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1st MPT arthrodeses and Immobilisation

Discussion in 'Foot Surgery' started by rosherville, Jun 12, 2010.

  1. rosherville

    rosherville Active Member


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    Following an arthrodesis it was always normal practice to immobilise the foot, usually with pop, for around 6 weeks; treating it as a fracture.

    Of late I am hearing from some quarters that research shows that immediate mobilisation and weight bearing, within a post-op shoe, has just as good outcomes as does 'resting' the site. Part of the motivation is that non casting saves time and money !

    I have recently come across some mal & non unions where this approach had been adopted, revision with casting resulting in good union.


    Am I too sceptical in not wanting to follow this course, believing that 'perfect' fixation would be necessary for a start, and that the 2 crossed screws technique requires some post-op immobilisation ?
     
  2. Good question. When I first started performing 1st metatarsophalangeal joint (MPJ) procedures 20 years ago, I had them non-weightbearing (NWB) for 6 weeks with crutches and used 2 screw fixation (cross screw). I am doing these 1st MPJ arthrodesis procedures much more frequently now with a dorsal plate and cross screw fixation which is a much more stiff surgical construct. Myself, and many of my other podiatric surgeon friends, are weightbearing these patients in a post op shoe fairly early. I have the patient use crutches with a post-op shoe for two weeks with touch down pressure then they walk full weightbearing on the foot with or without crutches and the post op shoe starting at 2 weeks post op. Without the plate fixation, I don't think I would be near as confident to weight bear these patients early. One of my very good podiatrist friends at Kaiser weight bears his patients immediately without crutches in a post op shoe. I'm not that brave yet.
     
  3. drsarbes

    drsarbes Well-Known Member

    Hi Kevin:

    Still fusing?

    With the implant they could be walking in regular shoes at two weeks, and have a toe that bends to boot!!!!!!!

    I just have to say (again) that the trend in every other joint in the body is to save it or replace it - except the 1st MTPJ.

    Why is that?

    Steve
     
  4. Steve:

    I am not alone in my preference for 1st MPJ arthrodesis surgeries vs implant surgeries. This is a common procedure here in California. Also, podiatrists like Drs. Tom Chang, Richard Bouche and Tom Roukis (all friends of mine) use the procedure regularly and prefer it over implant arthroplasty. It is a predictable, long-lasting procedure and I have patients running marathons and dancing 3-4 times a week with my 1st MPJ arthrodesis procedures. What type of procedure do you prefer for end stage DJD of the first MPJ?
     
  5. drsarbes

    drsarbes Well-Known Member

    Hi Kevin:
    How are you?
    I don't doubt the popularity of the procedure.
    I only quest why?

    It seems to me that we go out of our way to accept first MTP joint fusion when
    every other joint, even the ankle, is "progressing" in the implant category.

    We - in fact- test and treat 1st MP joints that have less than optimal range of motion, even to the point of describing secondary symptoms due to altered gait, but then have seemingly no qualms
    in fusing this joint and calling it a success when it has zero ROM!

    Again, why is that?

    Kevin, I don't really care who is fusing these. That's not the point and name dropping does not strengthen your position. The point, quite simply, is why fuse this joint when you can perform a procedure that will give the patient a normal functional first ray?

    Steve
     
  6. Steve:

    I don't know of a single implant procedure for the 1st MPJ that creates a "normal functional first ray" without causing some other problem or needing revision within a decade. Do you? A close analysis of the literature will show that 1st MPJ arthrodesis is the most long lasting and satisfactory procedure for most patients.
     
  7. bob

    bob Active Member

    In my hands, a 1st MTPJ fusion has relatively predictable results, fewer complications and is technically easier than an implant. My preference is 2 crossed screws and I routinely use a slipper cast for 6 weeks post op. If I use a locking plate and crossed screw, I'll mobilise after 2 weeks (but I usually use these for cases where I predict they may have a greater chance of delayed/non-union so immobilise for 6 weeks in slipper anyway).

    Although, Steve's got a point about preserving motion. It's a shame that I don't have faith in the current implant technology - but I probably haven't done as many as Steve?

    Steve - what are your indications for 1st MTPJ implant, what's your prefered implant and what's your post op protocol?
     
