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#5 Surg > 65 - Arthrodesis Procedures of the Forefoot > Flashcards

65 - Arthrodesis Procedures of the Forefoot Flashcards

1
Q

Forefoot arthrodesis procedures

A
  • Digital arthrodesis (PIPJ, DIPJ)
  • Hallux IPJ arthrodesis
  • 1st MPJ arthrodaesis
  • Lapidus
  • Lisfranc’s arthrodesis
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2
Q

Digital arthrodesis

A
  • Can be used for any hammertoe correction
  • Used for EXTENSOR SUBSTITUTION etiology of hammertoe correction (this is the MAIN indication***)
  • Toe converted to a rigid lever (less floppy, more rigid and functional)
  • Fifth toe never fused – this would make the PIPJ too stiff
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3
Q

Three methods of digital arthrodesis

A

1 = Peg in hole

  • She used to do a lot of these to add more stability, but it takes a long time
  • You will shave off sides of head of proximal phalanx “peg” and then make a “hole” in the distal phalanx and shove it in there

2 = End to end (MOST COMMON***)

3 = Chevron

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4
Q

HALLUX IPJ ARTHRODESIS

A

This is what we’re starting with

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5
Q

Hallux IPJ arthrodesis indications

A
  • Neuromuscular Disease
  • Cavus Foot
  • Traumatic Arthritis
  • Iatrogenic Deformities
  • Hallux hammertoes

Notes
o Not done a ton, usually done in conjunction with other procedures (tendon balancing, cavus foot procedure, etc.)
o In someone who is healthy and has good neuro function, you will have 2-5 hammer toes but not hallux
o In someone with neuropathy, you will see 1st hallux as well

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6
Q

Hallux IPJ arthrodesis skin incisions

A
  • Transverse Semi-elliptical
  • Lazy “S”
  • Linear
  • NOTE: The hallux IPJ does not have a lot of room to get into the joint without going through the nail, so you have to come across the top of the toe with your incision
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7
Q

Lazy “S” incision

A

o Done when you need MORE exposure
o Can flap things both up and down to get good exposure
o Biggest problem you will have with “right angles” is that you will be cutting your vasculature to that area and wound dehiscence can occur
o It is a lot more fragile skin compared to an elliptical shaped incision which is typically really easy to close

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8
Q

Hallux IPJ arthrodesis cartilage resection

A
  • Resection of cartilage from head of proximal phalanx and base of distal phalanx
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9
Q

Hallux IPJ arthrodesis for angular deformities

A
  • Angular deformities can be corrected

- If you have some sort of an angular deformity, correct that as well while you’re in there

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10
Q

Hallux IPJ arthrodesis fixation

A
  • K-wire (crossed or intramedullary)
  • 4.0 mm partially threaded cancellous (solid or cannulated)
  • Put K wire right down the center of the toe
  • MOST people will do a screw instead
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11
Q

Notes on hallux IPJ arthrodesis diagram

A
  • This is how you put a solid screw in, but this is NOT typically done – you would usually do a cannulated screw
  • If you don’t have cannulated, you can drill the distal phalanx like this then drill the other side then go in through the tip in order to actually insert the screw for fixation
  • This is why cannulated screws are popular – if you don’t get your guide where
    you want it, you can always move it
  • If you have a drill bit already in, it is hard to move it once you’ve drill (downfall)
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12
Q

Notes on hallux IPJ arthrodesis radiograph

A
  • Want something wide enough to actually grasp the sides well
  • Make sure you have enough room for the screw, don’t want to crack the cortex
  • Also don’t want something too small that it won’t stay in
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13
Q

Hallux IPJ arthrodesis post-operative care

A
  • Weightbearing in postop shoe or boot for 6 weeks
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14
Q

Hallux IPJ arthrodesis complications

A
  • Delayed healing of soft tissue or bone – More so soft tissue than bone (especially with Lazy S”)
  • Varus or valgus rotation of toe if you do not have good alignment – Can lead to pressure points and ingrown toe nails
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15
Q

Next procedure…

A

FIRST MPJ ARTHRODESIS

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16
Q

History of first MPJ arthrodesis

A
  • Only two articles in podiatric literature before 1986
  • Used for salvage and reconstruction
  • First description in 1852 by Broca
  • Thompson and McElvenney discussed position in 1940
  • McKeever in 1941 brought procedure to popularity
  • NOTE: Podiatric medicine did not always embrace this procedure, but it is more of a gold standard now
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17
Q

