Name: Hallux Rigidus Treatment Algorithm of the 1st MTP Joint
Uploaded: 2020-08-20T00:00:00Z
Channel: Arthrex
Description: Thomas G. Harris, MD (Pasadena, CA), presents the complete biologic algorithm for hallux rigidus of the 1st MTP joint. Dr. Harris considers the progression of disease from mild to severe, as well as revision scenarios.

<p>Thomas G. Harris, MD (Pasadena, CA), presents the complete biologic algorithm for hallux rigidus of the 1st MTP joint. Dr. Harris considers the progression of disease from mild to severe, as well as revision scenarios.</p>

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VID1-001040-en-US | A | Hallux Rigidus Treatment Algorithm of the 1st MTP Joint

Thomas G. Harris

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Hallux Rigidus Treatment Algorithm of the 1st MTP Joint

Hello, everyone. My name is Tom Harris. I'd like to talk to you today about a treatment algorithm we developed for Rigidus. I developed it with my current fellow, Casey Powell, and I am the chief of Foot and Ankle at Harbor UCLA in Torrance, California. And I also work at Pasadena, California, at Congress Orthopedics, where we started our own foot and ankle fellowship there. In terms of the overview of this presentation, we're going to define how looks Rigidus first, we're then going to talk about the classification system that we used, and we're going to apply our detailed algorithm for how Rigidus. And then lastly end with some case examples in terms of our options. When you think of the first empty p joint, Arthrex has many options. Biocartilage Cartiform precut cause arthroplasty, interposition arthroplasty with the ArthroFlex, the bone dowels as well as MTP arthrodesis. And they all have a role in our algorithm. In terms of the definition Halex Rigidus represents a spectrum of arthritic pathology of the first Metatarsophalangeal joint. The first MTP joint. This ranges from symptomatic cartilage loss to subchondral bone lesions to full blown degenerative joint destruction. The first MTP joint is the most common site of arthritis in the foot, with ranges from about 3 to 5% of the entire adult population. Symptoms and findings include pain. Stiffness. Sometimes we'll see a visible nodule or a bone deformity at the first MTP joint, and patients will often note a loss of dorsiflexion at the first MTP joint as well. In terms of the clinical classification, we talked about pre radiographic disease, which consists of synovitis osteochondral defects, subchondral bone edema. Often those aren't able to be able to seen on x ray and require advanced imaging such as an MRI or CT scan. Patients will have pain with motion possibly history of injury to the great toe move into mild disease, which is pain with some activities. A mild decrease range of motion with an arc of motion between 40 and 60 degrees, and patients also have mild pain at the extremes of the range of motion. Pain with placid plantar flexion is really one of the early signs of rigidus as well. And moderate disease patients have pain with most activities. Range of motion arc is about 20 to 40 degrees, and they're going to have moderate pain at the end ranges of motion as well. In terms of severe disease, pain at rest is now a hallmark of that disease. It affects my treatment algorithm. As I'll show you later, patients are going to have pain with the mid ranges of motion now too. And they'll have minimal overall range of motion of anywhere from 10 to 20 degrees. And the last thing we talked about, revision surgery, which is a category in and of itself, and these patients have already undergone at least one prior surgery, be it a simple colectomy, perhaps a resurfacing, an arthroplasty of some type, or a fusion that just didn't heal and they don't feel like they've clinically improved. In terms of radiographic classification, pre radiographic disease are often normal x rays, but positive findings on either a CT scan or an MRI, and these might involve subchondral cysts, bone edema, or a cartilage injury. Mild disease on the x ray shows a mild dorsal osteophyte with maybe 2,550% joint space narrowing. Moderate disease. Now we're upping the ante on the moderate dorsal osteophytes a little bigger. They're going to have increased joint space, narrowing somewhere around 50%, perhaps all the way up to 75%. You're going to start to see some subchondral sclerosis as we move into more severe disease. They're going to have a very large osteophyte, greater than 75% loss of joint space and bigger subchondral cyst formation. Revision surgery radiographically is going to depend on the prior surgery they have. They might demonstrate bone loss, loose implant deformity, joint destruction, or a nonunion or a failure of a fusion. And now we're going to talk specifically about the detailed algorithm that we've come up with. This is a slide. It's a very busy slide. I don't want you to get intimidated by it. We can really break this down into some sequential slides. First one is going to be talking about normal x rays. Then we'll move on to on to mild disease, moderate disease, severe disease. And we'll also have a slide devoted toward revision surgery. So in terms of a patient who has a painful first MTP joint, but a relatively normal x ray will move on to