Cheilectomy, Arthroplasty, or Arthrodesis? During this webinar, Drs. W. Hodges Davis, Michael Campbell, and Jeremy McCormick discuss how to match the right patient with the right surgical treatment option for hallux rigidus, along with setting expectations for each option.
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it's It's a fascinating thing for me. Thio. See how Fassel we have come in this in this way to teach and how intimate this type of teaching can become. I love being on the call with with Michael and Jeremy guys who have gotten to know young, smart guys who are really focused on doing the right things for their patients and eso that fits with my philosophy. Um, as I told them early, I'm coming from Ah Park in Monaco, Wisconsin, and that's a longer story to tell you exactly why, but But it's all good. Um, so, um, we all know Alex Rijs, um, is an isolated arthritis of the big toe. The symptoms can be paying can be stiffness. We altered loading. So you see your kicking over to your lateral side activity modification and shoe fit limitations, and you can see here the the clinical picture, and then when you open it up, sometimes the joint looks worse than you would even expect. It is the most common arthritic condition of the foot. It affects one in 40 um, people over the age of 50 which is really amazing, considering how many of those air out there. So the estimated is 2.2 million new cases per year, 50 to 80% depending on what you read is bilateral. And it's interesting that 70% are women, which has certainly been my experience. Um, it is our belief that the cartilage issues to the MTB joint or a progressive continuum. The problem is that the X rays correlate poorly with patients, symptoms and Alex ridges, and our patients come in and they say, you know, reached the point where I got to do something, but I don't want to lose my emotion. And this is an example of a patient in my practice who has continued to have really a significant amount of motion. But the pain had gotten worse. Um, the classifications system that has kind of become the standard is by my friends Mike Coughlin and Paul Sureness. Um, and the reason why this is such a good classifications system, is it? It is combines exam findings with radiographic findings in grade zero is really a normal X ray with some stiffness Grade one extreme on the extremes of motion on Lee. Great to is kind of that in between grade three and four are getting pretty close to in stage where you're almost bone on bone on X ray. The surgical treatment options at least the way that I approach it are pretty consistent. Is that in the grade ones And to I like to collect me in the grades two threes and four I'm trending towards Arthur Plastic. Excuse me towards fusion or cart Eva in my in my practice, um, and Mawr and Maurin my practice the threes and fours Get a Knop sh in for cart Eva Infusion. Now, this is an algorithm that Judy Bomber Group came up with And so everyone gets non operative care. And then if they have persistent symptoms that are isolated dorsal with decent motion, you might consider a collect me plus or minus a proximal phalanx Ost IATA me. Um, if you want to preserve function and help with pain on day, don't have no muscle issues or Anglo deformities you might consider a cart Eva Polyvinyl alcohol implant with with possibly adding a proximal family exhaust IATA me and then final and definitive. Our first MP Arthur reduces um, the evidence based analysis of the effectiveness of cart Eva is a great A Fair evidence with Arthur DCIS and then Kyle Ectomy is a bunch of non randomized retrospective studies. But but so a great see the top patient factors when selecting a surgical procedure. For Alex, rigidness is one. Reduce the pain to improve the motion or at least maintain the motion. Three. Get me back to my day to day activities quick and consistently, and then the other thing is to burn no bridges. So have some different procedures. If if this fails, what else can I do? Um, and so what I like to call this is a continuum of care, and we've been talking about it a lot at right medical as we talk about ankle arthritis and we now talk about big toe arthritis. And we're now talking about it in Halik, Val Ghous and all of these things. Air matching the right operation with the right patient. The patient has failed non operative, their age, their expectations, their desire or not desire for motion, job or activity requirements. And so very often where they are on the continuum of of one, they're grading system, but also of their expectation and needs. So if you really want a motion sparing option. You really have to think about collecting me and cart Eva. The beauty of both of those operations is it doesn't burn bridges, and the pre op X rays don't necessarily correspond to the postoperative treatment. Empty fusion works well regardless of what the pre op X rays look like, and regardless of what the pre op motion is, but it is a definitive procedure, but we certainly know it has good functional outcomes. So, in our practice, collectively is a tried and true technique. We have used it for years, both open and M. I s as a first line surgical treatment. It's inherently simple. It's easy to explain to. The patients were gonna just take the bump off and straighten the toe. It preserves joint motion, and it can reliably decrease or eliminate pain. It rarely gives them a perfect big toe, and it's easy to revise if it fails to another procedure. So why am I on this symposium? I've been talking about Kyle acting me for years and you could see on the left. Um, this is an open procedure from from what we did for years, but on the right. You can see me doing it with an M. I s technique. And so I've always believed Henry Ford's adage that anyone who stops learning is old. Whether they're 20 or 80 anyone who's keeps learning stays young. And the greatest thing in life is to keep your mind young. So when the m. I s stuff came out and pro step really came on the market, um, I felt that that this was something that I might want to give a try. And in fact, my first cases work. I elect Amis. Um, I really I've always liked small incisions. And those of us who have been doing this for a while know how arthroscopy has changed the way that we look at things and do things. Laparoscopic surgery has changed general surgery for sure. We use mental incision for Achilles and fracture treatment. And robotics has changed that. Also, small incisions can be transformative, but it's been around for a while. Martin Polakoff, a new innovative podiatrist, reported a system of sub journal dermal office surgery with no power tools. Power tools came in the sixties, and in the seventies there was a textbook with curriculum at training institutions. In the nineties, there was an increased popularity with Maya's bunion surgery driven by the Italians in Bologna. I'm done with the Saw and fixed with and I Am K Wire. But then a couple of damning articles came out this one, and from F I i f I I. In 2007 Mark Myerson Group had 13 patients with 70% non union Mallya Union using the Djaniny technique in a different in a different edition in 2000 and five, a perky Tania's distal metatarsal, Osti Ami for Alex Ridges had