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Guido LaPorta, DPM, MS
Director Podiatric Medical Education
Community Medical Center
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TAPE STARTS – [00:00]
Harold Schoenhaus: Next two lectures that will be given will be provided by Dr. Guido LaPorta, who has been a faculty member at present from the beginning. He has been a friend of mine for probably 45 years. We have been considered academicians. We have incredible discussion on various things to try to improve outcomes and results. He is the chief of foot and ankle surgery and director of the podiatric residency program in Scranton, Pennsylvania and director of the residency program in Lady of Lourdes in Bennington, New York. He will be giving two topics, one dealing with hallux rigidus implant versus fusion, the other is CORA [Phonetic], which is an interesting discussion that you should be well aware of. So please welcome, Dr. Guido LaPorta.
Dr. Guido LaPorta: So the last interesting discussion that Harold and I had was whether or not we should get an Aston Martin and he won that one. Ross, if I send a picture of my patient shoes to the lab without them knowing, did I violate HIPAA?
Male Speaker: No. They already did successive agreement.
Dr. Guido LaPorta: Okay, just wanted to know that. Alright. So we’re going to talk about two things hallux rigidus and we’re also going to talk about CORA. Hallux rigidus is an interesting topic and I’m going to say some things that you might consider bias and you would be right because they are. Because I’m going to give you what my concept is of this whole thing over the years that I’ve been practicing, which now is unfortunately approaching 0. Here’s what happens. I think that the same conditions that produce hallux valgus also produce hallux rigidus. I ask the residence why does hallux valgus forms? The answer is simple. It has to and it can. What does that mean? That means that there is limited motion at the first metatarsophalangeal joint. The patient either because of their vocation or avocation needs more motion. It doesn’t have it at the joint. The first ray can get out of the way uncover the sesamoids, the join starts to move again. They form hallux valgus because they can and they have to. Now some patients have that same limited motion, but all their first ray does is go up in the air, it elevates. It can’t get out of the way. The metatarsal can’t rotate. So you have hallux rigidus. Hallux limitus is leading to hallux rigidus. The only two things that produce hallux rigidus that don’t produce hallux valgus or primary osteoarthritis impose traumatic arthritis. Everything else is basically the same. And when you read down this etiology list, you can ascribe the same etiology to hallux valgus that you can hallux rigidus. Then you come to classifications. How many of you use this? I think we both thank ourselves on this little issue. Do you mean if somebody is 55 degrees motion they have a moderate hallux limitus, and if they have 56 degrees they have a mild hallux limitus, I don’t think so. I think there’s a better classification that you can use that potentially helps you treat this patient, pick the right treatment program whether it be orthosis, whether it be surgical intervention, whether it be a combination of the two. And one of those things is, I have four classifications of hallux rigidus. The first is normal joint bad biomechanics. You have something that is elevating the first ray, limiting the range of motion and the patient has symptoms. When you examine that patient the joint pristine. You look at the x-rays, nothing is wrong with the joint, but you find a biomechanical abnormality that is producing that particular problem.
The second grade is one where there are arthritic changes but it’s outside the joint. It doesn’t involve the cartilage. You have periarticular spurring osteophytes, eburnation, et cetera, plus the biomechanical problem and that’s the kind of joint you can save without too much problem. The third is you have arthritic changes within the joint, the joint is appreciably narrowed and it’s worn out, and if you can save it, pretty much depends on when you see that patient. And the fourth is end-stage arthrosis. There’s very little problem in recognizing end-stage arthrosis. But the stage of arthritic changes throughout the joint follow this pattern, sooner or later, you’re going to see flattening of the first metatarsal head. Very early on, you’re going to see dorsal exostosis. You may or may not see loose bodies. The joint usually narrows make sure the joint narrowing is not your x-ray ankle. Think about this. If you’re taking all your x-rays at 15 degrees to the foot and the first metatarsal in that patient, when they stand is almost parallel to the ground, you’re overlapping the phalanx and the metatarsal head. Your narrowed joint may in fact not be a narrowed joint at all. Take a zero degree view to the joint and look through the joint space or look on the lateral. Does the lateral in the DP match? Because sometimes the joint looks great on the lateral, the joint space and you don’t see it at all on the DP. It’s purely a function of the angle of the x-ray being. So when you look at surgical considerations, you got to look at a few different ways to approach this. You can either salvage the joint or you can destroy the joint. And salvaging the joint will involve anyone of a number of procedures. The typical joint destruction procedures, when I was growing up and Harold was growing up, Keller was on the top of the list, and then that was followed by implant arthroplasty after Swanson introduced the celastic hemi, and nowadays, probably on top of the list is an arthrodesis for that particular joint. As far as joint preservation, you’re looking at colectomies, you’re looking at various osteotomies, whether or not they will plantar flexed metatarsal. Whether you do it at the metatarsal level, the joint level or the cuneiform level, you’ve got to get the metatarsal down in most of these particular cases. Whichever procedure you choose, your goals are the same. You’re trying to alleviate pain, you’re trying to gain motion if you can with the exception of the arthrodesis. And if you’re doing an arthrodesis, you want an adequate fusion. I could never understand that. You want a fusion, you don’t want an adequate fusion. You want a fusion. And you want to try to be able to impart some long-term results to this patient and each of these procedures is different in that regard. Let’s look at some joint destructive procedures, because it’s not all of just fusion. Fusion is certainly a part of that but as I mentioned the Keller arthroplasty, the Valenti arthroplasty, which Harold and I were taught by. Valenti, if you’ll believe that, in Rome, in the ‘80s and I was looking at the list of lectures, I see you’re going to get a lecture on the Valenti on Sunday and it’s a very interesting procedure. Fusion as I mentioned and implant be a total or hemi. So the Keller arthroplasty has some advantages. I get a kick out of the things saying it’s technically easy to perform. The next line should say it’s difficult to perform well.
