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Surgery without biomechanical consideration

Discussion in 'Biomechanics, Sports and Foot orthoses' started by David Smith, Dec 5, 2012.

  1. David Smith

    David Smith Well-Known Member


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    This lady presented today complaining of left 1st mpj and anterior tib pain and also plantar metatarsalgia 3rd 4th 5th mpj. Little wonder considering the surgical intervention where the 1st MPJ is pinned rigid and plantarflexed in line with the declination of the 1st ray which is also fairly rigid resulting in a forefoot equinus.
    You can see this in the picture below.
    The consequence is that she cannot progress over the planted 1st mpj/hallux and so she supinates the STJ and plantar flexes the lesser rays and dorsiflexes the 1st ray as much as possible to give what is effectively a f/foot supinatus. Therefore the medial aspect barely touches the ground in stance phase. Explaining the overworking of ant tib, compression of the 1st mp joint, and high plantar pressures sub 3-5 mpjs.

    [​IMG]

    The result of ill considered surgery in terms of the biomechanical sequelae, i would say. But what to do about it now? What type of orthotic intervention would you design? Or would you consider more surgery as a better option

    Regards Dave Smith
     
    Last edited: Dec 5, 2012
  2. Looks young. I'd look at surgery Before functional loss and secondary deformity sets in.

    With a different surgeon.
     
  3. David Smith

    David Smith Well-Known Member

    Lady of 63 years old but well preserved:D

    Dave
     
  4. Ryan McCallum

    Ryan McCallum Active Member

    I've treated quite a few of these over the last year or so surgically (5 patients I think since June according to my log). Unfortunately 2 cases resulting from intervention from the same surgeon.

    All managed with removal of a dorsal wedge from the fusion site. Technically simple to do, relatively straight forward recovery, just unfortunate for the patient to have to under go another surgical episode after what should have been a definitive procedure.
    Most significant risks include under/over correction and potential non union considering the bone can be quite sclerotic at the previous surgical site. Having said that, ground reaction forces increase compression at the fusion site as long as the patient is weightbearing or partially weightbearing so thankfully I haven't experienced any issues.
    Alternatively, the fusion could be converted to a joint implant but I'm not fond of these.

    Ryan
     
  5. Paul Bowles

    Paul Bowles Well-Known Member

    How can she have left 1st MTPJ pain if the 1st MTPJ is fused? Or is your definition of pinned and fused different? Does she have ROm at the 1st at all in that case? Is her IPJ fused as well? Why wasnt an interpositional arthroplasty considered alternative to fusion if function was a priority and confounding factors for failure were not?
     
  6. efuller

    efuller MVP

    An orthotic alone won't fix this. Assuming that the symptoms are an avoidance of loading the 1st toe then potententially increasing the load on the first met head would reduce the load on the first toe. It is conceivable that a rigidly plantar flexed 1st toe that became loaded would put a lot of load at the fused MPJ and this could cause discomfort their. It could be as high as body weight on the toe that is attempting to dorsiflex the fusion site.

    So, an orthotic with a lift sub 1st met head (Deep hole sub 1st toe.) in a rocker bottom shoe is what I would recommend if she really, really, did not want to have surgery.

    Can you send that picture to the surgeon? The surgeon might want to know of this outcome.

    Eric
     
  7. David Smith

    David Smith Well-Known Member

    1) The 1st MPJ is completely rigid to manually applied d/flexion - p/flexion force.
    2) The IPJ has good rom but is dorsiflexed.
    3) Don't know

    Eric wrote -
    I hadn't considered that,how would a surgeon feel about that do you think?

    Ryan wrote
    Have you ever done as Eric suggests? Why so many poor biomechanical considerations by surgeons? Is this a mistake or an unfortunate outcome? did you personally do the modification surgery?