  8. The ankle arthrodesis is still the standard surgical option for end stage DJD of the ankle joint even though ankle implant arthroplasty may be gaining favor in some regions. The subtalar joint arthrodesis is still the standard option for DJD of the subtalar joint. The first metatarso-cuneiform arthrodesis is used by many podiatrists as a viable way to treat hallux valgus deformity. The proximal interphalangeal joint arthrodesis is still standardly done for many hammertoe correction surgeries. Why is it so hard for some podiatrists to accept the fact that patients actually function quite well with a properly performed 1st metatarsophalangeal arthrodesis? What is their hang-up with fusing the 1st metatarsophalangeal jiont when they routinely perform arthrodeses on other joints of the foot and ankle? I don't quite understand it.

    Here is a good article on 1st MPJ arthrodesis versus 1st MPJ implant arthroplasty procedures along with references which support my contention that the 1st MPJ arthrodesis is a predictable and functional procedure for the active patient.

    http://www.podiatrytoday.com/can-locking-plates-improve-first-mpj-fusions

    And here are some comments on Podiatry Management on the same subject.

    http://www.podiatrym.com/search3.cfm?id=5162
     
  9. bob

    bob Active Member

    I don't disagree with many of your points Kevin, but I feel you should be cautious in using 1st met cuneiform arthrodeses for treatment of hallux valgus as part of your argument. I personally perform that op for HAV in the presence of a large IM angle, but I do not feel it is a 'one stop shop' for surgical management of hallux valgus. Isn't there a Christensen paper on reduced 1st MTPJ ROM post 1st MCJ fusion?

    I guess the point is that fusion may well be the 'gold standard' or standard surgical option for DJD for a great many joints, but doesn't this just reflect the relatively poor technological advances in joint implants for the foot up to this point in time?
     
  10. drsarbes

    drsarbes Well-Known Member

    "I don't know of a single implant procedure for the 1st MPJ that creates a "normal functional first ray" without causing some other problem or needing revision within a decade. Do you? "

    Obviously I do or I wouldn't be performing. them. And I would submit that an iatrogenic hallux rigidus does not yield a normal functioning foot.

    I will not go into the "in my hands" since this serves no real purpose. The fact is joint replacement when done correctly will give good - LONG TERM, results. If you're comfortable with fusions, fuse on. I'm sure you can fuse a knee as well and relief the patients joint pain. It doesn't make it a procedure of choice does it.

    As for ankles........gold standard?.....tell me the gold standard in 10 years. I doubt it will be fusion.


    Steve
     
  11. For someone who advocates restoration/optimising of lower extremity function at every opportunity (and rightly so!) - this is really a surprise, Kevin. I had a young 26y/o girl in to see me this morning who had recently undergone bilateral 1st MTPJ arthrodesis by a local orthopaedic surgeon (shoulder specialist) privately - and who now has great difficulty playing netball (semi-professionally) and with referred pain in her ankles and knees. For me, this procedure on this particular patient I would almost suggest is negligent or indeed malpractice. I would agree with Steve that 1st MTPj implant surgery with immediate mobilisation would be my preference for HR. Would even suggest TJR is a worthwhile revision procedure for 1st MTPJ arthrodesis!
     
  12. OK, everyone, just calm down. I don't perform 1st metatarsophalangeal joint arthrodesis surgeries on all patients with DJD of their joint. The original question is why I would ever perform this procedure. My answer is that it is a good procedure and this is not only supported by the literature but also by current podiatric and orthopedic practice around the United States.

    Mark, want to talk about surgical failures/disasters?....I've seen plenty of disasters from Kellers and implants. If arthrodesis is such a bad procedure, then why is it gaining popularity across the United States? Anyone want to answer that question? Patients with a properly performed 1st MPJ arthrodesis function incredibly well and you obviously have never seen a patient before and after this procedure and the amazing positive gait changes that occur with a properly performed 1st MPJ arthrodesis. Your young 26 year old probably should have never had a fusion and I have never performed one on a person this age. But this does not make it also a bad procedural choice for the 65 year old lady with a hallux varus deformity that could hardly wear shoes and hugged me 4 weeks after her surgery since she was already walking pain free in shoes for the first time in 6 years after my 1st MPJ arthrodesis surgery on her. Or how about the 62 year old Iron Man Triathlete that I performed a 1st MPJ arthrodesis on 6 years ago and competes regularly running marathon distances with his fusion. He loves it and I'm doing surgery on his wife once I get back from vacation.

    Steve, the knee fusion example you have been using in these discussions is ridiculous and getting old. Instead of using such a ludicrous example, why don't you use the example of another lower extremity joint that you do fuse regularly and ask yourself why you don't use a joint implant in these cases also?