So you can perform it easily but balancing this is very difficult and it will eliminate joint pain. The patient is allowed to bear weight immediately without any ill effects on the surgical procedure. It does eliminate retrograde forces on the first metatarsal. So consequently, you tend to see some reduction in the intermetatarsal angle when performing a Keller. And when people have cystic bone and you’re worried about them fusing, you’re worried about them supporting an implant, it may be a good choice. But it does have some disadvantages. You really lose control in most cases over the first MTP joint, in most cases, you lose toe purchase. And from a cosmetic standpoint, shortening can be a drastic result for some patients. In fact, you can have elimination of pain ability to wear shoes. You can restore all of that. The toe can shorten if the patient didn’t know that was going to happen. They’re not pleased with the procedure at all. So if you look at the literature, there were a lot of things that have been proposed to improve the results of Keller. The K-wire intramedullary placed in order to hold that until soft tissues heal. One of my mentors, Jim Ganley, always did a soft tissue interposition graft and reattached the short short flexor to the base of the phalanx. In fact, he did Keller procedures on a patient you would probably say didn’t require joint destructive procedure and that excellent results with his soft tissue techniques. One of the problems is that you obviously most length in the long extensor. But let me add this to that. The long extensor when it’s tight is a deforming force when the patient is sitting down. The long flexor is a deforming force when the patient is walking because it has to eccentrically lengthen when the patient takes a step. If it can’t do that, it’s a deforming force also. So do you lengthen the long flexor when you do a Keller? The Europeans do interestingly enough. That’s never caught on in this country. So you can see all kinds of results, some of which are very difficult to salvage and most of them require effusion salvage. So there’s that subset of docs who say, “Well, if the salvage for this is effusion, why not just do effusion in the beginning?” Get it over with, make your next procedure, your last procedure and not worry about function, because people function well with fusions even sporting activities. Valenti arthroplasty, as I mentioned, Valenti taught Harold and I this and they came over to Hershey one year and did it in the cadaver lab. What it is, is an exaggerated V resection arthroplasty. You take a fairly good size honk of bone of the metatarsal and a similar amount of bone of the base of the phalanx so that you create about a 75-degree defect dorsally after you excise this bone. What Valenti taught were the very most important parts of this procedure was not to remove the plantar aspects of either the met head or the phalanx. He left the plantar met head in order to show that the sesamoids would have an articulation and he left the plantar phalanx so that the short flexor would retain its insertion into the base of the proximal phalanx. This is not a procedure for young aggressively active individuals. This is more procedure for sedentary individual. First MPJ arthrodesis, obviously, you have to denude the met head and the phalangeal base. How you do that is really surgeon’s choice. Most of the plating systems now have reaming tools so that you can do it that way if you wish as opposed to cutting a flat surface.
There are some inborn advantages to that and that you can set the position of the hallux the way you want it and not have to worry about your crock being exact and you can fixate it almost anyway you want it, but remember one thing, the literature says the most effective fixation for this procedure is a leg dorsal plate. So if you do it a different way, have some support for that method. It exists. There are articles that describe all kinds of fixation for that procedure, just have some port. One thing Jim Ganley always taught me was that if I was going to do something that might be considered stretching it a bit, if I could find an article that supported that, I would put it in the patient’s chart and today, I scan it into their medical record so that I have quick access to that should it ever be needed. What are the advantages of an arthrodesis? The obvious, it eliminates pain, provides good stability, not only to the joint but also retrograde, allowing their first ray to their weight. You can maintain the length of the medial column and it’s a definitive procedure. It’s over. The disadvantages are you lose motion if that’s a disadvantage. Some patients think it is, refuse to have a fusion done, so then you have to look at other options. Now this non-weightbearing four to six weeks, using the interfrag screw and locking plates or non-locking plates, they don’t all have to be locking, we actually have our patients bearweight in a 4 foot relief shoe as soon as they want to. And we’ve seen no difference in the post-operative management of those patients than when we use to keep them non- weightbearing for 4 to 6 weeks. Regardless of how you fix it, do the procedure or manage them post-operatively. The nonunion rate in the literature is 8% to 10%. I don’t care how you do it. You can look at any article you want. The nonunion rate is 8% to 10%. So apparently, you should be doing what you do best because that in fact is what counts. If you’re doing reduce, you may require graft that can be problematic. It adds a few other things that can go wrong to the procedure. But here’s an end-stage, just for an example, end-stage arthritis joint, it’s reamed. The base of the phalanx is easy to ream. You use the same size. The head of the metatarsal is problematic because none of these reamers seem to be the right size. If you use the reamer that appears to be the right size for the met head, by the time you get down to the cartilage in the middle of the joint, you’ve created a pencil. You don’t want to do that. So we use a wider reamer first. So we get the middle of the cartilage on the apex of the head and then switch to the correct size reamer so we can get the periphery and we can preserve the length of the metatarsal head. This type of plate is being use and this basically allows you to put an interfrag screw through the plate. Here you see it in place. The interfrag screw is placed and then the distal screws are placed. Typically, if you look at this theoretically, this is going to fail on the bottom when it fails. If you are going to put a plate on this, you would typically want to put the plate on the tension side of this whole problem. That happens to be the bottom. You can’t do that. You have to combine interfrag with locking or non-locking plate, or if you use a non locking plate, prestress the plate so that when you drive at home you compress the opposite side of the fusion and not just the side right underneath the plate. This is the constructed as tested the strongest for this type of fusion. Here’s an interfrag outside the plate perfectly acceptable.