    Dave
     
  8. Ryan McCallum

    Ryan McCallum Active Member

    Hi Dave,

    Eric's suggestion as in let the original surgeon know? Or the conservative option?
    I don't personally advise anyone if we are carrying out revision surgery on one of their previous cases. I guess it can be seen as inflammatory (although I personally would prefer to know) and I have been advised in the past to avoid it. I do however inform the patient's GP of the reason behind them requiring revision surgery.
    As for the conservative option, I have tried rocker soled shoes in these cases but found that most patients either don't get adequate symptom relief or alternatively, they do not want to be restricted to this type of footwear and so rarely stick with them.

    As for the poor biomechanical considerations, I don't know. The only cases I have seen where the hallux has been fused in line with the metatarsal or in one case plantarflexed have been orthopaedic cases from St Elsewhere. I'm not sure if there is a lack of understanding/experience in foot surgery or if they have been mistakes or poorly judged on the table. Either way, this is a fairly inexcusable mistake to make even taking into consideration that there is differing opinions as to the best angle to fuse a 1st MTPJ.
    If you do enough of anything, you will get a poor outcome eventually. I frequently tell patients that if any surgeon says that they get 100% good outcomes with a procedure then they have either only ever done a few and have been lucky or they are lying.

    I've personally done 3 out of the 5 cases we have carried out (I mentioned in the last year, that was a mistake, it has actually been 5 in approx 2 years).

    Regards,
    Ryan
     
  9. A photo of the foot, from lateral, with the patient standing on an orthoposer or pedestal would be much more instructive as to whether the 1st metatarsophalangeal joint (MPJ) was arthrodesed in the proper position or not. Non-weightbearing photos do not give the best view of how they will be functioning in gait.

    I generally aim for the proximal phalanx of the hallux to be about 10 degrees dorsiflexed off the ground when standing post-op when performing 1st MPJ arthrodesis procedures. Many of my patients return to running/jogging after these procedures with little problems. It is a good procedure, but if you get the angle of fusion wrong, the patient will be miserable.
     
  10. eddavisdpm

    eddavisdpm Active Member

    I am not a big fan of arthrodesis of the first MTP joint. That procedure had been more in vogue with the orthopedic community in the US but became increasingly more popular among podiatrists starting in the 1990's. I attribute that, in part, due to decreasing attention paid to biomechanics. Another factor in that trend included the failure of poorly designed implants and implants used improperly. Implants, by themselves, often do not correct faulty biomechanics such as elevatus of the first ray.
    My definition of "improper" in this scenario is the application of such an implant without adequately addressing the pathomechanics that led to hallux limitus/rigidus in the first place. Two part "unconstrained" implants had a poor track record and may have skewed the overall view away from all implants.

    There are a number of papers published which list rather favorable outcomes for first MTP joint arthrodesis but one must carefully examine how a good outcome is defined. Certainly, fusion of any joint eliminates pain at that joint specifically. The gait changes created by fusion of the first MTP joint and means of compensation for a fused joint are often not adequately considered in the literature, in my opinion.

    I have seen many patients with lessor metatarsal pain, hip pain (hip joint, iliotibial band/tensor fascia latae pain), peroneal tenosynovitis as long term sequelae of first MTP joint arthrodesis. Some had fusion at too low an angle of dorsiflexion and some not. There remains controversy as to what that angle should be.

    Procedures designed to re-establish normal first MTP joint range of motion and function are more consistent with much of podiatric biomechanics. Osteotomies to re-align the first MTP joint, reduce first metatarsal elevatus, replace overly worn cartilage with hemi-implant type arthroplasties or total implant arthroplasties via the flexible hinged Tornier Primus have provided the most acceptable results in my practice. Use of custom orthotics is almost a constant.

    Some common orthotic considerations after surgery may include attention to reduce any forefoot supinatus and stabilize the first ray against the supporting surface in propulsive phase.
     
  11. David Smith

    David Smith Well-Known Member

    Thanks for your comments guys I'll keep them in mind in the consideration of treatment program. I'll see if I can get a video of her walking posted. Kevin this lateral view on a pedestal - is that with the 1st ray over hanging the edge? couldn't she then just choose to supinate the foot for balance? What is it you like to evaluate from this test and from this lateral view?

    Regards Dave
     
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