get an MRI or a CT scan. If that looks normal, we'll consider a NanoScope and a PRP injection. If the patient is still having a lot of pain in that area. Often we'll see something on the MRI, be it a bone edema, which might be a nice option for interosseous plasty if there's a cyst present. We consider again the NanoScope to see if it's violated the cartilage at all. If it has consideration of BioCartilage that can be applied, be it open or arthroscopic means interosseous Bio-Post is another nice option for that. And lastly, we'll commonly see a patient who has normal x ray positive MRI osteochondral defect. And again we can start NanoScope minimally invasive move on to open if needed and then perhaps use BioCartilage. If the lesion is very large then we'll consider a Cartiform implant for that. And then lastly an OATS is another option for it as well, especially if it's a revision type surgery or very large osteochondral defect. Now we'll talk a little bit about revision surgery. So this is a person who has a painful first MTP joint but has already had one type of surgery. And it's an important thing of what we're trying to achieve with this surgery. Does the patient want to have just one surgery? Does the patient want to preserve motion? Do you as the provider, want to preserve motion? Or perhaps just consider one surgery. And that's going to be a really complicated decision based on the patient and your interaction. In terms of motion preserving options, the rigidus arthroplasty with ArthroFLEX is a great option for that. We can also use precut cores to fill any bony defect, and we'll talk about that in the cases later involving perhaps a tiva implant that's in there that needs to be removed. And a moberg osteotomy can always be added to these to increase your dorsiflexion. Regarding revision arthrodesis a cannulated revision, bone dowels may be necessary to maintain your length. And then we're going to be using the MTP joint arthrodesis set with plates and screws, and a consideration of a BioSurge augmentation for that to increase your increase your chances for fusion, especially in a revision case regarding the painful first MTP joint mild moderate severe disease. As we mentioned, this is a continuum for mild disease. Minimally invasive is a nice approach, especially in Miss Colectomy. If it's really just more of a bone spur that's hurting them rather than joint pathology. Keep in mind a NanoScope can be used to look at the joint. When you're doing an mis colectomy, you're not going to have a lot of options to look inside the joint or address any intra-articular pathology. When you use the NanoScope that enables you to do that, and PRP is another nice option to accelerate the healing. When we're in between mild and moderate disease in terms of an open correction, we'll talk about doing an open colectomy with or without amnion, and then also adding that osteotomy to increase your dorsiflexion and fixing that with a DynaNite staples is a nice option that can still get patients moving really early with early weight bearing. When we're getting into more moderate to severe disease, joint preserving versus joint sacrificing, that's some of the most difficult decisions we're making for For Alex Rigidus. Terms of joint preserving Salix rigidus arthroplasty with ArthroFLEX is a great option. There's also the AnaToemic hemiarthroplasty, as well as a colectomy with a Moburg would also fill in that role as well. For more severe disease, we're talking joint sacrificing. And that's really going to be the MTP arthrodesis with plates and screws and adding on a BioSurge augmentation as needed for that as well. In terms of applying this algorithm, you should keep in mind that this is a continuum of disease. It's a spectrum of pathology, and not all patients will fit nicely into a certain category. For example, a patient might just have radiographically severe joint space narrowing and a large dorsal osteophyte, but really only complain about that dorsal osteophyte. And doing a simple colectomy might be the best option for that patient, rather than a joint fusion. Ultimately, it falls upon us as clinicians and surgeons to consider the clinical presentation of the patient, the radiographic findings that are seen and the patient's desires, and then applying them to the algorithm to help guide the decision making. And we're going to end the presentation with five different case examples. The first case example is a young 28 year old female. She's had about a 1 to 2 month history of pain and stiffness in the first MTP joint. She does note she jammed her toe playing recreational soccer a few months ago. Didn't think much of it, but continued to have pain ever since. She has pain at the extremes of motion and in heeled shoes. And her X-rays look radiographically normal. And so this is a patient. We're going to get an MRI or CT scan on and look for more advanced imaging. And in those cases we'll often see an osteochondral defect. We'll see a cystic like lesion or a bone edema that's present there. And all of these are nice options, be it a NanoScope arthroscopy BioCartilage for some of your smaller lesions. Cartiform for some of your larger lesions. And then the OATS type procedure. Be it revision cases or very large lesions