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Gait changes after 1st MPJ fusion

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, Apr 13, 2006.

  1. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
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    Optoelectronic gait analysis after metatarsophalangeal arthrodesis of the hallux: fifteen cases.
    Rev Chir Orthop Reparatrice Appar Mot. 2006 Jan;92(1):52-59 [article in French]
     
  2. DaVinci

    DaVinci Well-Known Member

    Do they consider that a good thing in France :confused:
     
  3. davidh

    davidh Podiatry Arena Veteran

    IMO studies like this, which are carried out using very sophisticated equipment, but on small cohorts (n=12), are interesting, but meaningless.

    Less sophisticated equipment/a bigger cohort would be far more meaningful.
    Also, I'm interested in how accurate Vicon data is without the forceplates (as in ascending/descending stairs......... :confused:

    Cheers,
    davidh
     
  4. Craig Payne

    Craig Payne Moderator

    Articles:
    7
    I don't necessarily have a problem with smaller sample sizes in these types of studies - thats what we have p values for - to measure the "strength" of the association. It would be somewhat unethical to use a larger sample size if the strength of the relationship between variables is strong.

    CP
     
  5. davidh

    davidh Podiatry Arena Veteran

    Hmm..

    Let me look in my copy of The Big Boys Book of Statistics before I answer :cool: .
    Regards,
    davidh
     
  6. Lee

    Lee Active Member

    Hello David,
    Not quite sure which aspect of the vicon system's accuracy you're questioning. It's useful for 3d kinematic data collection (infrared cameras and retro-reflective markers) not kinetics (force plate). So you'll get as accurate kinematic data when ascending/descending stairs as on flat ground (as long as you've calibrated the correct volume and positioned the cameras so they pick up the right sensors for what ever space your subject's moving in).
    I'd be interested to see their marker clusters for the relative movement of the distal to proximal phalanx to assess pure IPJt movement. Bearing in mind, you'll have to have at least three markers per segment, I bet the noise they got was a nightmare. Also, I wonder how much movement you get of the skin on the proximal phalanx relative to its underlying bones. I've not read the paper yet, but it sounds interesting. Hopefully, they've included a picture of their marker set up. They also say in the discussion section of the abstract "Function of the interphalangeal joint was not assessed" so I think I should read the paper before further comment as they've concluded that the IPJt compensates for 1st MPJ fusion and I'm not quite sure how they've found that out if they didn't assess it's (the IPJ) function.
    Happy easter,
    Lee :cool:
     
  7. Did these researchers study the cohort before and after surgery, or only after surgery? It appears to me that they studied the subjects only after surgery and, if they did, what did they use for a comparison sample???

    I perform 1st MPJ arthrodesis surgery occasionally and have had very nice results on a routine basis. The thing that I have come to expect is that, after 1st MPJ arthrosis surgery, there is a increase in dorsiflexion stiffness of the first ray and medial column. This is likely due to the hallux now being in a constant slightly dorsiflexed position that, in turn, pretensions the medial slip of the central component of the plantar aponeurosis, thus stiffening the medial column. However, this could be caused by some other unknown mechanical reason.

    The last patient I had performed this surgery on is one of the top over-60 Ironman Triathtletes in Northern Californa. I did a cheilectomy of his first metatarsal about 15 years ago, did a shortening ostotomy of the first metatarsal about 7 years ago, and did the 1st MPJ arthrodesis about 3.5 months ago. He is now running, biking and swimming with no pain and is very pleased with all aspects of this procedure for his athletic and regular walking activities.

    Another patient I performed a first MPJ arthrodesis on about a year ago is a 42 year old that had a motorcycle accident about 20 years earlier and developed a plantarflexed hallux that did not allow a plantigrade foot (due to the surgeon at the time rerouting the EHL tendon to the first metatarsal neck). He competes nationally in water skiing and races mountain bikes. A few podiatrists in Los Angeles said that there was nothing that they could do for him. When he moved to the Sacramento area, he looked me up and I did the 1st MPJ arthrodesis procedure on him. He is now back to competing in mountain biking and water skiing, which he previously had to gradually reduce over the last few years due to plantar hallux pain. See below his preop and postop photos.

    If functional hallux limitus is such a terrible thing and is the "root of all evil" as some of my podiatric colleagues believe, then why do these patients who have surgically induced 1st MPJ "hallux rigidus" do so well with their foot in all types of physical activities?!
     

