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Joint replacements- why fuse bones in foot?

Discussion in 'Foot Surgery' started by mamatootsies, Nov 5, 2009.

  1. mamatootsies

    mamatootsies Member

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    :dizzy:Hi, I'm 2nd year UK pod student, just experienced 4th week of biomechanics, looking at 1st ray, discussed why movement is limited etc... We have been encouraged to always look to getting efficient gait with insoles & orthotics and I understand we don't need to change all the pathologies of the foot, just the compensation mechanisms. I realise I have little experience & a lot of learning to do, but what I'd like to know is when there is a problem with a hip or knee surgeons replace them with artificial joints, and try to get normal use back.... so why do we fuse bones in the foot? permenantly rendering them unable to become the 'loose bag of bones' for shock absorption during gait, and potentially inducing further foot pathologies following surgery. Has anyone tried replacing the met heads/ IPJ's with some sort of artificial joints? Is this a silly idea? My logic is it would possibly resume normal function of 1st ray? ... just one of those thoughts that arrived whilst supposed to be doing something else.....
  2. sam_wallwork

    sam_wallwork Active Member

    there is something called The Moje, which is a ceramic implant.

    Not sure how successful it is though. The only reason i know about it is because i had a friend who worked for a company that used to sell them.

    hope this helps

  3. Paul Bowles

    Paul Bowles Well-Known Member

    There are lots of options other than fusion. There is also lots of reasons to choose other options than joint replacement (esecially at the 1st MTPJ).

    PubMed is your friend (so is McGlamry's Comprehensive Textbook of Foot and Ankle Surgery).
  4. drsarbes

    drsarbes Well-Known Member

    Hi Mama:

    Some joints in the foot (and hand) when they become arthritic are just not conducive to replacement. The sub talar joint is a good example. There is no easy way to produce an artificial STJ because of the patient to patient variations as well as the fact that it's not a simple hinge or ball and socket type joint.

    Gliding type joints, when arthritic, are more accessible to fusion than replacement, however, replacing the surfaces of these joints would seem a better treatment (if they were available), such as the CC, TN, intercuneiforms. The fact that these joints do better when LOCKED into place during weightbearing than being unstable is mostly responsible for the popularity of fusing these joint. Plus, what else are you going to do if no artificial joint has been designed? If rigid, non painful weightbearing and propulsion is the main objective then fusion of the midtarsal and or STJ's make sense.

    The Ankle is really the last of the large joints to give-in to joint replacement. The anatomy and stress forces have made designing an ankle joint difficult. But even this joint is more commonly replaced and, I would predict, will be much more common than ankle fusions in 5-10 years.

    Which brings me to the reason I think this is an excellent question: Given the above reasons for fusions in the foot WHY is 1st MTPJ fusions so common? Why fuse instead of replacing?
    A replacement certainly heals much quicker, gives better functional outcome and lasts at least 15 years.

  5. Paul Bowles

    Paul Bowles Well-Known Member


    Do you have much experience with 1st MTPJ hemi-arthrectomy and capsulorrhaphy where a portion of the capsule is pulled through the joint after the hemi procedure effectively providing a "joint buffer"?

    Some of the Pod Surgeons in Australia use this technique and from what I have seen short term results seem favourable. Would be interested in your opinion of it?

    By far the most common procedure I see from Orthopods down here is fusion.

    The reasons I would imagine?

    Cost - Measure twice, cut once. Fuse it and forget it.

    Effectiveness - minimal need for revision, even after 15 years.
  6. drsarbes

    drsarbes Well-Known Member

    "Do you have much experience with 1st MTPJ hemi-arthrectomy and capsulorrhaphy where a portion of the capsule is pulled through the joint after the hemi procedure effectively providing a "joint buffer"?"