    Even though I am on vacation in Kauai with my family, this discussion is kind of fun.....gives me something to challenge me between sipping Mai Tais, snorkeling and hiking with my family. See photo taken yesterday evening....four generations enjoying the sun and water of Kauai.:cool:
     

    Attached Files:

  13. Popularity is not a good outcome measure, Kevin. The Keller's was a very popular procedure in the UK in the 1970s and 80s for HAV - as was Zadek's procedure for ingrown toenails. I can't think of many patients I have seen over the past 30 years who would thank you for having either procedure. Why is it gaining popularity in the USA? Firstly, I would have to ask how you know that it is - and if I were to hazzard a guess I would say - more simple to perform; lazier surgeons; greater number of obese patients requiring 1st MTPj surgery.
     
  14. bob

    bob Active Member

    Steve - please can you tell the board which procedure you're doing, your indications and your post op protocol? I totally agree with Kevin and his stance on your knee arthrodesis comments. Please give us a small amount of credit and enter into a reasonable discussion about this. I am genuinely willing to learn from your experience with implants and I for one am keen to provide my patients with a reasonable alternative to fusing any joint. My point regarding the 'in my hands' comment is that I have got good and bad results from both procedures, but better long term results from a fusion. I feel this may be due to the life span of some of the double stem silicone implants I have been using and their 'hinge' design not replicating true 1st MTPJ function. Don't get me wrong, in the right patient, it works really well.

    Mark - the indications for (I am hoping I speak for podiatric surgery in the UK on this) a 1st MTPJ fusion do NOT generally include fusing the joint of an active 26 year old. You don't go to your local butchers and ask for half a pound (or kilo these days) of apples do you? Go to an orthopod specialising in shoulders for foot surgery and get a 1st MTPJ fusion indeed. Poor girl. It is possible to revise this as an implant, but this will be complicated by the original surgery and may have to be revised at a later date given her young age anyway. It would be interesting to see her pre-op x-rays and work up to surgery as I doubt she would have had late stage hallux limitus/ rigidus sufficient to warrant any such joint destructive surgery. I'm guessing the original surgeon's options for any stage of osteoarthritis of the 1st MTPJ consist of cheilectomy or fusion!

    Kevin - get off your computer! You are completely insane! Go and spend time with your family on your holiday in your lovely surroundings and stop thinking about work for a little while. You guys in the states get about 2 weeks a year out of your office (or something crazy like that) - enjoy the time away. I hope you have a great vacation ;)
     
  15. Worse than that, Bob, she had mild HAV with a normal MTPJ ROM! Asked why he performed an arthrodesis, his reply was "she's got a nice stright toe, hasn't she?!" Looks like a (regrettable) revision with our friend in Rochdale, methinks. :mad:
     
  16. bob

    bob Active Member

    What a pillock. Hope he has his shoulders fused as he gets older! I hope the revision is podiatric and goes well. Still, they say you can't polish a turd, so the patient needs to be councilled on their potential outcomes - they will never have a 'normal' 1st MTPJ again and might want to put this to their original surgeon who fused a normal joint with mild HAV. If I was the expert witness, I'd struggle to defend his choice of surgery and I feel she has a strong case based on the limited information. :confused:
     
  17. Don't worry too much about me, Bob. All my postings today were done before and after I took a four mile run and before the rest of my family had got out of bed. We're going snorkeling at Tunnels (see photo below) this morning.....once everyone else wakes up.;)
     

    Attached Files:

  18. bob

    bob Active Member

    See attached. Sorry Kevin - I don't think I can respect your judgement anymore given your preference! :D
     

    Attached Files:

  19. bob

    bob Active Member

    Update from Kevin Kirby -
    "Wish I was on podiatry area rather than here!"
    :D
     

    Attached Files:

  20. Even though I am a male, I am able to also multitask.;)
     
  21. drsarbes

    drsarbes Well-Known Member

    Hi All
    Ok, I'll make just one more comment, and only because Kevin is egging me on (he's quite good at that!)

    "Steve, the knee fusion example you have been using in these discussions is ridiculous and getting old. Instead of using such a ludicrous example, why don't you use the example of another lower extremity joint that you do fuse regularly and ask yourself why you don't use a joint implant in these cases also?"

    Kevin, I use this example for a very good, NON RIDICULOUS, reason. Knee arthrodesis is NOT common anymore simply because of the advent of knee replacement arthroplasty. It's a very good comparison.

    SO..........the obvious question is.........the one I already asked.

    (AND - I WISH I could run four miles!)

    Steve
     
  22. bob

    bob Active Member

    No,

    I'd prefer answers rather than the same question. Given that there are a variety of different options for implant arthroplasty for the 1st MTPJ and you claim good results from your choice of your procedure (in your hands) I'll ask again (politely) that you share your indications, type of implant and post op protocol with the rest of the board please?