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    Last edited: Apr 17, 2006
  8. davidh

    davidh Podiatry Arena Veteran

    Craig,
    You said:
    "I don't necessarily have a problem with smaller sample sizes in these types of studies - thats what we have p values for - to measure the "strength" of the association. It would be somewhat unethical to use a larger sample size if the strength of the relationship between variables is strong."

    My "stats" bible (Practical Statistics for Medical Research - Douglas G Altman) defines the P value as the "probablility of having observed our data (or more extreme data) when the null hypothesis is true".

    I agree with you in principle, but I can't help but feel that this study has gone overboard on expensive equipment, but sold itself short of subject numbers, and perhaps study design?

    Lee,
    You said:
    "I'd be interested to see their marker clusters for the relative movement of the distal to proximal phalanx to assess pure IPJt movement. Bearing in mind, you'll have to have at least three markers per segment, I bet the noise they got was a nightmare. Also, I wonder how much movement you get of the skin on the proximal phalanx relative to its underlying bones."

    I've seen Vicon in action, but not used it myself. However, the fact that we are dealing with little joints, big markers, and skin movement, throws up a question on how accurate the reading actually are. Big difference between this, and looking at a combination of kinematic and kinetic data (force-plate and Vicon combined) when the reflectors are positioned on major joints like hip, knee and ankle.
    Cheers,
    davidh
     
  9. davidh

    davidh Podiatry Arena Veteran

    Kevin,
    You said:
    "If functional hallux limitus is such a terrible thing and is the "root of all evil" as some of my podiatric colleagues believe, then why do these patients who have surgically induced 1st MPJ "hallux rigidus" do so well with their foot in all types of physical activities?!"

    Just to make you aware that I go along with you on this one.
    The theory of FHL (which I bought into for quite a while) is just too neat and compact to be true.
    In my experience pretty much all the biomech problems which present clinically have an overridding frontal plane component, while the 1st MPJ sagittal plane component, if present at all, is usually very much a secondary feature.
    If the 1st MPJ is a real problem, I send for a surgical opinion.
    Regards,
    davidh
     
  10. B.Yates

    B.Yates Welcome New Poster

    Kevin and others
    There are 2 papers recently in foot and ankle international which support the idea that 1st mtp fusion works very well for patients with hallux valgus or rigidus.
    Brodsky et al "functional outcome of arthrodesis of the 1st MTP using parallel screw fixation". OF 53 patients (minimum 12 months post-op) 75% were able to return to jogging,92% hiking,80% golf etc.
    Couglin et al. "arthrodesis of the 1st MTPJ for idiopathic hallux valgus: intermediate results. 21 patients, 100% satisfaction, mean post-op 8 years. IPJ arthritis noted radiologically to have developed post-op in 7 cases but none were symptomatic.

    I routinely perform 1st mtpj fusion for end stage hallux rigidus (approx. 300 cases) and patients do extremely well with the procedure. I see far more symptoms of hallux rigidus compensation pre-op that I do post-op which i assume is because of the pain they are experiencing from the joint. I have had one case who deleveloped ipj arthritis that was symptomatic who required surgery.
    cheers
    ben
     
  11. Ben:

    Your observations are the same as mine. It is very interesting to me that many podiatrists get so excited over functional hallux limitus thinking it will cause pronation of the foot and that without normal windlass function the patient will have severe dysfunction of the foot. Once the arthrodesis procedure is performed at the 1st metatarsophalangeal joint (MPJ), then there is no hallux dorsiflexion so, in effect, the patient has a surgically induced hallux rigidus deformity in addition to no windlass function at the 1st MPJ. However, these patients seem to walk with improved gait function and can be quite athletic. If anything, these patients develop a higher medial longitudinal arch after the 1st MPJ arthrodesis procedure, not the lower medial longitudinal arch that the sagittal plane facilitation theorists have been proposing for many years.

    If it is a restriction of hallux dorsiflexion that indeed caused medial arch flattening as the sagittal plane theorists propose, then why would medial arch raising or medial arch stabilization occur when the hallux is completely prevented from dorsiflexing after the 1st MPJ arthrodesis procedure?? This is a major weakness of the sagittal plane facilitation theory and indicates, as I have been arguing for the past 10 years or so, that the restriction of hallux dorsiflexion seen with functional hallux limitus is not the cause of medial arch flattening, but rather is the result of medial arch flattening.