a 25% rate of postoperative mala alignment despite reporting a 70% satisfaction rate. So at that point, everything died. But like most things that it's often worth revisiting ideas. And here's a picture in of of Becky, Cerrado and Mercy. Who would tell you that that she's not sure how she became a bunion surgery? But when she started doing in my ass, that's what she does. So what's the difference? The difference is the burgers. Power box imaging techniques are better, fixation is better, and the education is better. So what about the birds? Each procedure has a specialized burr In addition, the hand in the box provide us with low speed, high torque option which eats away bone without burning things around it, including nerves and skin. And finally, many cr miss so much better now than it was back when I first started practicing the nineties. But even back in the eighties, when M. I s was popular before, the technique is well defined and the things that we can do extra articular are great. The intra articular things that we do like an m s collect me also provide, um, advantage with smaller incisions. Finally, our fixation is better. We kind of know where it needs to be. And the training, um, that the pro step franchise has rolled out has changed our approach to this. So what about literature and support of this iteration of M i s, um Here's one from Tom Sherman and Greg Guidon, who's been a real proponent. Here is 1/5 metatarsal ost IATA me for Bunia net. And here is a great review of dorsal collecting me for Hallett ridges. Eso How do you engage? Uh, in a low strips way for both both the surgeon in the practice. Well, The key is to get used to the burr and taking bumps off is really nice. In addition, you learn that you've gotta let the burr do the work and you pivot rather than push. And the correct burr for the right procedure really makes a difference. Um, X ray position and related to your dominant hand is key. I found out for 4 ft surgery. The X ray always needs to come from the patient's right side for Kyle. Act Amis. I use a three by 13 wedge Berg Um, and then I use these. These soft tissue instruments that will will release the soft tissue over the top of the bump and allow us to get to it. You can see the goals are exactly the same as an open procedure. You get the burr in the right direction, uber across it, and you get the the loose piece up and then you bird bird towards the skin, which takes the piece off so you can see the angle. Theosophy penetrates the joint and then use your thumb for tactile feedback and uber towards your thumb to get rid of the ossified. You never want to plant a flex because the h L under stress can be cut. You can stay here. I'm still working on this and really getting all of the proximal phalanx off. There's a serape did instrument that allows you to get some of these pieces off the end. It's easy to get the ossified off the first metatarsal as well as the proximal phalanx, and that's what we're doing here. And you can see we've got the proximal Phalanx Austin fight and the metatarsal head Austin fight, and it looks like you've done and open procedure with the bird. Um, Joe Vanua and his group looked at this, and they reported that 86% of patients returned to ordinary footwear in normal daily activity or employment both off. What I would say is, it's still foot surgery, so I tell the patients they could walk, but they need to be careful because they will get some swelling. Um, and here's the functional outcome out of a group, um, by Dr Morgan and showed significant improvement and foot pain function and social aspect of the M s group compared to the open group using for for Open and M. I asked Kyle Academies I also would tell you that you need to consider a proximal phalanx Ost iata me What? Coffin insurance when they were looking coffins patients which Alex Ridges discovered is that there was significant Alex August Inter phalanges in particular in the grade threes and fours. And so back then we started thinking, maybe this is a lateral collapse, but also maybe we wanna unload the lateral side by straightening the toe because our patients like straight toes. In addition, Moe Berg described a door silly based wedge which, when closed down and fix, can give you some increased Dorsa flexion and helps. Uh, this is the description of the family exhaust IATA me, Moe Berg really popularized in 79. Um, Bob Anderson likes to call it a pseudo dorsal flexion, but it definitely puts less stress on the Hallock and improves your your fixation. Uh, the indications are running athlete, regardless of severity. Um, and in my opinion, if you've got Alex Valda center phalanges, I'm going to do approximate last iata me for collecting me as well as cart Eva. So you see here and this is what it looks like. Um, loud described 21 of 24 ft with 90% satisfaction. And he used a K wire to fix hiss. So the Mohican procedure is easier to do, m i s than it is to do open. It's a biplane aroused. Iata me in the proximal phalanx to realign the Alex and add this pseudo dorsal flexion. You do it after you've done the Cadillac to me, and this is what it looks like you're doing oblique cut. You don't go through the far side or the lateral side and you close it down and fix it with the head of headless crew. Um, you take 10 2 to 4 millimeters wedge, and you can take mawr door slowly than planner quite easily. Um, so the increased doors reflection in a straighter toe, in my opinion, increases my patient satisfaction. I do this procedure with the collective me and I use the m i s Berg to do it with cart. Eva, Um and I I really if they don't have a straight toe, I'm adding this procedure, so keep learning. Keep your mind young m. I s is here to stay in my opinion, and you need to take on new things that collecting is an ideal way to get started. And the Mohican procedure is much easier, M i s than it is open, which is saying something. Um, I used to collect me in grade ones and twos. In certain grade threes, I add a proximal phalanx estimate cost IATA me quite often. All right, Michael, I'm gonna give it to you. I'll stop sharing. Hey, Hodges, while while he's pulling up his talk Just a question. A technical question. Uh, when you're doing the collecting me particularly some of those images you showed there was a fair amount of bone spur on the dorsal part of that metatarsal head. What happens to that bone? Um, does the water running through kind of allow it to run out? You're making small incisions. Do you have tow the consciousness that you ever need a counter incision? Just some technical thoughts about how toe boned up out of there. I used to sometimes at a lateral incision if the if the spur was more over there. But I've stopped doing that. It creates a paste almost, and you've got to get water in there. Some guys using use an arthroscope to get water toe. Get all of the Dietrich. It's out. Um, there is a serrated instrument in the disposable instruments that you can that you can sweep it in and the bone pieces will come with it. I don't use a a, um, an arthroscope just is. It's one more big set up, but I But I do irrigated with a with a a syringe with a with a you know, 18 gauge, 16 gauge. It really gets water flowing through