to planar and you’re taking a little bit more of the planar part. That becomes important for two reasons. One, you’re decompressing, and two, when you place the stem of the implant down the shaft to the phalanx it follows the contour. The phalanx has a concavity component plantarly. If you go straight down with a straight cut, you will often bud against the planar cortex and can even penetrate it. So it’s minimal resection but enough to decompress the joint. So here you are looking down into the space and you see a beautiful membrane which extends from the sesamoids to the phalanx. Or, remodeling on the head is done and rather regressive. So you take the appropriate amount of bone off and then you can use whatever instrumentation you elect to make your life easy. Obviously, residents enjoy the fact that things could be cannulated and measured so that appropriate identification of size is selected. In here we are just remodeling and getting ready to place the implant into the great toe joint. I don’t care what system you use, the instrumentation is unbelievably simple today. It’s a case principle. Keep it simple stupid. I want the results to be predictable. So the companies that we utilize have provided us with instrumentation to make our lives very simple. The art of surgery becomes easier when the instrumentation has been perfected. And as all types of reamers and different broaches that can be used. Selection of the size is important to be sure that you seek the implant against the periphery of the cortical margin of bone of the phalanx. It shouldn’t be overhanging dramatically and certainly should not fall within the confines of the resected shaft because you can create bulldozing. I like different shapes of implants, the trocar is probably simple because it’s stable and goes into the phalanx without problem. One of the biggest problems that I have seen in implant failure and even in Keller bunionectomy failure is limited motion postoperatively. It’s because of the failure to identify a condition which I call sesamoiditis. Arthritis to the great toe joint can affect the head, the base or the sesamoid apparatus. Those are your components of the great toe joint. If the sesamoids are bound down to the head in arthritic, you’re not going to get an excursion of motion of proximal phalanx over the metatarsal head. You need the sesamoids to allow motion and excursion of motion. What do you do intraoperatively?
[10:01] You do recognized it exist. And you take the magic shovel which I call the McGlamry elevator. And you put it in there. And you separate the sesamoids. You create that nice celery sound. And you crunch. And you look at the range of motion. And you say wow, dramatically improved. And again, you put your implant in, everybody is happy. What happens to an arthritic joint that you broke in the ankylosis or the arthrodesis in a sense but don’t do anything at the interface. What’s going to happen? Line is down again doesn’t it? So sesamoiditis becomes a major problem. So I started using a technique about two to three years ago of resurfacing of the metatarsal head which is also an interesting approach by the way if you have degenerative arthritis on the head in conjunction with abnormality of the joint. Because what we’re trying to do is promote an interface, a material between the sesamoids and the head to allow for an excursion of motion to take place. And here’s what I do, we just remodel the head. Critically important to get down through the subchondral plate for you, the sesamoids, put your implant and if you’re going to use one. And then I actually use a material which is acellular dermis which changes the actual make up of the join complex. And when I first started doing this, acellular dermis is recognize by the body is non-inflammatory. And it’s regenerative. If you put it in ligament it creates ligament. You put on tendon it creates tendon. So to me it sounded why not put it over a metatarsal head and maybe we will get cartilaginous regeneration at that place. Now that certainly was a lot of conjecture in myself and a number of other surgeons have utilized this technique, Steve Bridger or Chris Heyer. Heyer and Lee wrote an article on this. Heyer and Bridger wrote articles on resurfacing to show exactly what happens. And this is just the technique I used. I’m not going to bore you with it. Here is the covering if you will of the metatarsal head which is been denuded. The membrane is place d between the metatarsal head inferiorly and the sesamoids. I used fiber wire. And this is what it ultimately looks like. I hate to use the term but it looks like a prophylactic over the head of a metatarsal. And here’s my hemi-implant in place. So now, I’ve got a membrane separating sesamoid from metatarsal head inferiorly and a beautiful excursion of motion occurring at the joint. So I like implants and I’ve always used the term motion in the ocean. God gave us that great toe joint for a reason. If I have to fuse it I will. But I used that on limited circumstances. And I’ve done this resurfacing on a number of cases. I’m not going to bore you with all these cases. Here’s that magic shovel. Here we go, putting it in. It is effective. It’s the best instrument to separate the sesamoids. But don’t think that’s the end of the game. It was just the technique again of doing that all process of remodeling. You could see how we now have beautiful joint which is resurfaced and contoured. We have a space which is been created because I’ve decompressed the joint. And there are numerous application is that I’m not going to bore you with. But here’s another example of a simple sesamoiditis with graft jacket and external fixator. No base resection had to be performed. This was a patient had previous surgery. Now, interestingly we’ve had the opportunity go back into the joint and see did we in fact create cartilage at the sight that I put graft jacket as it was called or acellular dermis over the head. And we can see very nicely infiltration of cartilaginous cells, chondrocytes into the acellular dermis. And there they are. So here we have a technique now of resurfacing a metatarsal head because the argument is always been where is the majority of the disease. It’s on the head. There’s really no implant that I’ve ever used that I’m satisfies with by placing something on the head to resurface it. Now, I want to show you. Here’s again.
[14:58] Unfortunately in this presentation I didn’t have the picture to show you that we’ve gone back in a year after surgery then have the opportunity to look at the metatarsal head. And we see highly in cartilage taking over where this acellular dermis had been placed. So it’s very positive that we’re looking at how to resurface joints, keeping in mind the disease can affect the sesamoids, the head and the base of the proximal phalanx. So this is just a little thought of getting your head out of your back side. Keep your mind open. I always like to try to introduce techniques and technology that my residents look at me like I’m half nuts which is okay. Because the end result is experience, experience, experience. And then go back and then look at your results determine if in fact you’ve applied the methods that make sense. I try to incorporate biomechanics and surgery in every procedure that I do because you can’t separate one from the other. Thanks for your time.