    With a 1st MPJ arthrodesis procedure, the hallux will no longer be allowed to plantarflex into the ground, relative to the first metatarsal, due to excessive tension in the plantar aponeurosis during late midstance that would have routinely occurred pre-arthrodesis. As a result, the increase in tension in the plantar aponeurosis that normally occurs in late midstance as a result of a rapidly increasing Achilles tendon tensile force will help stabilize the medial longitudinal arch (i.e. increase first ray dorsiflexion stiffness) after the 1st MPJ arthrodesis procedure, rather than causing first ray dorsiflexion and medial arch flattening pre-arthrodesis. This increased stiffness of the medial arch results from "tighter plantar supporting cable" in the form of a plantar aponeurosis that has greatly increased tensile force now during late midstance. This increased first ray dorsiflexon stiffness will cause greatly increased resistance of the first ray to dorsiflexion to weightbearing loading forces during late midstance which will cause the following cascade of events:

    1. Increase in magnitude of GRF plantar to the 1st MPJ

    2. Shift in the CoP medially toward the 1st MPJ

    3. Increase in magnitude of STJ supination moment in late midstance from GRF

    4. Normalize STJ function in the foot that may have otherwise been undergoing late midstance STJ pronation before 1st MPJ arthrodesis.

    I just wanted to get these thoughts off my mind and into written form so that it can be preserved for future reference. Thanks for the stimulus, Ben.
     
  12. Frederick George

    Frederick George Active Member

    While the theoretical implications are interesting, perhaps the overriding cause of observed improvement in foot function post mpj fusion is the elimination of foot pain. Alternative procedures that eliminate pain may do equally well.

    Although fusion is usually thought of as an end stage procedure, where the alternatives are Keller, or implant, I have seen several postoperative orthopedic procedures recently where the initial complaint was simple HAV with adequate preoperative ROM.

    Rather than MPJ joint fusion as a treatment for hallux rigidus, this would seem to be what the French study is exploring as "degeneration of the metatarsophalangeal joint . . subsequent to hallux valgus" is common to some extent in many bunion cases, where pain free ROM is adequate.

    Shorter steps, difficulty walking up steep hills, the inability to wear shoes with an elevated heel, compensation (jamming) of the IPJ with likely subsequent DJD and dorsal spurring, and reduction in propulsive gait don't seem to be the best of outcomes for HAV surgery. Trading Hallux Rigidus for Hallux Valgus seems a poor deal.

    Perhaps it again simply comes down to "do no harm." Or, doing the appropriate, least damaging surgical procedure to address the diagnosis. Dr. Kirby's three procedures on the same patient over a 15 year period is appropriate surgical management at each stage. Fusion 15 years ago perhaps wouldn't have been appropriate.

    Some surgeons may jump to early MPJ fusion, not just because it is technically simple, but because the bunion simply never comes back.

    This is akin to dentistry a couple of generations ago, when at the first sign of a problem, dentists commonly pulled all the teeth and replaced them with dentures because the teeth would eventually be lost anyway.

    Cheers

    Frederick George
     
  13. tarik amir

    tarik amir Active Member

    Hi Ben,

    A close colleague of yours as you know from Melbourne had 1st MTP joint Sx some months ago (it wasn’t a fusion). To date his inability to purchase the hallux to the ground has been causing lateral foot problems and really has been driving him mad. He said that improving hallux purchase far out-weighs the need to improve 1st MTP joint dorsiflexion.

    Maybe this is another reason why we see hallux rigidus compensation pre-op :- poor hallux purchase.

    This maybe another reason for the success of a good fusion (apart from eliminating pain), where hallux purchase is also no longer an issue and may over-ride almost completely the importance of 1st MTP joint dorsiflexion/ windlass mechanism in these patients with degenerative 1st MTP joints.
     
  14. From what you describe, the 1st MTP surgery your friend had, if it decreased hallux purchase that much, also detached the sesamoids from the proximal phalanx base (probably was a Keller-type procedure). When the sesamoids are detached from the proximal phalanx base, they will retract so that they are no longer located under the first metatarsal head.

    As a result, your friend not only has a lack of hallux purchase, but also, more importantly biomechanically, has retracted sesamoids which are decreasing the ability of his first ray to bear a significant proportion of the plantar loads from ground reaction force acting on his forefoot. As a result, lateral forefoot symptoms will almost always occur, especially in younger individuals who still had a propulsive gait before the procedure was performed.

    Lesson to be learned: only perform Keller bunionectomies in individuals with end-stage arthritis of the 1st MTP, that are older and apropulsive.
     