there. You you really have to do that. And then about the learning curve, which I think is really important here, you're showing cases with Kyle luck to me, which I think make make good sense to start. What was the learning curve like for you? When did you feel comfortable doing this on a patient is compared toa training in a lab. Just maybe a few thoughts on that, you know, I think collect me is one of those things that you could you could do on a sawbones and do it in a patient. I really do believe that some of the bunion stuff that we're doing, um, a a cadaver really makes a difference, But if you do it on a saw bone and kind of get a feel for cutting across and then blurring towards the bone. Um, then you really do do have that. But the first probably five or six m I asked procedures I did were bump act Amis and diabetics. And you get a feel for how the borough works when you're just taking a bump off, which is different than a nasty autumn e the ost iata me like I showed the aching Moe Berg is so simple because you go straight all the way across you go up you go down and then with the with theme Oberg, you come up again and you squeeze it down. Love it. You come up again and then you put a little screw in there and you're done. So I think the aching of the Aussie autumn ease that we do is the easiest one to do. Yeah, thanks. Just thanks a lot. That's a great introduction from my talk on Guy. Couldn't agree more with the comments you are making about the proximal failings. Osti autumn ease for the, uh, Alex rigidness patients where you're trying to do some type of motion sparing procedure. I can't remember the last time now that I've done to collect New York art Eva without one. So I think that's pretty critical and really good. Take home point from this, um so talking a little bit about cart Eva, You know, before cart Eva came along in, you know, 2015 or so you know, was first mtp arthritis a solved problem because we had fusion and we all do fusions. And we're all usually very happy with the results of our fusions because they provide great durability and they provide great pain relief. But there's a problem with fusion. It doesn't allow for someone to come in wearing a pair of high heels. And it doesn't allow for people to do things like run on the beach or or yoga or Pilates. And there is certainly an advantage anytime you're doing the foot and ankle surgery, if you can maintain motion versus losing motion, and you know this is something that kind of hit home. I trained up in Pennsylvania and I moved, and I started my practice in Virginia Beach, Norfolk, and, um, it's a little bit of a different population. I have a lot of really athletic people. I have a lot of people who live at the beach. They spend a lot of time barefoot and walking in the sand and stuff. And selling someone on a fusion is a tough sell. I'm selling someone on the motion. Sparing procedure is really easy. Um, you know, And like you spoke about earlier, You know, collecting me is a great surgery. And for the earlier stage, how it's Richard is probably all you need to dio. Certainly something, you know, if I open someone up and they've got a bump, but they've got good cartilage, they're not going to get a cart. Eva. There's no reason, Thio, um you know, when it comes to trying to do motion sparing people have tried this in the past on drily, The problem was, the results were unreliable. Hemi, Arthur plast ease Total joint replacements, silicone joint replacements. Really none of them had great results in any large studies. And more importantly, like you alluded to earlier, these procedures burn bridges. You know, if you do it a total joint replacement in the first metatarsal. Flynn, Jill, joint. You're gonna lose a lot of bone Any of us have ever taken out an old silicone Arthur plastic, where there's bad silicone ST Vitus and trying to convert it to a fusion. It's sort of like a bomb went off in there from all the the breakdown. So Kartik became along, and I was pretty excited about this because this is really a solution I was looking for, you know, for, uh, that I didn't have a good alternative for And you know, the purpose. The importance for how its origins patients. You're looking for long term mobility and reduce pain. The Kartika implant. It's indicated for this problem, and it's something that came along with absolutely incredible, uh, research backing it. You know, the bound our study that has been so many times quoted his Level one study, Great a Evidence 236 patients. It was the largest randomized multi center trial for first mtp osteoarthritis. So it's always nice when you're talking to your patients and you could say this is the success rate, you know, this is how I can tell you that. And there's and there's riel actual data because there's so many things in foot and ankle in orthopedics in general, where the data is sparse or or low quality. Um, what's nice about that study to is they follow those patients out now, and they have published long term 5.8 year results on what they've shown in nearly six years is there's significant pain reduction, 97% significant functional improvement and good patient satisfaction. Three. Other thing that's always nice, just from an efficiency standpoint, is cart Eva surgeries air quick. I could definitely do a cart even faster than I could do a first MTP fusion. On average, it's 23 minutes quicker. So when this came out, I started looking at my patients and collecting data because I wanted to see if it really was working. Um, you know, there was some conflicting evidence in the community, you know, whether it worked or not, and whether the results really were as good as published. So I went back and I followed my patients with FAM scores and pain scores and also range of motion and, you know, going back and looking between 2016 in 2018 at 87 patients that I did cart Eva on. I had an average follow up 38.7 weeks. The average patient age was 56.6, with a pretty wide range from 21 all the way to 80. And the results were pretty good. I had, uh, family else, scores of 81.2. Um, and I had pain scores that on average work 0.6. So certainly pretty close. And And this is, you know, this wasn't a perfectly clean study population. This was a real world data. People have had previous procedures, people with diabetes, you know, different co morbidity, ease and certainly different activity demands. Of those patients, two of them were converted to fusion and about 7% had some type of complication. Several of them had pain that I treated with a corticosteroid injection. I had one patient who had some pretty significant sesamoid itis. I was probably a bad call. I probably did the wrong procedure because of the sesamoid issue. One patient who had some persistent arthritis Afterwards, I had one patient who had a stress fracture. She was a marathon runner who really pushed the limits with it. Um, clinical data. You know what the recent studies show? Things study that was published there is going to be published in July. 2020 ft ankle Um, showed follow up 13.9 months with promised scores and the patients who had had the cart. Eva did really nicely. They had improvement in physical function, paying interference, pain intensity on