Indications for first MPJ arthrodesis

A
  • HAV: Neuromuscular
  • Hallux Limitus/ Hallux Rigidus MOST COMMON INDICATION
  • Failed Bunion Procedures
  • Failed Keller or Implant
  • Hallux Varus
  • Arthritis: DJD, OA, or Inflammatory arthidities
  • Combination with a Panmetatarsal resection
  • Loss of extensor or flexor function
  • NOTE: Many different indications – If you do it with a bunion, you are removing some of the deforming forces and can potentially reduce recurrence
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18
Q

Contraindications for first MPJ arthrodesis

A
  • IPJ arthritis or limitation of motion
  • Osteoporosis
  • Patient factors: occupational or functional expectations
  • NOTE: Motion has to be taken up somewhere, so it is going to go somewhere else, usually the adjacent joints which can be problematic if they have issues with nearby joint problems
    o You will not be able to wear high heeled shoes
    o Not going to be able to get into a 3-4 inch heel
    o But normal shoes will now be pain free
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19
Q

Technique for first MPJ arthrodesis

A
  • Dorsomedial incision
  • Capsular release
  • Resection of medial eminence (only if it is a bunion procedure)
  • Get rid of any exostosis (spurring with hallux limitus is common)
  • Removal of cartilage or fibrous tissue
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20
Q

Ways to remove cartilage or fibrous tissue

A 
o	Curettage  (scape until you get to good bone)
o	Saw  (you lose a lot of length)
o	Special cup and cone reamers (maintain good length and joint motion) – produced by plate manufacturers
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21
Q

Cup and cone reamers for first MPJ arthrodesis

A
  • Special cup and cone reamers – Make sure the joint is exactly where you want it to be
  • Spins really fast, you can get down into subchondral bleeding bone really easily
  • Cone reamer can be difficult – you already have a tight joint because they’ve had hallux limitus for a long time, so plantarflexing the hallux enough to get into the joint this way can be difficult and you could even damage the surrounding structures
  • **The biggest thing to think about is JOINT PREP – NEED to get down to bleeding subchondral bone **
  • If you don’t do this it is really hard to et healing here and you will get a non-union
  • Basically you poke holes into the subchondral bone, get bleeding coming out, this will assure better, faster healing
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22
Q

First MPJ arthrodesis lengthening

A
  • In patients with neuromuscular disease, may want to lengthen EHL
  • Bone graft (if necessary)
  • Corticotomy with callus distraction
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23
Q

Bone graft in first MPJ arthrodesis

A

o Particularly if it is a salvage procedure (failed Keller or implant)
o Either from the patient, cadaveric, or artificial graft
o You will need a good chunk of bone
o Can get it from the back of the calcaneus, so that you can get cortical and cancellous bone
o If you have a LOT of shortening, you may need to think about callus distraction

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24
Q

Corticotomy with callus distraction in first MPJ arthrodesis

A

o May need to do for salvage procedure with extreme shortening
o Staged procedure
o This way you can stretch out the other structures as well (vasculature)

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25
Q

First MPJ arthrodesis positioning

A
  • 15 degrees of dorsiflexion
  • 15 degrees of abduction
  • 0 degrees of frontal plane motion – NO rotation
  • Take into account metatarsal declination
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26
Q

15 degrees of dorsiflexion

A

o Tip of hallux should be elevated 10 mm from WB surface when foot is loaded\
o Do NOT elevate it a lot because you will be stuck in high heeled shoes or their toe will rub on shoes

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27
Q

15 degrees of abduction

A

o Try to keep hallux parallel with lesser digits

o This is the normal curvature of the foot and of shoes – prevents rubbing

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28
Q

Intraoperative evaluation for first MPJ arthrodesis

A
  • Sometimes in the OR, you will check the trays you have, you can take the tray and load the foot
  • On the right – pushing up on it, parallel to WB surface – this is how you want to correct it
  • On left – Before pushing up, too much loading of hallux
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29
Q

Fixation for first MPJ arthrodesis

A
  • K-wires or Steinmann pins
  • Screws (MORE COMMON)
  • Compression plate
  • External fixation
30
Q

K-wires or Steinmann pins

A

o Threaded or smooth
o Single or double
o Intramedullary or crossed

31
Q

Screws (MORE COMMON)

A

o Cortical
o Cancellous
o Herbert
o Generally 2 screws used in crossing fusion – This allows good compression on both sides and prevents any motion or rotation out of alignment

32
Q

Compression plate

A

o Some compression plates are even already pre-bent into 15 degrees of dorsiflexion
o A lot of compression plates are locking
o 2-3 screws should be placed on either side of fusion
o I used to use plates a lot but I have gotten away from it because I almost always have to take the hardware out because there is not a lot of soft tissue so there can be a lot of plate irritation

33
Q

External fixation

A

o External fixation is better for salvage procedures with excess lengthening needed or osteoporotic bone