  15. tarik amir

    tarik amir Active Member

    Hi Kevin,

    the sx performed was a 'clean-up' procedure. I believe a chielectomy/ valenti. The friend is a prominent pod surgeon in Australia. I found it interesting that post op he has made little comment regarding a problem with improving dorsiflexion ROM of 1st MTPJ/ windlass mechanism and has had considerable issues with hallux purchase/ lateral column overloading.
     
  16. Tarik:

    I have heard of, but never seen or performed a Valenti procedure for hallux limitus. I can't remember how this is performed. I remember it being something about a 45 degree wedge of bone being removed, but little else. Please help....an illustration would be nice.
     
  17. tarik amir

    tarik amir Active Member

    Kevin,

    I believe the original technique was a sagittal plane 'V' resection of the 1st met head and the base of the proximal phalanx. The plantar portions of the head and prox. phalanx base were preserved. At the end of it the plantar poriton of the joint remains and the rest has been removed.

    The times i have seen it done would be desrcribed as a 'modified valenti'. A chielectomy was initially performed on the met head and then a 'valenti cut' performed on the base of the proximal phalanx. However the amount of bone resected from the dorsal aspect of the base of the proximal phalanx was not aggressive. I would say that only the dorsal degenerative portions were removed.

    Hope the above made some sense.
     
  18. Tarik:

    Thanks for that. I prefer to do a shortening osteotomy of the first metatarsal neck (generally about 2-3 mm bone removed for shortening) in addition to the cheilectomy. This will generally still allow sufficient hallux purchase while increasing dorsiflexion range of motion by 20-40 degrees. If the joint is bad enough, however, I will do an arthrodesis. Both procedures work well for my patients with a minimum of post-op biomechanical problems.
     
  19. Dieter Fellner

    Dieter Fellner Well-Known Member

    Kevin and colleagues:

    Because this formed part of my early training, I was accustomed to the use of the Valenti - Valenti procedure, in the case of the intermediate hallux rigidus when there is notable cartilage erosion affecting the upper quadrants of the 1st MTP joint articular surfaces only. The exact angle was around 70 deg. (P1 base) :30 deg. (MH) but in reality this was subject to the intra operative findings. The aim was to resect and decompress the joint but without sacrificing FHB insertions (ref; Keller's a.) And assessing the joint motion immediately after the operation the signs were good indeed.

    Overall, I was less impressed with the mid to long term outcome. The procedure has now fallen by the wayside. As a substitute, I now greatly prefer the Kessle Bonney osteotomy (often as an isolated procedure) + / - 1st metatarsal decompression with plantar flexion. The actual combination will depend on an intra-operative evaluation, to know if surgical objectives have been met, at least on the table.

    The resurgence, and growing interest in the Podiatry community, or so it seems, of the 1st MTP joint arthrodesis is interesting - a favourite orthopaedic procedure in England, at least among those Orthopaedic Surgeons that I know of.

    Kind of ironic the Orthopaedic Surgeon has been doing this all along whilst the Podiatric Surgeon 'knew better'; and certainly in my early career retention of 1st MTP joint function was considered paramount. An entrenched view and it is hard to shake off; along with the 'hypermobile 1st ray'. :D
     
  20. Dieter:

    Thanks for the posting. I don't know of anyone doing a "Valenti procedure" here in Northern California. I haven't put in a 1st MPJ implant for about 5 years but have been impressed with the functional results of 1st MPJ fusions that I routinely do now.

    Yes, orthopedic surgeons have long been telling us how good 1st MPJ fusions are and that 1st MPJ implants are no good, but did podiatrists listen?......no.....not until 20 years later. Now podiatry is singing the same hymn that the orthopedists have been singing for the past two decades, and podiatrists now act like they were the ones that wrote the hymn in the first place!

    Isn't it funny how each medical specialty and its "experts" like to take credit for things that aren't their own original ideas? It's almost as bad as the Democrats and Republicans here in the States who we will have to listen to for the next 8 months until the November elections.:bang:
     
  21. W J Liggins

    W J Liggins Well-Known Member

    Dieter, Kevin et.al.

    I concurr with both Deiter and Kevin's postings. The major long term problem I found with the classical Valenti procedure was shortening of the TEHL (even after initial 'Z' Plasty), caused the distal phalanx to be pulled into a dorsiflexed postion and thence under the metatarsal head. The result, of course, was jamming, dysfunction of the windlass mechanism and the sesamoids.