global health domains. Um, what was interesting was what was a negative prognostic factor was patients who had had previous surgery on the M T P J. They tended to have more pain, and what it also showed was something that Hodges was talking about earlier, that a failing sauced IATA medium Oberg or a Mohican type of Osti Autumn E tended to be beneficial and helpful. One of the things that's critical of any foot and ankle surgeon is picking the right patient and then setting realistic expectations. So what is the ideal cart Eva patient look like? You want a patient who wants to maintain motion? It's not realistic to expect them to dramatically increase motion just like any total joint replacement. The best predictor of post op motion is pre out motion. They need to have good bone stock to implant the cart Eva implant into they can't have any significant or severe angular deformities. It doesn't correct a Bunyan. Andi, Uh, it doesn't correct for, says Moya. Arthritis. If that's a significant source of their pain, the patient at the I should say so. Cart Eva indicated how it's rigidness, typically for a great 23 and four. Um, they need to have some motion. If they have no emotion whatsoever, it's probably not gonna be so beneficial. They need to have a reasonable alignment. Contra indications for cart Eva and these air pretty self explanatory. But someone with an active infection, someone who's allergic to that type of implant polyvinyl alcohol, someone who isn't adequate bone stock. Um, or if someone has a You know, you know, Gowdy, Toaff, I things like that, Uh, more than anything, sort of common sense, um, other considerations. Things you really need to look closely at. And and more importantly, I think in in my hands it's my clinical exam, you know? Are they having pain with, says voids? And then if they've had previous surgery of the great toe, you need to be cautious, and you probably need thio temper their expectations a little bit, Um, in the initial study, 17% of the patients who have persistent pain had some type of fracture, or they had a inadequate bone room to contain the cart. Eva, 22% of them who had persistent pain, had diabetes of sesamoid arthritis, and 17% had had prior surgery. So, for example, I just saw a patient this week in 2015. I did a collect me on and she did well initially. But she's developed arthritis. Um, and she's pretty much lost all the emotion and she has pain. And when she came in and we started talking, I did not bring up party. That's an option, for I just recommend she goes straight to fusion, realistic expectations or critical. One of the things and I have another slide that I'll talk about this. But the pain reduction is graduate cart Eva. It's not as fast as with fusion, and really, it takes probably a good 12 months to get to the point where the patient's gonna be as good as they're going to be. Patients receive a We'll have to gradually return to activities, even though I let them immediately wait there. That doesn't mean they should go back to running or high impact sports. Probably not the perfect thing for someone who's really interested in in, you know, extended or long runs or super aggressive athletics, and you have to tell them sometimes they don't work. The good part is it doesn't burn any bridges. I think this graph is really critical, and this is actually something that I carry a picture of around on my phone. When I'm talking to a cart Eva Patient, I show them this so they can see your pain will get better, but it's not going to get better at six weeks or three months. You have to be patient. You have to give it some time. It typically around three months, is where you start to see the pain really start to drop off. And then somewhere between three months and a year is really where the cart Eva implant is optimal on. What's need is if you look at the same graph, but you carry it out from two years to 5.8 years. It maintains, in fact, improves on the pain relief. So this is what I tell my patients when I'm counseling and we're talking about a cart, Eva, my goal is paying improvement and maintaining your current motion. The one of the most important things I try to drive home is immediate. Weight bearing does not equal immediate recovery, swelling and stiffness or normal initially. And if you lay this down ahead of time and you know what patients you know, expect this, then they're not surprised, and they're not worried. And the most important thing is we're not gonna burn a bridge. Thank you, Jeremy. I think it's a little bit about arthritis fusion. Correct. All right. Hey, Way had a couple of questions. Uh, Michael, the first is, um there's, ah, surgeon out in California who has been fairly, um hey, says that 50% of the cart Eva's have failed in his practice. Um, what? What do you think is the reason he's had a different result than you have? Well, I don't know for sure. Obviously, um, I think there's a couple things you have to take into consideration when you're doing a cart. Eva, I think you have to be careful about who you're putting it in. Um, that's one of the things. It's it's if you have someone who is expecting to go out and run on it, Um, or someone who is going to be doing heavy manual labor on it. They're gonna have some degree of pain. It's not really perfect for that. It's better for lower demand folks. Um, I think part of the problem and I think part of it is a confusion. Andi, I think I'll show you in a case towards the end here later. But I think sometimes people you know their patients come back, they x ray it, they look at the X ray and they say, Well, it doesn't look like a normal joint, So therefore it must not have worked. I've seen people who have come to me in second opinion, who they're They're referring Surgeon is recommending revision, and they have little to no pain. And they're only four months out from the surgery. You know, in those cases, I think it's just simply just just, you know, not being patient and not understanding. Um, I think 11 issue with the cart Eva's and something that I'm always very careful with subsidence in patients, especially osteoporotic patients. If you put the implant too deep, sometimes it can fall sort of into a cavity. I always probe after I drill my cart Eva implant to make sure that there's a decent bone block, and I often take some of the remains from the, uh, the rumor that is used to make the whole and I impact shin bone graft the area. And if there's any concern or doubt, I'll even put a little backstop in a little screw or block. Just to make sure that the implant doesn't fall into a cavity in the metatarsal head, you may have mentioned about the proximal phalanx ost IATA me. What percentage do you think you're adding? That at this point I'm adding it 100% of the time? I really don't see a disadvantage to it. If they have any angular deformity, I correct it. If they don't, then I just do. Ah, straight. You know, dorsal Moe Berg type of Aussie Autumn E. It's such a simple, quick procedure. And it, uh, Doctor Giuliano, my mentor. He used to say, I've never been sorry for doing an aching, but there's been times where I'm sorry that I haven't so that's something that I carry around with me. Yeah, I really do think there