    Hi Paul:
    Yes, pulling the capsule or purse stringing it after a Keller type procedure works rather well. If you have a patient who cannot undergo a replacement or fusion or a geriatric hallux valgus/DJD, this is a successful procedure. You can also place a piece of Graft Jacket in the interspace. THis keeps the resected portion of the base from retracting against the metahead (although in time it's going to anyway)

    As for the 15 year thing. I've been doing these so long that I'm actually getting some (at least 6 to date) that have been in for at least 15 years and the patients are starting to get a break down of the implant. I've replaced these replacements and they work just fine. Another 2 weeks in a post op shoe and their good for another 15 years - (assuming the rest of them lasts that long.

  7. Paul Bowles

    Paul Bowles Well-Known Member

    Are these hemi replacements or totals? Stainless steel or silastics?
  8. nicpod1

    nicpod1 Active Member

    Mammatootsies, I hope you're ready for this, as you are based in the UK and this will be relevant to your question!

    Ok, here goes.......the MOJE joint replacement for the 1st mtpjt was much better than the previous silastic implants, but this has now, largely, been superceeded by metal-on-polyethylene joint replacements, which are better, however, they can still, sometimes, end up stiff, especially if not rehabbed properly, so can sometimes be an 'expensive fusion' - this is a quote from a Pod Surgeon!

    Ankle replacements are also done more now by experienced foot and ankle surgeons and the ones that I've seen back have all been really good.

    But, here's the rub..........from an NHS point of view (and this is a current situation where I am in the UK), a K-wire / screw is cheaper than a replacement, therefore, REPLACEMENTS WILL NO LONGER BE FUNDED!!!!!!

    My opinion would be that were there are limitations in this technology, surely is better to keep trying, rather than to revert back to old technologies? But that is where you have to stop thinking logically in this game, as the NHS is not logical!
  9. drsarbes

    drsarbes Well-Known Member

    I've used many hemi's but for the past 15 years I use, almost exclusively, total silastic implants - LaPorta and now Lawrence design.

  10. Paul Bowles

    Paul Bowles Well-Known Member

    Oh ok wow - I would really like to see your technique Steve, I have seen a ton of these fail. Granted I imagine it all does come down to good technique & correct/appropriate patient choice.

    I was just in the US doing some work and I was astounded as to the differences in approach from the patients/practitioners in Aus to the U.S.

    In the U.S. patients/practitioners embrace the concept of secondary surgical intervention. In Australia the concept is shunned, and having to cut twice to get it right is looked upon as failure to a large degree I am sure.

    Thanks for your input Steve - its invaluable!
  11. Mama:

    This is an excellent question, but is a rather complex subject that deserves much discussion. By the way, Mama, if you gave us your real name to go with your excellent question, it would help inspire others to contribute also.

    The question of whether to fuse, or arthrodese, a joint of the foot and lower extremity is not just a question of what will produce the least pain and best function for the individual, but also is a question of the particular surrounding anatomy of the joint and whether it is amenable to having an artificial joint placed into it that will not cause long term problems or sequelae.

    In the case of the 1st metatarsophalangeal joint (MPJ), many podiatric surgeons here in the US now prefer the arthrodesis due to it's permanence and excellent function, with a minimal of sequelae and ability of the patient to walk and run after the surgery with less pain and minimal loss in function. Dr. Arbes and I have been around this stump before so I will acknowledge there are plenty of podiatric surgeons that still prefer the implant procedures over arthrodesis and I don't have any problem with this approach. However, in my hands, over my last 25 years of performing foot surgery, I have moved toward preferring arthrodesis of the 1st MPJ as the better procedure for most patients.

    The joints that are larger in surface area, such as the hip and knee, are quite amenable to joint implants since the implants are subjected to relatively less pressure (force/surface area) than are foot implants. In the ankle, the joint forces are probably about 2x more than in the hip or knee, but the joint surface area and available bone surrounding the joint that can be used as an interface between the implant and the bone is far less in the ankle than in the hip or knee. The combination of increased joint force along with decreased implant-bone surface area in the ankle implants greatly increases the contact pressure at the implant-bone interface which may lead to degradation of the bone at the implant-bone interface over time and which may, in turn, cause loosening of the implant, requiring eventual removal of the implant and a difficult revisional ankle arthrodesis procedure. The newer ankle implants that use a short tibial rod to provide more implant-bone surface area in the tibia to decrease implant-bone interface pressures, will likely be the future of ankle joints implant designs.