    If the problem is hypertrophic lipping of the 1st met head with good cartilage dorsally on Xray, I tend to go for a 'radical cheilectomy'. If the cartilage is reasonable then a shortening osteotomy restores function but if the cartilage is very poor then I agree, an arthrodesis is the best option.

    All the best

    Bill
     
  22. Dieter Fellner

    Dieter Fellner Well-Known Member

    Kevin:

    I have made good use of the arthrodesis; generally the impetus would be a patient who has already had a good result on the other foot - typically at the hands of an orthopaedic surgeon. Puzzled, and unable to explain the paucity of 'adverse sequela from altered foot mechanics' I would, and this is with the benefit of 20:20 hindsight vision, resist the urge to make a correct connection from the evidence. Instead, I rationalised, this is as an idiosyncratic / rare / atypical finding (i.e. Podiatric theory cannot be THAT wrong, right? :dizzy:) , adopt a philosophical stance, and 'just run with it' because : hey it worked fine on one foot already

    Treatment paradigms, like seasons, change. But, I do have take issue with the fusion. In particular when it is applied to the more 'demanding' female patient (please: this is not intended to be sexist - just never yet had a male patient presenting the same concerns about this).

    This group of patient can have three main concerns. Firstly often they will baulk at the idea of a permanently stiff joint. Even when the joint was already severely compromised. Secondly, and depending on positioning, on weight-bearing the hallux can be somewhat extended (to accommodate heels) and slightly abducted to facilitate 'roll off'. This causes concern with some limitation in the choice of shoe (i.e. heel height) ...... and finally some of the outcomes, when following the concept of DF/Abd, this can at times look just so damn ugly. (Though in your pictures I note this is not so dominant, but it is a man's foot ergo no special footwear concerns ?)

    For male patients in general, though not always, and also the very active patient, including the sports enthusiast, this operation would seem to provide for a good, stable joint.

    Contemporary articles e.g. http://www.podiatrytoday.com/article/4902 (By Lawrence A. DiDomenico, DPM, and Alfonso A. Haro III, DPM ) helped to reignite again my interest in this procedure, and caused me to re-evaluate those entrenched views. Certainly, and with experience, I would now consider this option with much more interest.

    Yet, at the same time I also find the Primus Flexible Great Toe Implant has an important role to play - the patient seems to like it, and careful patient evaluation and selection remains a key aspect.

    As an aside I have had experience with other types of implant, notably ceramic designs, but never quite got the outcome promised by the marketing literature and there were too many problems with this. The 'new' joint would predictably stiffen up even when there was near normal ROM on the table. Perhaps others can do better with it. Some patients would have a mouse-like squeak, at each step ! Kind of annoying to have to live with that. Last I heard, just before I abandoned this implant, was the Germans used a passive joint ROM exercise machine ( a strange looking motorised, hinged contraption, akin to a medieval torture rack : Rx: 2 hours a day post - op ! :wacko:
     
  23. Dieter and Bill:

    I will likely be doing another 1st MPJ arthrodesis in the next few weeks on a female patient, depending on the appearance of the joint during surgery (my other surgical alternative being an aggressive cheilectomy with horizontal "L" shortening osteotomy at the metatarsal neck with screw fixation). I will spend a lot of extra time preoperatively with my female patients explaining to them that when doing an arthrodesis that they will be limited to shoes with heels that are 1" in height or lower. If they don't want to be limited in shoe heel height, then I would consider an implant, but I usually talk them out of wearing higher heeled shoes.

    I have a few male patients (one over 60 years old) that run marathons very comfortably after I have done 1st MPJ arthrodesis on their arthritic 1st MPJs. The bottom line is that the increased 1st ray dorsiflexion stiffness and 1st MPJ/sesamoid weightbearing potential that is gained with a 1st MPJ arthrodesis far outweighs any "decreased windlass" effect from fusing the joint. I suppose a 1st MPJ arthrodesis is sort of like a "permanent Cluffy Wedge".......:rolleyes:
     
  24. drsarbes

    drsarbes Well-Known Member

    Reading these posts with interest.

    I guess I would describe my approach as the anti-kirby. I have not fused an MTPJ in over 15 years and do not plan to fuse any in my remaining years in practice.

    I routinely replace joints with the Sutter Total joint (now Astra) La Porta (now Lawrence) design.
    I have found that, when properly done and on the correct patients, they are a wonderful procedure. Quick healing (two weeks in a post-op shoe) with full activity expected.