was a recent paper out of H s s that talked about the patients that had proximal family exhaust. IATA me did better. I think there's something to that and and the more that I talked to folks who continue to love this maybe, and one of them have made that evolution Thio adding approximate families Aussie on a me, um, contraindications Got a question, um, psoriatic arthritis, even though there no large erosions can use it for for auto immune issues. Well, so I think this is something that's changing. You know, I think I think 20 years ago, inflammatory arthritis really required fusion is the only way to treat it. Um, And I think now, with, you know, the better disease modifying rheumatoid agents. Um, if I have a patient who comes in who's really well controlled and it seems like they're doing well, um, then I'll consider, you know, conventional bunion surgery, as opposed to only go into a fusion where cart Eva. If the patients having pain from inflammatory arthritis, well then carted is not going to fix that, it doesn't address the pathology. I mean, really the you know, the cart. Eva is going to be successful when there's, ah loss of cartilage of the metatarsal Flynn Children, and that's source of the pain. So I think that's really the key. Is trying thio figure that out? So you know, if it was a board exam question, I would say definitely it's, you know, it's not the indication for it, but I think in the real world, I think if you have a patient who has an arthritic joint and and it's probably not the inflammatory arthritis and you sort of feel like they're, well control, then it's reasonable to try it. Um, one other question. Um, there there's a trend and I've heard this from a couple of folks going, you know, the original cart. Eva came out and they said, Make it is Bigas You can as long as you have two millimeters on either side and and now more and more people are doing a little more aggressive collective me and going with an eight or even a six rather than a 10. Um, have you continued with the 10 or have you changed the sizing at all? I would say the vast majorities of mine that I do At this point, I use an eight, I think for the Daleks MPPJ The six is pretty small, but I try to stay away from the 10 if I can. Just part of it is, I think, leaving more bone stock if you have to do something else. Um, I think one of the most important things and I think one of the mechanisms of failure And I had a few of these early on. Andi, I've learned from my mistakes in my experience is a lot of times you get the patient who has the osteo fight on the dorsal aspect of approximate failings. And my initial reaction, as soon as I used to open the joint, was to nip that off. But in a lot of cases, I leave that and and by doing so, I could get away with using a smaller cart, even implant, Um, if the if the patient has pretty decent motion and you lied and you take those osteo fights off. And sometimes what I was finding was the cart Eva, the failings with sub blocks under the cart, Eva and sometimes wedge. And then the solution was either you had to bury your cart even deeper, You or you're potentially have something that's gonna be unstable and edge loading. So, um, I one thing that I've learned is I leave that osteo fight in the central portion, and actually that allows for a larger range of motion without subluxation and allows me to get away with a smaller cart. Eva implant. I think that's a really good technical trick. Alright, to other questions. You mentioned the screw, and, uh and we know that that's in theory. Off label. Um, but I just wanted to say that, um have you ever thought about taking down in the M. P J Fusion and converting it cart? Eva, Um, I had one patient who came in with a M p j nonunion times two. And it had the last time it was revised, you know, kind of got the works. Bone graft, bone stimulator, vitamin D supplementation, um, augment. You know, everything. You could throw it this thing and it just wouldn't heal. Andi, In that case, I took it down and revised that to a cart. Eva and he had minimal motion. Um, but he a good pain relief, but, you know I think the problem is, if you take a standard fusion down, you're not going to see tremendous motion. So I don't think there would be an advantage, so I certainly wouldn't. Wouldn't look at it. Like the way we maybe you look at a total ankle, you know, ankle fusion takedown. All right, a couple of more quick. Uh um I think we're gonna have an X ray with cart, Eva and I can Maybe. But, uh, when those you you emulate him, quickly fix him with the screw and get him going. Yeah, I typically, uh, typically fix my aching with staple. And because I'm doing it open with the cart. Eva, Um, and it's just quick and easy, and I let mine walk immediately. What a post op shoot. Um, the new cart. Eva Instruments Now, um, provide you with, um, it leave. Leave the implant proud. 2 to 3 millimeters around three. Have you found you needed to do the little free or trick anymore? Or the new instruments are are pretty sound. Got the I think the new instruments are definitely better. Um, one is I like how it's sort of. It seats the cart Eva. In the whole, it's less likely to miss and go shooting across the room. Um, but number two I usedto under drill all of mine for that exact reason. And leave him prouder than that. So you don't really, you know, now it Now it's setting for you, and you're not guessing. Yeah, The new instruments do do that. Um, alright. And final is, um um a supposed to previous, especially him implants. Why not interpose soft tissue into the first M p. J is supposed to putting putting another form of implant? Our experience with soft tissue is they get super super stiff regardless of what you put in there. We've tried everything from graph jacket to the patient's own tissue. Um, and carted has been been more consistent. Same thing with you, Michael. Yeah, I've tried several those techniques, and I've never really had anything that was overwhelmingly successful. Eso I'm much happier with the Cartago results personally. All right, beautiful. Great. Well answered. Jeremy, uh, we're gonna kick it to you for your favorite operation. All right? Sounds good. Well, thank you. I think great discussion and and certainly is with any of these procedures there certainly are some technical tips that that I learned every time. You know, hearing these talks with folks who have a wealth of experience doing it. So I think really good questions along the way. And I think the interactions important. Um, I have the job of talking about, um, or tried and true operation the first empty PR through Jesus. And you know, here's the case. Just a start. As an example of 54 year old male who's got Alex rigidness and we see some Osti fights, we see some joint space narrowing. Importantly, we look at the, says Moyes, and we see significant arthritic disease that the metatarsal, sesamoid articulation and, as we think about options for him, joint preserving procedures such as the Kyle Ectomy or implant Arthur Plast year interposition Arthur plastic that we've just been talking about. But perhaps also for consideration, I would propose first mtp Arthur DCIS, and that's what we did for this patient. Unfortunately, he