34
Q

Image of screw placement options for first MPJ arthrodesis

A
  • The middle image of crossing screws is more common
35
Q

CASES TUDY on first MPJ arthrodesis

A
  • Patient had had a bunion procedure in the 80s or 90s
  • Probably had an implant or Keller
  • It left her with a floating hallux
  • Toe is starting to cross over and cause pain as well
  • With this plate you can put a compression screw right through the middle
  • She did fairly well, did not have to take hardware out
36
Q

Post-op management for first MPJ arthrodesis

A
  • Protected WB in boot for 6-8 weeks
  • If extensive grafting done NWB for 6-8 weeks
  • If external fixation or K-wires used, remove in clinic 6-8 weeks
  • Do NOT do a post-op shoe – too much pressure across the joint
  • Usually she does non-WB for 2-3 weeks then allow WB in the boot
  • If you’re doing a lot of grafting you need to keep them non-WB
  • NOTE: there are a couple different theories on what to do post-op
37
Q

Complications of first MPJ arthrodesis

A
  • IPJ arthritis
  • Lesser metatarsalgia
  • Stress fracture
  • Varus/valgus rotation (ingrown nail or calluses may be present)
  • Sagittal or transverse plane malposition (Difficulty with shoe gear, Overloading of hallux if fused too plantarflexed, Bunion or sesamoid pain)
  • Delayed or nonunion
38
Q

Next procedure…

A

FIRST METATARSAL CUNEIFORM ARTHRODESIS

39
Q

Introduction to first metatarsal cuneiform arthrodesis

A
  • Advocated by Lapidus in 1934
  • Initially described as an indication for juvenile hypermobility
  • Gaining popularity because a lot of theorists think the deformity lies in this joint and fixing it here will be able to prevent recurrence
40
Q

Indications for first metatarsal cuneiform arthrodesis

A
  • Juvenile HAV with hypermobility
  • Osteoarthritis and Degenerative arthritis
  • Charcot osteoarthropathy
  • Severe adult HAV with IM angle exceeding 15 degrees
  • Medial column instability
  • Ligamentous laxity
41
Q

First metatarsal cuneiform arthrodesis skin incision

A
  • Dorsal incision extending to the medial cuneiform
42
Q

First metatarsal cuneiform arthrodesis articular cartilage resection

A
  • Curettage or saw resection to bleeding subchondral bone
  • Transverse and sagittal plane correction is done before fixation
  • Make sure you are fenestrating here to boost healing
43
Q

First metatarsal cuneiform arthrodesis fixation

A
  • 3.5 or 4.0 partially threaded cancellous screws (in a crossing fashion similar to in the previous procedure)
  • Plate (does not do this as much anymore because lack of soft tissue coverage – has to take our a lot of plates from irritation – Union rates are still good, but there is a higher risk for breaking screws than the plate)
  • Pins
44
Q

Incision for first metatarsal cuneiform arthrodesis

A
  • Watch the dorsalis pedis – do NOT do this incision, do it more
    medially over the metatarsal shaft, NOT in the intermetatarsal space
  • Do it where the red line is
45
Q

Supplementary screw placement in Lapidus

A
  • In the traditional Lapidus paper, he does talk about this screw position with the MM screw
  • Some will have hypermobility in the other joints, so this may be necessary
  • More traditional is just one screw placed from the 1st cuneiform to 1st metatarsal and one from the1st metatarsal to the 1st cuneiform
46
Q

Post-op care for first metatarsal cuneiform arthrodesis

A
  • Non-weightbearing short leg cast for 6-8 weeks
  • Partial weightbearing for 2-4 weeks
  • Physical therapy at 3 months
  • NOTE: This is a downfall of this procedure – once you start to see bony consolidation, you can allow partial or full WB then send to PT to transition out of the boot
47
Q

Complications of first metatarsal cuneiform arthrodesis

A
  • Nonunion: 4-10%
  • Malunion: usually 1st ray elevation will occur due to bending of plates and screws with WB too early (non-compliance)
  • Excessive shortening
  • Neurovascular compromise
  • Transfer lesions (if you have a 1st ray elevation, 2nd and 3rd metatarsal head lesions)
  • Hallux varus (if you were too aggressive with the correction)
  • NOTE: recent metaanalysis (Willegger, 2015) showed a 4% non-union rate and a 16% complication rate overall, so patient compliance is HUGE – some of the hardware construct can fail with weightbearing too early
48
Q

Advantages of first metatarsal cuneiform arthrodesis

A
  • Eliminates 1st met cuneiform hypermobility
  • Stabilizes the medial column
  • Allows for large amount of correction
49
Q