    When I see a patient with symptoms but their joint is not to the point where a replacement in indicated, I'm almost sorry for them. The Cheilectomies should be seen as a stop gap procedure. Unless it's a geriatric or the patient is incredibly inactive, these joints will continue to degenerate to the point where the implant (or fusion) is needed. Any shortening osteotomy of the metatarsal somewhat precludes a future implant.

    How odd that the trend in every joint in the body (with the "possible" exception of intervertebral) is for improved function via replacement or rebuilding ...........EXCEPT the foot. We had it right originally, in theory at least. Did anyone give up on total knees when compartmentals had poor results or when the original total designs had poor outcomes?

    NO.

    When is the last time you saw a knee fusion on the schedule?

    I don't think that totally omitting a joint should ever be viewed as improving function or anything other than a salvage type procedure.

    My opinion

    Steve
     
  25. Steve:

    Thanks for recognizing me with the "anti-Kirby" comment. However, here on the west coast and other parts of our great country, 1st MPJ arthrodesis is very commonly done so I guess you are also "anti-Chang", "anti-Bouche", "anti-Roukis" and "anti-whole podiatry departments here in Kaiser Northern California" as well as "anti-Kirby". The biomechanics of the properly performed 1st MPJ arthrodesis are quite clear, this long-lasting, time-tested procedure greatly improves the function and stability of the foot in most patients.
     
  26. drsarbes

    drsarbes Well-Known Member

    "I guess you are also "anti-Chang", "anti-Bouche", "anti-Roukis" "

    Hi Kevin:

    I don't see a problem with that. I welcome it.

    You, as well as I, know that in private practice, it's all about the results.

    I've been around long enough to see the arthrodesis come and go.... and come again. If you get good results with the fusion, fuse on. I happen to be one of many "nonconformists" (now) in private practice that happen to get very good results with the implant. No reason to go back to the fusion.

    I don't see a right or wrong here. That's why this is MY OPINION. I never argue against success. We both, apparently, have successful approaches to Hallux Rigidus
    -
    But, no one will ever convince me that it's better to fuse a joint and hope that the rest of the foot compensates for it rather than restoring function to that joint. I would think that, as an authority on lower extremity biomechanics, you would be on "my side of the fence" on this. Oh well..it just wouldn't be as much fun if we didn't butt heads!

    Steve
     
  27. tarik amir

    tarik amir Active Member

    There's been a mention of a number of procedures above including arthrodesis, kessel bonney, chielectomy, valenti, implant arthroplasty, keller etc.

    Anyone performing the interpositional arthroplasty for hallux limitus/ rigidus ? I would like to hear anyones views on what is exactly occuring with this procedure.

    cheers
    Tarik
     
  28. W J Liggins

    W J Liggins Well-Known Member

    Hello Steve

    I respect your point. However, I have taken too many silicone implants out to have a great deal of faith in these. Certainly they work for 8-10 years but I have noted sesamoid recession in addition to rapid degeneration of the prosthesis. Again, this may be due to the surgical practice of the individuals who originally placed them. Like Deiter, I have largely stopped using ceramic implants in the 1st MTPJ although still find them useful in the lesser MTPJs. As a colleague on this side of the pond stated 'this is the most expensive way of creating a 1st MTPJ arthrodesis, even with intensive post-op. physiotherapy'. I suspect that the failure rate is due to the complex mechanics of the 1st MTPJ but am happy to leave Kevin to comment on that aspect.

    I agree that the search must continue, but in the meantime, for the severely degenerative 1st MTPJ, arthrodesis does appear to offer complete pain relief with less mechanical dysfunction than might be expected. I have found this particularly so when the MTPJ is fixed at 30 degrees of dorsiflexion.

    Kevin, have you found long term degeneration of the 1st MCJ and hyperextension of the IPJ in these cases?

    All the best

    Bill
     
  29. Bill:

    I have not found any problems with degeneration of the 1st MCJ and hyperextension of the IPJ from 1st MPJ arthrodesis. I totally agree with your assessment above. From a biomechanical standpoint, first MPJ arthrodesis creates a significant improvement in gait function for patients.

    If you want to be able to do another surgery in 8-10 years on the patient, then do an implant. However, if you want to give your patient a trouble-free, permanent solution to 1st MPJ pain and symptoms, then do an arthrodesis.:drinks
     
  30. Frederick George

    Frederick George Active Member

    The trouble with converts. . . With over 250 different bunion procedures, no one has come up with the answer.