was very happy. Hey had a fairly reliable procedure that gave him a pain free toe, and he was able to function very well. Doesn't need to worry about any further surgery. And he did very nicely. And so why him? What makes a great fusion? What makes a great fusion patient? How do we know who to choose for this operation? And so we're gonna look at that in this next few minutes here review what makes a great fusion with regards indications for MTP, Arthur DCIS and some technical considerations that I think are important and then looking at the patient selection. And then, lastly, why do some patients hate their fusion and just some words to the wise to try to be sure that we're educating our patients appropriately? So what makes a good fusion? We'll hear the list of indications, and tonight we're talking about how it's rigidness, so mtp Arthur DCIS for end stage. How it's rigidness. But we know that it can also be used for severe how it's analogous or failed. How its value on the surgery Alex Various deformity, rheumatoid arthritis. We talked about inflammatory arthritis and some of the problems associated with that, and in addition to salvage procedure when one of the other procedures hasn't worked well for a patient theme MTP Arthur DCIS could be the tried and true. We've seen this chart already tonight and there are three. DCIS really is used for these great three and great four patients who've got significant joint disease, particularly as Hodges mentioned the cough insurance classifications, which incorporated that physical exam finding of mid range pain or grind on exam. And these patients are the ones who are really gonna lean more towards on Arthur Dcis. Eso great three complete loss of visible joint space obvious as it fights. Evaluating the, says Moyes, is important. It was mentioned both talks evaluating, if they're, says, more pain where that patient may not do quite as well with the joint preserving procedure certainly any subconscious cysts or other type bone abnormality that may put a cart Eva at some risk of collapse or failure with great four, as we know from the classifications, the same is great. Three. With that pain, mid range motion, the important thing here is that the physical exam drives decision making. I think this is really a critical concept here. You can't simply rely on the X rays, and both of the previous speakers have mentioned that as well. Um, on on exam, you'll see this dorsal prominence. You'll recognize their tentative pal patient, they'll have a decreased range of motion. Those things were pretty consistent, but I think further assessment involves the pain with range of motion. Any actual grind pain pain through the mid range of motion is a key term that's used pain in the area of the C. S. Mott articulation and examining that very carefully. We actually studied this in our institution, and we identified really that the patient reported outcomes. In other words, how they felt their pain was did not correlate with the X rays. It really didn't seem to correlate well with Justin isolated X ray as they reviewed independent of any patient exam eso your exam as the provider is really critical and decision making. Here. Here we see another example of a patient you know, painted extremes of range of motion painted mid range as I mentioned sesamoid pain and grinding axial compression again just emphasizing. If you just look at the AP on this X ray, you'll see some minutes of joint space and think, Man, I think maybe we can save this joint when you evaluate them clinically and then importantly, look at this, says voids. You'll identify that maybe the Arthur DCIS. Maybe a better choice. Here is another case. Example. 42 year old male with first MTP Joint Pain has that dorsal prominence. It's fairly consistent with limited range of motion. This patient has painted end range, but in addition has painted this as Moyes. Pain with Grind has thes clear osteo fights, medial and lateral. And as we review options for this patient, I felt like an empty PR through. DCIS was the most reliable and most predictable. And so here's this patient before and after and again ah, happy patient with a predictable result. This patient did very well and was very happy with their outcome. And so if we're choosing this patient, what are some technical considerations? How do we make sure we give them a good result? Why choose screws versus plates versus plates and screws, and what's the thought process there? Well, there's many techniques and implants available on the market, and here's a complete list. Staples K wire suitors Really the most consistent in what I use in my practice is a dorsal plate with across compression screw, and the reason is that I think it gives you some mechanical support when we look at joint preparation, this is very important. There's options for flat cut techniques or cup and cone reaming. Now with some of the minimal invasive techniques, tryingto make a more minimal incision approach, perhaps preserving some blood supply to the construct. Um, in my hands, I like the cup and cone. It's been shown it in L. F s presentation to be shorter time the union and fewer non unions as compared to a flat cut. Um and so this is the most consistent for me, and I like to have a match on the metatarsal head and to the phalanx match the sides. Usually it's an 18 occasionally bigger to a 20 sometimes the smallest 16 about 18 probably most consistent in my hands. And as we look at fixation, this is what I was alluding to earlier. When we look at ah, lag, screw with the dorsal plate. This is a significantly mawr firm and more stable construct, as compared to a plate alone or K wires or just lag screws on DSO. This is really important because as we think about progressing our patients in their recovery, this can give you more confidence that the construct will remain more stable because there's biomechanical evidence to support that. And so why choose a plate? Well, it's the obvious choices of strength and rigidity. We've shown that we've shown that it's better than some of the other constructs. There's gonna be better compression, as you can compress through the plate on. Therefore, as we've talked, maybe allowing earlier weight bearing or progression with patients. And the newer generation plates tend to have a lower profile them or anatomical in their consideration, not only with a slight valdas bend to the to the plates, but in addition, slight doors reflection in various options of 05 or 10 to try to fit three reduction as you've placed it optimally. Additionally, most of the plates haven't integrated. Ah, lag screw option, whether it be to compress to the plate or the cross check plating system has a lag screw that goes through the plate for those who prefer a technique like that. But the plates all offer the advantage of being, um, strong and stable and allowing patients to heal reliably a Z. We consider the option of locking screws or locked plates versus non locked place. I think it's important that we recognize a locked plate will absolutely be stiffer and have a higher loads failure and perhaps less planner Gapping. This was a study by my good friend Can hunt, and what they showed was that the lock plates would