Dr. Jeremy McCormick discusses how to match the right patient with a MTP Fusion for hallux rigidus, along with setting expectations for this surgical option.
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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 to start as an example of 54 year old male who's got Alex rigidness and we see some osteo 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 chi locked to me or implant Arthur plaster your 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 rigid ISS. But we know that it can also be used for severe how it's analogous or failed. How its value on the surgery, how its 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, Theo 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 a 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 Aussie 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 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 for as we know from the classifications, the same is great. Three. With that pain on 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 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 sesamoid 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 providers really critical on 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. Um, you'll identify that maybe the Arthur DCIS maybe a better choice. Here's 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 is 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 wires, 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 in my hands. I like the cup and cone. It's been shown it a Neff's presentation to be shorter time the union and fewer non unions as compared to a flat cut on DSO. This is the most consistent for me, and I like to have a match on the metatarsal head and to the phalanx match the size. 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 going to 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 lock plates. 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 are through 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 that Dorsey 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 MTP Arthur 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 a 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 2019. 50 patients with an average age of about 50 years old and they were five years status. Post First NTP are through Jesus. So what they did is they reviewed these patients as it pertained to their activities. 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 with 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 Doris Reflection Um, al Union. And you could 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 the patient mind 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. What the take home points Alex MTP Arthur DCIS could be used for many pathologies, particularly how its richness is. 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 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 coming to 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. Um, and just maintain some 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 collective 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.