    "However, if you want to give your patient a trouble-free, permanent solution to 1st MPJ pain and symptoms, then do an arthrodesis." C,mon Kevin, it sounds like a guarantee.

    It certainly is permanent. Isn't there anyone else out their who has had patients come to them to fix their fusion? And what does one do? Orthotics?

    Maybe we shouldn't give up so easily.

    Cheers

    Frederick
     



  31. Fred:

    Even though I give no guarantees to any of my surgeries (or any of my treatments for that matter), I feel that first metatarso-phalangeal joint (MPJ) arthrodesis is the most predictable and long-lasting treatment that I have seen for treatment of end-stage degenerative joint disease of the first MPJ.

    In addition, I wouldn't consider doing a first MPJ artrodesis for a patient with end-stage degenerative joint disease of the first MPJ "giving up". What do you propose then is the best treatment for patients with end-stage DJD of the first MPJ?

     
  32. Frederick George

    Frederick George Active Member

    Dear Kevin

    Now you are saying "end-stage degenerative joint disease," whereas earlier it was "a trouble-free, permanent solution to 1st MPJ pain and symptoms."

    And I certainly believe, as you state you do, that (fusion) "is the most predictable and long lasting treatment."

    As I said in an earlier post:
    "Perhaps it again simply comes down to "do no harm." Or, doing the appropriate, least damaging surgical procedure to address the diagnosis. Dr. Kirby's three procedures on the same patient over a 15 year period is appropriate surgical management at each stage. Fusion 15 years ago perhaps wouldn't have been appropriate.

    Some surgeons may jump to early MPJ fusion, not just because it is technically simple, but because the bunion simply never comes back.

    This is akin to dentistry a couple of generations ago, when at the first sign of a problem, dentists commonly pulled all the teeth and replaced them with dentures because the teeth would eventually be lost anyway."

    We all have seen toes that have been amputated by orthopedic surgeons. Predictable and long lasting, and the corn never comes back.

    Aren't we primarily in business because orthopedic surgery has never thought the foot was very important?

    Certainly fusion, or a Keller variant is a last resort, and I too have had good results with both. I think better with my Keller variant.

    But that's not the point. Substituting a "permanent solution" when a less drastic procedure may offer a better result for the patient, but is less "predictable or long lasting" sounds like it might done for the surgeon's benefit.

    Yes, California is a litigious environment, but the procedure that offers the most promise for the patient is, I think, superior, even if the results aren't as predictable.

    So, I think the multiple surgery management of the case you mentioned was probably appropriate.

    And I guess I have seen too many bunion fusions from orthopods recently.

    Cheers

    Frederick
     
  33. Dieter Fellner

    Dieter Fellner Well-Known Member



    Frederick:



    This thread is about 1st MTP joints fusion - as a rule this procedure is used for the OA joint i.e. hallux rigidus, not hallux valgus patient.

    I would challenge the assertion there are
    Firstly, those procedures are for a complex deformity called hallux abducto-valgus. The 'bunion' is but one component of this deformity. There is not a surgeon anywhere who would open the surgical toolbox, scratch his head and select one of 250 hallux valgus operations.

    Secondly, whenever this figure is cited, the number of available ops grows exponentially (fisherman's tale of the one that got away?) In reality there are perhaps a dozen or so procedures which get to be used on a regular basis. And the majority of the rest are but minor variations with competing surgical egos keen to have their name attached to 'a new procedure' IMHO Probably it is possible to condense this number further anatomically:

    1. capital / metatarsal neck
    2. mid-shaft 1st metatarsal
    3. base of 1st metatarsal
    4. 1st MCJ fusion
    5. +/- hallux P1 osteotomy

    You can see from the above I have excluded the 'bunionectomy' - it is merely an adjunctive procedure, and, in my ops, only rarely used in isolation. You must add to the above soft tissue balancing to include capsule, co-lateral ligs, sesamoid ligs, add. halllucis tendon etc. all prn and subject to intra-op evaluation. However I exclude from the list the soft tissue HAV correction; simply makes no sense to me - whatsoever.

    Lastly, I would argue there are now exceptionally powerful HAV corrections and conservatively well over 80% of patients can expect excellent outcomes.

    Guarantees? : No.