for those. And in terms of case two, this is a 40 year old male one year history of progressive pain and stiffness in the first MTP joint. It's worse when performing certain yoga poses. Pain mostly at the end ranges of Ranges of motion. And you can see on that lateral view a little bit of a lateral osteophyte on that AP view and a little small dorsal osteophyte on the lateral view. And for this patient that might be the best option of either an open colectomy with a moburg. Or if it's purely that bone spur that's bothering the patient, a NanoScope or even an mis colectomy might be a nice option here. You can always augment your repair with a PRP to help enhance the healing, but I think those are your options there for the more mild rigidus. As we get into more moderate halex Rigidus, decision making becomes a little harder. This is a 55 year old male. Several years of stiffness in progressively worse pain at the first MTP joint. He's having difficulty walking, having difficulty playing golf, and it's affecting his swing mechanics and he's painful throughout his range of motion. And on those x rays in both the AP and the lateral, you'll note a diffuse joint space narrowing, especially noted on that AP view. So the treatment options for joint preserving involve x rigidus arthroplasty with ArthroFLEX and AnaToemic hemiarthroplasty or a colectomy with a moburg. Keep in Keep in mind that the helix rigidus arthroplasty with ArthroFLEX does address sesamoid articulation as well. So be it. Medial or lateral sesamoid pain in addition to arthritic pain in the MTP joint. The nice option is that the helix rigidus arthroplasty with ArthroFLEX addresses all of those things in terms of more severe helix rigidus. This is 68 year old female multiple year history of progressive pain and stiffness in that first MTP joint. Minimal motion pain with any movement and pain at rest. And when patients are having pain at rest, I'm more inclined to perform an arthrodesis for those patients. And on these x rays, you can see near complete radiographic obliteration and destruction of that first MTP joint. And so for this person, she might be best served with an MTP joint arthrodesis with plates and screws. Biosurge augmentation can be added to increase your chances for fusion. And then the Angel system as well as AlloSyncPure, is another thing to have on hand for any type of arthrodesis type procedures. And lastly, revision surgery. This is case 565 year old male history of prior synthetic first MTP joint synthetic cartilage implant two years ago, now complaining of progressively worsening pain and stiffness in the joint for the last 6 to 12 months. And you can kind of see the difference in x rays there and the subsidence of that implants. And where there was once a space, there was no longer a space present. And here you have basically two options. There's the revision arthrodesis type option. And this is really going to depend if you need to use those bone dowels, if you need to maintain length. So if you're removing a metallic implant that's lost a lot of bone from the first MTP joint and you want to preserve your joint length, then I think you need to put revision dowels in there. And that's going to be supplemented with the MTP arthrodesis plate and screws. Biosurge augmentation can be very helpful for these cases because you want to just improve your odds any way you can to get a solid fusion afterwards. So when you have significant bone loss, use the dowels to maintain the length of that first ray. The other option would be non arthrodesis and that would involve either a precut core of osteochondral allograft there. If the rest of the cartilage around the joint looks viable, and it's just that center portion where the component was is removed and the rest of the remaining cartilage looks viable. Then I think that's a good option for you. There's also the helix rigidus arthroplasty with ArthroFLEX, which can be used if you just pack the defect, and then you're going to cover over the first metatarsal head. And that's going to preserve the motion in there as well. And that depends on the discussion you're having with your patients, what you're looking for post-op as well, where you want to maintain motion or you want to do the arthrodesis. So in summary we have many options for first MTP joint disease. We have BioCartilage that can be used, the Cartiform which can be used as well for larger osteochondral defects. We have the fresh cut cartilage core as well. Arthroflex can be used to cover the first MTP joint and to really maintain that range of motion. The precut bone dowels are helpful when you're trying to maintain length, and one of the workhorses is the first MTP fusion plate and screw system. So thank you very much for your attention.

Hallux Rigidus Treatment Algorithm of the 1st MTP Joint

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Hallux Rigidus Treatment Algorithm of the 1st MTP Joint

Verwandte Seiten

Orthobiologie

ArthroFLEX® zellfreies dermales Allograft

Produkt

Fuß & Sprunggelenk

ArthroFLEX® zellfreies dermales Allograft

Produkt

Fuß & Sprunggelenk

Proximale Osteotomie der 1. Metatarsale

Operationsverfahren

ArthroFLEX^® zellfreies dermales Allograft

ArthroFLEX^® zellfreies dermales Allograft