Disadvantages of first metatarsal cuneiform arthrodesis

A
  • Extensive surgical exposure required
  • May shorten 1st ray
  • Can be technically demanding
  • Prolonged postop period
50
Q

Next procedure…

A

LISFRANC’S JOINT ARTHRODESIS

51
Q

Indications of Lisfranc’s joint arthordesis

A
  • Post-traumatic arthritis
  • Degenerative joint disease (DJD)
  • Charcot osteoarthropathy (COMMON)
  • Pes Cavus
  • Metatarsus adductus
  • NOTE: More commonly we see Lisfranc’s injuries with car accidents and the foot going through the floor of the care – I’ve also seen it in some people with DJD and they have some flexible pes cavus
52
Q

Diagram of Lisfranc’s joint arthrodesis

A
  • This diagram makes it seem like it’s really simple but it isn’t
  • The dissection is meticulous because of all the neurovascular structures
  • Need to be very careful not to damage tissue here
  • A couple dorsal skin incision will be necessary
53
Q

Pre-op evaluation for Lisfranc’s joint arthrodesis

A
  • Radiographs (stress radiographs)
  • Bone Scan
  • CT Scan
  • NOTE: May need multiple studies due to bony overlap on xrays
54
Q

Example of Charcot

A
  • The only way to fix this is to cut through entre Lisfranc’ s joint and fuse all the joints
55
Q

3 components of Lisfranc’s joint arthrodesis

A
  • 3 distinct components to tarsometatarsal region
    o Medial = 1st met cuneiform joint
    o Middle = 2nd and 3rd met cuneiform joint
    o Lateral = 4th and 5th met cuboid joints
  • Any one of the 3 components may be fused in ISOLATION for focused arthritis
  • NOTE: These are things to think about when you’re fusing Lisfranc’s – 3 distinct components
  • Sometimes if you fuse the 1st, the 2-5 will fall into place
56
Q

Soft tissue dissection in Lisfranc’s joint arthrodesis

A

Soft tissue dissection and incisional approach
o Generally 2-3 longitudinal or curvilinear incisions dorsally
o Must have meticulous dissection due to neurovascular and tendinous structures present

57
Q

Incisions for Lisfranc’s fusion

A
  • Get the C-arm out and make sure you are where you think you are
  • Then make the incision accordingly
58
Q

Techniques for Lisfranc’s joint arthrodesis

A
  • Inlay Graft

- Joint resection with end-end arthrodesis

59
Q

Inlay graft

A 
o	Dowel Graft Arthrodesis (Inlay Graft)
o	Iliac crest bone graft
o	In situ fusion
o	No correction
o	Crossed k-wire fixation
60
Q

Joint resection with end-to-end arthrodesis

A

o Curette and do a basic end-to-end arthrodesis

61
Q

Sites for bone graphs in Lisfranc’s joint arthrodesis

A
  • You may not need to do all of these points – these are sites for bone grafts
62
Q

Resection for Lisfranc’s joint arthrodesis

A
  • Joint Resection with end to end arthrodesis

- Truncated wedge resection

63
Q

Joint Resection with end to end arthrodesis

A

o Correction of subluxed/dislocated joint achieved

o This is MORE COMMON

64
Q

Truncated wedge resection

A

o For pes cavus correction

o Can do a truncated wedge resection if you’re doing a lot of these and are very familiar with the procedure

65
Q

Temporary fixation for Lisfranc’s joint arthrodesis

A
  • Fixate 1st and 5th mets 1st to evaluate parabola and foot alignment
66
Q

Permanent fixation for Lisfranc’s joint arthrodesis

A
  • Screws
  • Plates
  • K-wires
  • Staples
  • Combination
67
Q

NOTES on permanent fixation

A

o Permanent fixation – up to you what you want to fixate with
o Staples are the easiest because of angles for drilling the screws in
o Plates have the same complication of soft tissue irritation and have to take plates out
o This is where I use stapes the most

68
Q

Example of Lisfranc’s joint arthrodesis

A
  • This is an example of fixating with screw – A LOT of hardware needs to be used
69
Q

Post-op management for Lisfranc’s joint arthrodesis

A
  • NWB for 6-8 weeks
  • May initial want to put in splint for postop edema, then go to cast
  • Then, WB in boot for 2-4 weeks
  • NOTE: Since this is the middle of foot, it needs to be NWB until you achieve bony consolidation
70
Q

Complications of Lisfranc’s joint arthrodesis

A
  • Delayed or non-union
  • Nerve damage/entrapments or vascular damage
  • Malalignment or stress fractures
  • NOTE: A lot of things you need to go in and dissection (nerve damage)
  • Stress fracture if you have one metatarsal that ends up being lower or higher than the others

#5 Surg (12 decks)

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