    I will agree with you. I doubt any operation will ever offer a 100% guarantee. I don't know any positive, constructive and comparable facet of human undertaking when this is possible. Certainly I have revised a very few 1st MTP joint arthrodesis procedures, and if I recall correctly, problems are then related to poor hallux alignment, but not mechanical sequela. Unlike Bill, I have not been called upon to revise too many implants either. Certainly those plastic pieces can implode at times dramatically, but even a broken implant doesn't necessarily cause problems for a patient - sure looks impressive on x-ray, and the intra-op appearance will provide good opportunity to suck air between teeth (for that hissing sound - makes the bill more palatable to the patient?) and of course there is also the ever reliable 'tut tut' .


    Regards

    Dieter
     
  34. drsarbes

    drsarbes Well-Known Member

    "If you want to be able to do another surgery in 8-10 years on the patient, then do an implant. However, if you want to give your patient a trouble-free, permanent solution to 1st MPJ pain and symptoms, then do an arthrodesis"

    HAHA
    That's how you build a practice!!! (only kidding)

    Actually, I tell my implant patients they can count on 13-15 years, most last longer (contrary to studies I've read). I have replaced a few replacements, very easy to do. The down time for TWO implants is still less then ONE Fusion.

    I think the reason many do not last as long as they could and why outcomes are not as good as they could be is due to the fact that surgeons are not putting them in correctly.

    As for Fusions? Well, let's not lead everyone here to believe that ALL fusion patients are 100% pain free and pain free forever.

    As for revisions for fusions.... a Keller is my procedure of choice unless the arthrodesis itself failed then you can re-fuse it. If the hallux is too dorsiflexed you have a problem. If they have pain laterally try orthotic control. Sub second metatarsal - orthotics then possible surgical correction if still painful. IPJ - again, problematic. If you have a patient who had arthritic changes in the IPJ prior to MTPJ fusion you can almost count on the IPJ becoming symptomatic.

    Many have pain if the are trying to keep up with a friend that has had an implant!!!!!! lol


    Surgeon's choice.

    Steve
     
  35. Dieter Fellner

    Dieter Fellner Well-Known Member

    funny ! :drinks
    Indeed ! And what works in the hands of one surgeon won't necessarily work for the next guy .... :wacko:
     
  36. Frederick George

    Frederick George Active Member

    Dear Dieter

    As I hope everyone on this thread knows, bunion is used all the time as a general all encompassing term. I don't think we need to be too pedantic about it. We're all grown ups here.

    This thread is actually about a French study: "Degeneration of the metatarsophalangeal joint of the hallux is a frequent secondary lesion of the first ray subsequnt (sic) to hallux valgus." It doesn't say hallux rigidus.

    How degenerated is exactly the issue. Got it?

    Bunion procedures have been performed for 100's of years. The fact that there have been so many, and so many "modifieds" or variants, illustrates that no one or no small number of procedures work all the time. Because you don't know this doesn't make it untrue.

    Congratulations that you can have good results with a handful of procedures. We all have good results, and we all use the procedures that work for us.

    Cheers

    Frederick
     
  37. Dieter Fellner

    Dieter Fellner Well-Known Member

    Frederick:

    You say pedantic, I say accurate. Do we on PA really use the term 'bunion' to encompass any number of very different clinical entities ? Or are we professional people?

    Thanks, Pop - all is clear now !

    A sage like and respect worthy observation, never once did this fact occur to me also.

    Frederick old bean, are you serious ? Or have you lost the plot completely ?

    100's of years ago ? :pigs: Sure, in the same way that brain surgery was performed hundreds of years ago - i.e. dagger thrust in the eye socket for your lobotomy. Sorry, I forget, there is no need to be 'pedantic' - let's say the practice dates back to Hippocrates, if this makes you feel better.

    All the same, please send me a reference of a studious piece of work from, say, 1748 illuminating the art of 'bunion' surgery.

    Tut tut - don't make assumptions about what I know. Has my writing offended you to the extent you need to patronize? Freddie, it's not very professional.

    I have hundreds of research papers, probably also reaching back, as you say, 'hundreds of years' - sure the studious are looking at, comparing, evaluating and 'developing' this operation. The real point I make is the astute surgeon has moved it up several gears, and although an element of unpredictability remains, the outcome today is very much better and predictable than 'hundreds of years ago'.

    Thanks, but if it's all the same, I don't need it.

    Thanks for this most entertaining response - keep it coming :boxing:
     
  38. Frederick George

    Frederick George Active Member

    Dear Dieter

    Likewise.

    Cheers

    Frederick
     
  39. Admin2

    Admin2 Administrator Staff Member

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