And what position do you fuse this in? Always the question. And when you read this or when you ask somebody what that position is, well I fuse it 10 to 15 degrees dorsiflex. And my next question is, to what the floor, the first metatarsal, because you’re assuming when you refuse it 10 to 15 degrees dorsiflex that all metatarsals are 10 degrees plantar flexed so that the hallux balances it up, but that’s not the case. I think a more correct answer and a more functional position is to place a weight supporting surface under the operated foot and allow the hallux to be weightbearing and fuse it in that position. And if you do that and they requires a motion, they’ll get it at the IP joint. But if you fuse it in a higher than that, the first thing that happens is that they can track their IP joint, they start getting symptoms there and that becomes problematic, patients aren’t real happy about that. So I usually recommend that it be fuse by resting against the weight supporting surface. You can also use it in geriatric hallux valgus, very good procedure that allows you to reduce the intermetatarsal angle. And if the patient has any joint space narrowing arthritis then it’s a doubly good procedure because it allows you to address both of those. The fixation summary is prepare the joint well, interferag screw plus the plates. Plates rarely require bending. The rate of hardware removal is 4%, the rate of nonunion is 8% to 10%. Stimulate weightbearing intraoperatively to give you the appropriate fusion angle and the proximal phalanx should be parallel to the ground. About implants, let’s switch gears a bit. And there are a number that you can use interpositional. You can use it as an adjunct to a resection arthroplasty, as I mentioned before. There’s a total joint replacement resurfacing both surfaces of the joint or there’s a hemi-implant, either metallic or celastic which allow usually for immediate ambulation afterwards. I’m a fusion guy but I wouldn’t hesitate to use an implant in the right person. When I do, I try to use a hemi. Most of the total joint systems remove too much bone and the only thing I think about when I’m doing a procedure is how am I going to salvage this if it goes bad and I would rather remove less bone at the first MTP joint so my salvage won’t require a graft, then use a total joint system that is much more than joint resurfacing. They all call them that but they’re not that. They’re not a resurfacing procedure. You resect bone and then put the total joint system in. The only thing even close to a joint resurfacing is an arthrosurface. Alright. So the definitions of implant, you can have a flexible hinge implant, those were the original. Swanson was the original design and you can have two component implants which have a phalangeal and a metatarsal side. The indications were obviously are in fact discussing hallux rigidus. What is most important is to tell you what not to use an implant for. Don’t use a hinge implant to reduce an IM angle. It’s not designed to do that. It will eventually wear out, not the implant, the bone. So the fallacy is when the implant starts to go then we’ll in fact take it out and replace it. The problem is they rarely hurt when they start to go. And by the time you see it, it’s the bone that’s gone, not the implant and then you’ve got to talk about grafting and it becomes a very involved procedure.
The biomaterials are anything from stainless steel, cobalt-chrome, titanium and ceramics. Ceramics really haven’t been tested in the foot very well. There is a device in Germany which is now being tested. It has allowed much more motion, but it has a ceramic problem. It’s a little bit on the brittle side and it squeaks. So that could be an issue. Alright. You remember the Swanson hemi-implant? Still an effective design. Philip Basile in New England still uses the Swanson hemi-implant made out of celastic in his elderly patients who have little demands on their foot. And the only thing I’ll mention is the only design that caught on as an addition to that was the wild modification of that which was use because most of the people who got this, once you remove the bump and once you corrected the intermetatarsal angle, they had a gap on the DP x-ray. What they had was an abnormal joint orientation angle and the wild design was designed to fit that in. So whether you decide to do fusion or implant, I think both are indicated. The literature supports the use of both. Just be judicious in figuring out your indications. And the most important thing to me is what the demand level is of that particular patient. So if have somebody who’s a roofer or works on construction, they’re not getting an implant. They’re getting fused. If I have someone who works in the garden and at most goes for one or two block walk three times a week, I might consider an implant, because it’s the easiest thing for them in the immediate post-op period and it keeps them functional.
TAPE ENDS – [27:18]