fail at the plate bone interface, where the non lock would tend to bend through the plate. So it's definitely stiffer if it has a lock screw construct. The concern is, is it too stiff? And when we think about basic fracture healing or Arthur Jesus healing, and so typically I'll try to use a combination, I'll use locked and non lock screws, as we consider bone quality is an important angle or aspect of this. The other aspect of the technical consideration I think that's important is the dorsal flexion angle of Arthur DCIS. There was a robotic gate simulator that was used to evaluate position of varying Dorsey flexion angles of fusion. This was published in J. B. J s, and they identified the 20 to 25% degrees of Doris Reflection gave the optimal mechanical gait most similar to that without Arthur Jesus. And so now, technically, we've got it figured out We just have to be sure we choose the right patient. And so what patient is gonna make a great fusion? Well, it's the right indications, and we reviewed some of those. But even with the right indications, there's some choice. The first empty PR through DCIS for severe Bunyan may have the option of considering a Lapidus to maintain motion at the first MTP joint. Or perhaps you could consider a fusion versus soft tissue reconstruction. Interposition Arthur Plastic implant Arthur classes we've talked about with CART Eva and I think critical here is a careful, honest conversation with the patient. This has been brought up in both of the talks previously tonight. They have to know what they're getting into. We know that the fusion is going to do well, and here's a chart of many studies that have been published high satisfaction rates and high union rates greater than 95%. So the fusion is a procedure that works. Some patients are concerned that they may lose motion, so we know it's gonna work. They're gonna have pain relief. But here's a patient of mine. And if we look at this, we see as they walked down the hall. It's different, but these air bilateral mtp Arthur D. C s and so this is the patient is walking down the hall in shoes. And if you didn't know any better, you look and say that there really isn't much difference between what you think of normal gate might be. And here's this patient's X rays. And so those first MTP joints refused. The foot accommodates fairly well. You still have I p. Joint motion in a well positioned fusion will give pain relief and functionally will do very nicely. Scott Alice, I think, did us all a favor. If you haven't seen the study, please refer to it because I think it's very helpful when you're talking to patients. They published it in F A I in 19 2050 patients with an average age of about 50 years old and they were five years status post for sent to PR through Jesus. So what they did is they reviewed these patients as it pertained to their activities, and they looked at 22 different sports and activities, and they identified that the patients reported no physical activity that was discontinued post operatively and in fact, 20% were able to do mawr difficult activities, as was characterized by the level of function necessary. In other words, biking less strenuous than playing basketball. 96% were satisfied regarding their return to sport. And so I think it's all about expectations. They're not gonna have normal joint, but they'll have relief of pain and, by extension, than better activity. So after the careful conversation, the patient needs to believe it's the best choice. And I would offer that if they have doubt or you think you're convincing them that they need an Arthur DCIS when perhaps interposition or maintenance procedure maintenance of motion procedure might be still on option? Um, it may be OK to do that. You don't want them to be disappointed with their outcome. If you they feel like you're convincing them for an Arthur DCIS, you might want to consider other options. Some patients end up hating it, and my experience is that those are the ones who just didn't know what they were getting into or had inappropriate expectations. Sometimes, unfortunately, it's also the patient who's had a complication. And so what are those complications? Well, nonunion, of course, and those aren't fun. I think that happened. Everyone. If you do enough of these, you could have too much Dorsey flexion. Um, al Union. And you can see here that the I P joint is extended that Alex is lifted up and that toe will rub on shoes and be uncomfortable. You could have the opposite. Too much planter flexion. You can see here that the I P joint now is essentially dislocated because there's so much pressure on the distal aspect of that proximal failings. Because of the mall union that's been created at the Arthur D Society, you could also have too much Valdas. This is a patient of mine that was left in too much. Valdas has some rubbing on their second toe, and some impingement there on the patient wasn't satisfied as I would have liked. The other part of this is inappropriate expectations. We mentioned that shoe air activity expectations, recovery expectations you don't want to hear. I didn't know my toe would be stiff because in my view, if I hear that I didn't do my job explaining what their outcome was going to be, the pre op conversation is critical. I can't say it enough, help them understand what they're going to have after surgery. And so we've reviewed a lot of stuff. One of the take home points, Alex Empty PR through DCIS, could be used for many pathologies, particularly how it's prejudices. We talk about it tonight. I would offer that it is the definitive MTP procedure when it's the procedure used as salvage. When the other ones don't work, it's gonna be the one that's tried, and true patients will love it if it's technically done. Well, if expectations are set appropriately, if not, the patient might hate it. And obviously you want to avoid that. Clearly, we keep looking for new solutions. And that's what tonight, in part, has been about. How do we maintain motion looking at minimal incision? Collect Amis looking at the cart? Eva, some of these interposition procedures that exist on out there, um, but I think importantly, you can always come back to fusion. It predictably corrects deformity. It relieves pain. It heals reliably. It allows the high level of function is definitive. Usually this is gonna be the last operation, and I think for all of these reasons, it really is my favorite forefoot procedure because I think patients do very well and reliably well with it. Again. Importantly, if it's the right patient for the procedure, Thanks. So, Jeremy. Couple of quick questions. Um, do you have an age cut off where you would say, anyone older than this I'm going to a fusion or younger than this? I'm going straight Thio, cart Evo or guy like to me? No, I think the age come into play. E think pathology comes into play mawr than age, although I will offer if it's a younger patient, I might b'more inclined to think about a joint preserving procedure because that younger patient more commonly will have different activity goals much on the opposite end. If it's a patient, that's a little bit of a tweener, but they're more sedentary. I might be more inclined to go right to an