    My favourite thing about podiatry arena is the chance to discuss real, practical tips that can (almost immediately) help all our patients so it would be great if you could help us (at least me) and provide some answers to my questions.
    :bang:
     
  23. Sorry Steve, I'm too young to remember knee arthrodeses ever being used for knee DJD. I forgot you are quite a bit older than me.:cool::rolleyes::drinks
     
  24. drsarbes

    drsarbes Well-Known Member

    Kevin: Touche ( and I'm pretty sure I feel older as well, although I did break 80 yesterday)

    Bob: Sorry, I wasn't ignoring you, I didn't see your question.

    I've been doing the total joints since around 1985, replacing the hemis I was using before that.
    Not sure if there is enough space here to answer your question fully, but I'll try.

    Criteria: pain in the first MTPJ limiting the patients activity level; A joint too damaged to expect good, long term results from a debridement;non osteoporotic; no general health contraindications. I tell all these patients that they may need a replacement-replacement in 15 to 20 years. (I've replaced quite a few, very simple to do)

    For the past few years I have been using the Lawrence design total joint (I believe Astra now distributes this) before that I used the LaPorta design. No Grommet. Neutrals.

    My two basic Pearls of the procedure itself: first - take out more (usually at the base) than you're replacing; two, be aware of a long and or dorsally mobile first ray preoperatively so you can adjust the implant if needed.

    Post op: simple. I stress to all my patients that they need to be compliant. If they cannot I do not do it. It's very important to get these patients into a tennis shoe in 14 days with ROM exercises. They walk as much as their foot allows, daily, and they walk with a heel to toe gait as soon as possible.

    I think it's important to remember that many of these patients have not used a normal gait for years. They need to reeducate themselves. I instruct on normal gait and what that entails. One simple teaching image I have found helpful is to have them imagine a bug under their first metahead and they need to squash the bug with each step.

    Not complete..but I can only type for so long.

    Hope that helps Bob

    Steve

    ps: one more "pearl" in the procedure itself; thin the capsule (remove synovitis) but do not resect too much. You need the capsule very loose.
     
  25. rosherville

    rosherville Active Member

    mmmmm. I seem to have set something off !

    I only asked about post-op arthrodesis immobilisation and received only one answer. Would like to hear from anyone who doesn`t believe in immobilising the 'fracture'.
     
  26. drsarbes

    drsarbes Well-Known Member

    Rosherville!!!!
    HAHAHA
    You are right!
    Tangents. Aren't they wonderful?
    Sorry about that.
    The answer is, do the implant and let your patients walk as much as they'd like.
    Steve
     
  27. bob

    bob Active Member

    Cheers for the reply Steve.
    I use a double stem silastic implant (similar to a Swanson) with no grommets. When you say "...be aware of a long and or dorsally mobile first ray preoperatively so you can adjust the implant if needed..." how do you adjust for this? What's your incidence of transfer metatarsalgia? I don't do that many implants, but I generally try to resect minimal bone from the metatarsal head in an attempt to maintain a normal met parabola and hopefully minimise transfer metatarsalgia (see quite a bit from some local surgeons who are more happy to offer implants than I though!).
    In the first 14 days post-op do you have the patient's non-weightbearing?
    I tend to have them 7 days non-weightbearing, then begin exercises for 1st MTPJ ROM and begin weightbearing - increased after week 2. Although I do try to get them to start flexing and extending the hallux as soon as the immediate post op pain has reduced.
    I do get good result with my implants generally, but I am very conservative with my patient choice. :)
     
  28. bob

    bob Active Member

    Whether your resecting the joint surfaces, doing a congruent fusion or using some sort of reamer, the fusion site is not compressed by weightbearing, so I can not see a reasonable argument for early weightbearing. I'd like to see some research on non or delayed union rates (in a reasonable number of patients across different centres) in patients with (for example) 2 weeks non-weight bearing vs 6 weeks. Having done quite a few of these procedures over the years, I'd rather err on the side of caution - rather get it right 1st time than 2 or more procedures.
     