    Finally, the question of whether a joint should be fused or not should not come down to looking solely at just the function, or lack of function, of that joint itself, but rather should come down to looking at the weightbearing function of the foot and lower extremity complex, as a whole. For example, if there is too much first ray dorsiflexion/adduction compliance (i.e. too little stiffness) in the first ray, the choice for the patient that works best may be a Lapidus procedure (fusion of the 1st metatarsocuneiform joint) since it increases the first ray and medial column dorsiflexion and adduction stiffness, even though the function of the 1st metatarsocuneiform joint (MCJ) has been totally lost. The redundancy of function of the other joints of the foot surrounding the 1st MC joint will allow the whole foot to still function fairly normally after a Lapidus procedure. Therefore, time has taught us that the Lapidus procedure works very well in many cases since the total function of the foot is improved by the stiffening of an overly compliant 1st MC joint with this procedure.

    In regard to the decision to either use a joint implant or a joint arthrodesis, maybe it is best said that one must not lose sight of the forest, by paying too much attention to only one of its trees.

    Hope this helps.
  12. mamatootsies

    mamatootsies Member

    Dear Dr Kirby,

    Thank you for your beautifully put reply. I will be spending any 'free' time I have continuing to look at this topic.... I can see how this could become an obsession!
    I have one regret about taking my degree, and that is that I didn't do it years ago....there are so many things I want to find out about, and so little spare time.

    Thank you for futher inspiration. I look forward to reading the interesting and amusing exchanges on the arena.

    I will, as advised, add my name to details if it will encourage more posts....
    Thank you again

    Sarah ;).
  13. Paul Bowles

    Paul Bowles Well-Known Member

    I agree with Kevin Sarah,

    Adding your name definately allows people to identify with you more. There are plenty of people who are prepared to throw stones on these forums from an "anonymous" vantage point - how convenient.

    If what you are saying has any worth, put your name to it!

    Good luck with finding the answers you need!
  14. Sarah-Jane

    Sarah-Jane Member

    Hi thanks for all the really interesting opinions and views. I wonder if I might be able to ask a question as I've been thinking about a particular patient for quite a while.

    I've been treating a patient, a female in her 60's for the past few months. She presented with a large dorsal exostosis on her left midfoot. It is causing a lot of pain while walking, with significantly reduced dorsiflexion. On review of x-rays there was significant arthiritis in the talonavicular, calcaneocuboid and midfoot area. She contracted polio when she was younger and also had a surgical correction of her left foot in her early teens.

    The foot is quite cavus in a non-weighbearing position however there is some medial deviation of STJ axis while walking and again, limited dorsiflexion. The ROM in her left STJ is more limited than the right...

    Anyway, I referred her to a surgeon as there was little I could do besides making some adjustments to shoes to give her more comfort and support. I didnt go with functional orthoses as I thought that she already has very limited dorsiflexion due to the exostosis and the pronation of her foot was compensating for that....so reducing the pronation wouldn't really do much except cause more pain....(what do you think???). She is more comfortable now with some in-shoe adjustments but cannot walk very far or spend too much time on her feet.

    So after having a surgical consultation, the surgeon would like to do a triple arthrodesis and possibly also fuse her midfoot. I thought maybe they would reduce the exostosis, wasn't expecting a rearfoot fusion. Basically wondering what some of you think about the decision on the arthrodesis for this type of case or whether you've seen cases like this. I'm not an expert on surgery obviously!

    Opinions much appreciated.