Arthur DCIS because their activity goals might be a little bit different. Just maintains a mechanic at the joint, but ages and specific. It's more activity goals than anything else. Do you? Do you ever say, Look, we're going to just open you up and we'll decide, Um, at the time of the surgery, what we're gonna do? Yeah, I don't, um and I think that is maybe a little bit of individual preference. I would much prefer toe have that decision made ahead of time, I think. Especially if you're looking at a joint maintenance procedure versus and Arthur Jesus procedure. That's very different. Their toes gonna be very different in between. Um and you know, I think maybe you could say, Okay, we're going to do a collecting me, but if the joint looks bad, we're gonna add a cart. Eva, I could see that maybe is an argument, but I would personally have a hard time saying, Well, maybe it collecting me. But you know what? You might have a joint views when you come out of the operating room. Those were different. Enough procedures where I think that's something that the patient should know in advance. Well said, Okay, Jeremy, won't you take us through a few cases? We probably have five minutes. Sure. Eso We'll look at case one here. Um, you know what? Stop sharing their hang on one second and we'll get you pulled up. There we go. Sorry about that. So case one Miss Dr Campbell's case. So This is a 52 year old female schoolteacher, several years their first MTP joint pain. Um, conservative treatment with the Mortons extension and inflammatories. Cortical steroid injection have failed, and they were unable to make it through their school day without an inset and pain ready. They're paying nine out of 10. At the end of the day, the patient reported that the limp up the stairs to go to bed um, non significant past medical history on exam have about 20 degrees of Doris Reflection, about 10 degrees of plan reflection. They do have an actual grind tests and painted end range. Doris Reflection. I'm no pain under the, says voids as a key point. Eso Hodge says, This isn't your case. This is Dr Campbell's case. You're looking at these X rays with that history, so no pain under the says voids. But they do have some pain with Grind limited by the 30 degree arc of motion. What are your thoughts with this 50 something year old patient? What's your conversation gonna be like? You know, my experience with Collect Amis is that if they don't have a bump to collect me, doesn't do much and So this is a patient. If this is patient, I would inject. And if the injection helps him even in for a short period of time, I would definitely consider cart Eva in this patient. Um, and And I probably would do, um Oberg also because they're a little stiff. So this is a Coughlin grade 0 to 1, and, um, and I I think it's probably a one, and that's where I would go with that. If they don't have a bump. I think car, um kinda like me doesn't work particularly well. And if they had pain under their says voids with a joint that looked like this, would that change your decision making? If I'm clinical exam, they had planner pain for sure, for sure it would. Because I just think the sad boy is a nonstarter for the motion deriving operations and and I've even to the point said, all right, I need to make that. Sure that says more pain is right, especially in a joint that looks like this. And I'll often doing memory just to make sure that the says boards are involved. And sometimes you know the dorsal pain is the least of it. It really is arthritis and says more joints and in my hands, fusion works better for that. And so here is the patient. Um, Dr Campbell elected to do a cart. Eva for this patient on here, their x rays, 24 months post up any comments, Mike on, um, some of the discussion we had or Hodges about about choosing what case to do. Well, so So I definitely agree with Hodges what he was saying about getting the m r. When you have a patient that has a joint, that doesn't look bad. Um, and you know, for this patient that, you know, this would be something that I would definitely get a memory because I've seen sesamoid pain sort of be very difficult to distinguish from, uh, intra articular mtp pathology. And you don't want to get that wrong with cart Eva on. You know the other thing too. This is one of the early ones. I didn't You could say I did it without the Moe Berg and definitely 100%. Now, this would get a Milberg. This was one of the ones from 2016 that I had longer term. Follow up. But part of the reason I wanted to pick this was you know, when I look at this post op X ray in 24 months, I don't think that joint looks great. Um, you know, it looks to me like there's not a tremendous amount of space and, you know, I think I think if you show this to people that say, Oh, maybe that cart Eva subsided or something. But the reason I picked this was because she had a tremendous outcome with this joint right here. She's having no pain. She's got great motion, not great motion, but, you know, functional motion and improvement over what she had pre operatively and little to no pain. So but definitely again, you know, Adam Oberg to this and the outcomes even better in the motions. Better, and Hodges or Mike for those patients in the audience who have experience with interposition Arthur plastic, whether it be, you know, we alluded to it earlier, whether it be the patient's own tissue or whether it be some of the dermal Allah graphs that are on the market graft, jack or likes, Um, what would you say toe to a provider who might say, Well, I could get Justus good. A result with an interposition Arthur plastic rather than a cart. Eva, what would be some points you would make Thio proponent cart Eva by comparison, my experience with those is that they get stiff really stiff and then then you're gonna have to do something to the proximal phalanx. And so either you could do a fairly aggressive Moe Berg or you can you could do ah Keller type thing, which is they've all been described. My experience is that they never get their strength back, and so so that they just don't love it. And you think the stiffness is any different than you know? I mean, Mike was saying that this patient didn't have a great arc emotion, but their pain was better. Do you think the stiffness is different enough, or is it mawr? If you have to come back, you know, it's a little easier to address this type of joint. I'm talking. They're just rock stiff and often with without pain relief. And so then you're coming back to a a joint. You've done a bunch of work to and try to do a fusion later. Yeah. You know, those the resurfacing ones that I've done when you see him a year, two years down the road, there's still kind of swollen and boggy and just just it seems like they get to the point that cart Eva's at at four months and they never get past there. So in my hands, this works better. Okay, Um, how we doing on time, folks? Um, yeah, I think we can probably dio Let's do one more Jeremy. And then we'll go from there s Oh, this is just a little more data that was presented with Mike's case fans Score was was very good for this patient, and she did very well, Azaz was pointed out.
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