  29. docbourke

    docbourke Active Member

    The argumeny for fusion vs replacement still has a long way to go. The prosthesis for 1st MTP replacement are in their infancy and with improvement may prove to be clearly beneficial but at the moment they are a little unpredictable. I have performed over 200 1st MTP replacements over 10 years and 100 fusions. If they are both pain free the replacement patients are happpier because of the movement but the fusion patients overall seem to have a more reliable pain free operation. If you cant get 30 degrees of dorsiflexion then you may as well fuse. I use plate fixation for my fusions and both patients spend 6 weeks full weight bearing in a post op heel walking shoe.(see post ops hoe biomechanics thread)
    Gerard Bourke
     
  30. drsarbes

    drsarbes Well-Known Member

    Hi Gerard:
    "The prosthesis for 1st MTP replacement are in their infancy......."
    I wouldn't say INFANCY! They have come a LONG way since the first Sutter hemi I put in in 1978.
    In fact it was a year earlier I scrubbed in on my first (and the orthopods first) knee replacement.

    I think they have both come a long way.

    Can I ask why you say they are unpredictable? Do you mean the amount of ROM you get? Symptomatically? both?

    Bob: To answer your question: I do tweak the placement if the first met is dorsiflexed and long. I tend to make the metahead cut more aggressive (take more head) and more plantarflexed. Of course it matters which implant your using. It was a bit easier with the neutral LaPorta than the Lawrence (which is made on a dorsiflexed angle.)

    Steve
     
  31. docbourke

    docbourke Active Member

    The unpredictability lies in the ROM, pain relief, sesamoid pain and radiographic appearance as the years progress. The instrumentation is not reproducable especially compared to a total knee (I do 30 knee replacements a year). The prosthesis have design faults especially relating to sesamoid impingement, sizing and dorsal shape to encourage full dorsiflexion. I enjoy joint replacement surgery and am persevering but patients have to be counseled preoperatively that it is an operation with unknown long term outcomes and may need revision surgery as the years progress. I think we should continue to perform replacements but it is important we follow patients up and report problems so that the overall result can be improved.

    Gerard
     
  32. drsarbes

    drsarbes Well-Known Member

    Hi Gerard:
    I gather you're an orthopod since not many of us lowly pods do knee replacements!
    I'm wondering: On the cases where you either have sesamoid pain and/or decreased ROM, do they have anything in common? Have you found any preop finding in your evaluation that might allow you to predict these poorer outcomes?



    Steve
     
  33. Gerard:

    Welcome to Podiatry Arena.:drinks:welcome:

    My current system for performing 1st metatarsophalangeal joint (MTP) fusions is the Integra Hallu-Fix system. The plates are angulated in the sagittal and transverse planes. These plates only need to be bent (i.e. adjusted) slightly introperatively in about 50% of cases. The best part about the system, however, are the reamers, one concave for the metatarsal head and one convex for the proximal phalanx base, that are used with a power drill that makes the accurate removal of the cartilage for both the metatarsal head and proximal phalanx base about a 4 minute process, versus a much longer time for "hand sculpting" that I was originally trained on. I introduced this system to the orthopedic surgeons I work with and they have found it to be much more to their liking than their prior procedures for 1st MTP fusion. And, no, I don't have any financial interest in Integra....it's just a good product.

    Don't know whether it is available in Oz or not?
     
  34. docbourke

    docbourke Active Member

    Kevin I use the Fyxion plate (EOS surgical a French company and I get no royalties) as it has an outrigger that allows a screw to cross the joint built in so that it is truly a compression plate. The Hintegra is not out here. The reamers are useful but I am very wary about taking too much bone and shortening the first ray otherwise transfer lesions are common.

    As far as the 1st MTP replacements I routinely debride the sesamoids now to prevent impingement and have had much better results. If they are normal at operation (rare) i will consider leaving them alone. I also make sure the prostesis is very loose and does not overstuff the sesamoids.
    Gerard
     
  35. Gerard:

    Never seen the Integra system cause excessive shortening...all you need to do is to be careful on the drilling . The reamers do produce perfect matches of joint surfaces which is much better than I could ever do by hand sculpting with drill and saw. Also, never seen a transfer metatarsalgia to the 2nd MTP with an arthrodesis of the 1st, but have seen so much increase in 1st ray stiffness from the 1st MTP arthrodesis that mild sesamoiditis had resulted. I use generally a five hole plate with one or two intefragmentary screws across the plantar half of the joint and then patients are weightbearing fairly fully from two weeks on. Most of them are walking painfree after 4-6 weeks.
     
  36. drsarbes

    drsarbes Well-Known Member

    Hi Gerard:
    Perhaps you are taking a bit too much off the head, or on too much of a right angle to the long axis of the met.
    The Lawrence design is made to decrease this possible post op complication with distal segment dorsiflexed, thus you can make the metatarsal cut angulated more dorso-prox to plantar-distal.

    Also, the dorsal profile has been modified from the LaPorta design to a much flatter surface.

    Steve
     
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