  15. drsarbes

    drsarbes Well-Known Member

    Hi Sarah-Jane:

    Usually when a patient presents with a midfoot dorsal exostosis secondary to arthritis they become painful due to pressure on the neurovascular structures and or tendons in the area. At times a small ganglion can also form adding to the pain. In my experience it's much less frequent that the joint itself is painful on ROM (usually the second met-cun)

    When these fail to respond to conservative treatment (accommodative dressing, extra depth shoes, cortisone injection) then an exostectomy procedure is carried out. These can be tricking since the dorsalis pedis and superficial peroneal nerve always seems to pass over the spur, and, there is a tendency to take too much bone off, interrupting the dorsal cortex and creating more bone callus deposition.

    A triple would be indicated if your patient is not plantigrade or if her midtarsal - STJs are painful on ROM.

    Difficult too say without examining her.

  16. Sarah-Jane

    Sarah-Jane Member

    Hi Steve

    Thanks for the reply. I spoke to another colleague about it and he examined the patient also. He reckons that the athrodesis would be the best option as she is in a lot of pain and unable to weight bear for very long.

    On palpation of the met-cuneiforms she experiences pain. ROM causes discomfort also.

    An arthrodesis will stop rearfoot function, but it doesnt stop dorsi/plantar flexion....wondering if the surgeon would reduce some of the exostosis while doing the arthrodesis....Indeed the DP artery and superficial nerve would be a problem. I hope to hear from the surgeon again soon...

    I'll see her again for footwear adjustments. She is very positive and would like to go ahead with the arthrodesis.

    Thanks again, much appreciated

  17. Tom Galloway

    Tom Galloway Member

    Hi - my first post on a site for years

    I was enjoying browsing through the very well informed postings on the site and I noted the post by Sam

    "there is something called The Moje, which is a ceramic implant."

    In a comparison between the Swanson double stem Silastic implant, the Reflexion implant and the Moje ceramic implant , I found that the Moje was astonishingly more likely to give complications and within the period I was using them suffered two different types of failure.
    For all its well documented problems with wear and silicone sinovitis, the Swanson gave the best outcomes and this was over a 15 year period, the reflexion was good (but more problematic to revise if there was a problem and also the period of time they had been in was ony 6 years) and the Moje were successful for a short period (a couple of years) and have almost all given problems.
    I had put all the implants in and I had taken equal care to use the recommended technique for each.

    I would never use or recommend Moje Ceramic 1st MTP joint implants for anyone - and I wish I had never used them just a warning.

    I have no axe to grind and no financial interest in any of the products

  18. Larry Zimmerman DPM

    Larry Zimmerman DPM Welcome New Poster

    We usually fuse bones in the foot when there is pain and need stability. There are artificial met heads, (lesser met heads) but generally work only as a spacer and to help a toe from retracting back when a met head is removed for some reason, but as far as I know there has been no artificial (lesser) met heads that are able to stand the stress of weight bearing.

    There are a number of artificial first metatarsul phalangeal joints ,but time has proven they too have their limitations. Usually they are used only as a spacer. I often use a stainless steel artificial (hemi joint) for older people with a narrow Keller proceedure. Younger people who are more active and need stability when they toe off and have a painfull hallux limitus, I fuse.

    There are artificial spacers that are used in the subtalor joint (usually kids) with a painfull flexible flatfoot that doesn't respond to conservative care and orthotics.

    There are artificial toe joints, but in my opinion, are not any better than fuseing a toe or doing and arthroplasty.

    This really is a complex subject and would take a lot more time to say everything. If you have a more specific question I would be happy to try and answer it.

    I am a podiatrist who practices in the states (Mansfield, Ohio)
  19. Adrian Misseri

    Adrian Misseri Active Member

    G'day everyone...

    Has anyone had any experience with the Biopro stainless steel hemi implant in 1st MTPJ surgery? If so, what were the outcomes?

    Also, according to literature, it seems that in the case of the 1st MTPJ with hallux limitus/rigidus, both arthoplasty-based and arthrodesis procedures appear to havesimilar positive outcomes in pain reduction, increase of foot function and patient satisfaction, both could be appropriate. Could this be another reason, nicpod1, why the cheaper procedure, arthrodesis, is indicated in a cost driven health system?

    Cheers all!

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