Name: Multilevel Midfoot Arthrodesis: Tips for Preventing Nonunion
Uploaded: 2018-07-11T00:00:00Z
Channel: Arthrex

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VID1-01368-EN | A | Multilevel Midfoot Arthrodesis: Tips for Preventing Nonunion

David J. Caldarella

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Multilevel Midfoot Arthrodesis: Tips for Preventing Nonunion

I'm going to talk on multi-level mid-foot arthrodesis. Ten minutes or less. The formal title is includes tips for preventing nonunion. So I'm going to focus on the task at hand and hopefully get you through this quickly. So by definition, mid-foot joints include the tarsometatarsal joints obviously, and the forearm joint just for for basis of understanding definitions. We all know this. I rarely, if ever will will fuze the fourth and fifth cuboid joint for any particular arthritic condition less than maybe a Charcot foot reconstruction. Jessie covered well the Charcot foot. Obviously the mid foot articulations are small joints. There are a number of different pitfalls in terms of getting reproducible outcomes in terms of fusion rates. When you're dealing with smaller joints, especially in deformity correction across this level. And we all understand the mechanics of the foot, especially in the mid foot arch, both transverse and longitudinal. The mid midfoot is basically a mechanical structure similar to a scissor truss. We had a bunch of discussions yesterday about the mechanics. I won't belabor that, but we definitely have to focus on the tension side of the fusion mass. So I'm going to go over Tarsometatarsal joint fusions primarily TMT one, two and three or some subset of them, as well as navicular joint fusion. I historically been doing this for about 20 years with solid stacked screws. And I'll show you the construct and the mechanics of how to get it done in an efficient way. I've now gone more towards specialty plates for some occasion, especially dorsal centrally, especially in the TMT two and three articulation which we'll go through. And then of course, we had a discussion earlier about the value added proposition of the staples. So clearly I think the staple line with the metallurgy, with the nitinol and the specifics to that particular product line will have some influence on how these are done more effectively and perhaps cost cost analysis as well. So let's start off with a subtotal Tarsometatarsal joint Arthrodesis. This is a patient with both primary osteoarthritis through the through the midfoot as well as concurrent deformity. And again, in my mind, this is a pretty simple operation. The patient's pain is central. Apex right on the tarsometatarsal joint, including sometimes in the low Cartiform joint. And here's the post-op just demonstrating the realignment arthrodesis through the CMT joint. Again, solid core screws. Fairly inexpensive. Cost effective. And medial neutralization plate. Same type of scenario here, including the navicular cuneiform joint. So we've gone down a little bit more proximal with degenerative change there. Again same kind of scenario. Here's a patient with post-traumatic arthrosis. So this is going to be a salvage situation. Neglected lisfranc injury. These are bad as you know, with the purely ligamentous injuries primarily. So he's got pain over the first, second and third CMT joints. This is a retired principal at 61. And he also has a Gastroc Aquinas and SAG through his NC joint. So again coupling both the TMT fusion including the NC SAG and really building up his arch large with a with an endoscopic gastroc was the plan of care. You can see on the CT exam just shows the degree of arthrosis of course. And again a little bit of realignment required, but not significant degree of deformity. Here's the surgical approach, which we'll kind of talk about a little bit more as we go through some additional cases. But again Extensile medial approach for the meal column. Small incision centrally. I think the key thing here is you have to prepare the joints well. And that's one key principle. And tip for preventing nonunion is you have to basically see the joints top to bottom. And you want to refit and pack this bone mass into a neutral alignment with with care to make sure you're on tri plane. You're accurate. So this is an example of showing the distraction. Solid core screws. Pretty straightforward. Again protecting the tension side. And here we have a solid arthrodesis. So you want to control the tension side mechanics a little difficult technically to place those screws in a stacked orientation across this joint with a confined footprint, That's this traditional way I've done them now. Contemporary means of how to do this with some of the innovations and products we have available to us. Key thing anatomic dissection, joint preparation techniques that goes through with every every joint fusion we do adjunctive biologics. I do use a lot of BMA in these particular patients on occasion with the Angel system. Dynamic compression with the nitinol I think is going to be an obviously an advantage compared to some fixed angle constructs as far as the mechanics of the metallurgy. And again, primarily whatever you use, you have to protect the tension side mechanics. I wrote two papers, one in the chapter, one in a course syllabus on the approach to this joint. I think this is reproducible. This is, I think in my mind, the cornerstone of how to get through this zone. There's a lot of structures at risk, including cutaneous nerves, neurovascular bundle and dorsal tendons. It's very reproducible. And I'm going to kind of highlight that essentially you just want to map out the neurovascular bundle. Either palpate it. If you don't have a pulse you can feel interoperably. Just Doppler it and identify that with the dotted line. I marked out two sites over the metatarsals. Those those little inverted V's just demonstrate the angle and dorsal approach to the second and third metatarsal shafts, and you follow that somewhat obliquely across the midfoot. Obviously, in this area of the foot, there's not a lot of subcutaneous tissue. You're relatively close to the to the deep fascia. And I want to preserve this tissue for closure over the extensors. So they work in function. And don't just make a small rent just medial to the second extensor tendon slip. This is the target tissue so to speak. Classically done here. Here's just slipping a Metzenbaum scissors underneath this. And then incising across this area controlling the deep fascia for future closure. All the extensors recruited laterally as a bundle. Medially, you'll find that some form or fashion of an obliquity of the muscle belly that's going to be gone immediately, immediately reflected. So here you have the reflection of the extensors as you see there. And you've got the muscle staring at you. You reflect that medial word with the neurovascular bundle, and then you're right on top of the periosteum over the second and third TMD joints. And that's pretty classic. Pretty reproducible. You have to get access for the specialty plate. I'm going to show the new dorsal midfoot plate. You want to be able to access the medial border of the second TMT joint and the lateral border of the third in order to get this footprint shape so you can have a small area real estate to work with. You can see this kind of illustration of the intraoperative findings here. Again, I think one of the keys to doing this is some form of distraction. Many distractions we have distract but they don't necessarily compress. And again, I feel it's really important to distract these joints primarily because of the truncated nature of the tarsometatarsal joint. You've got a joint that's fairly deep. If you do not get to the bottom of the joint, prepare it. Well. If my elbow is the metatarsal head and you're looking at the top of the metatarsal construct, you're bringing everything up and you're going to alter the forefoot loading of the lesser metatarsal. So I think it's really important to GAP this open. See down. Make sure you're precise with your preparation of the joint however you do it, and then bring these back in the right anatomic alignment. And this is just one technique to do that you can curette you can drill, you can fish scale. Bottom line is you have to get past the subchondral bone plate. That's a principle in all joint preparation. Here's showing BMA being placed into the surgical mass of the surgical arthrodesis site that's intended. The next step is to dynamically compress this. So I'm not a big believer in using an eccentric loaded screw in these types of mid foot procedures to gain that dynamic compression. I mean, we know that bone healing does not require compression, but you need to have great apposition and a surface area of small in these joints. So you want to encourage some type of apposition under some tension with your with your biologic substrate. And this is how I like to do it. With this particular device you just compress and distract. Now you've got compression across the area. And then this one single K-wires as you see here is going to serve to just capture that dynamic compression. Now you can use your anatomic plates a little bit more effectively. I do that on the TMT three side, doing the TMT two side. And then really the bottom line is now we're going to neutralize this with the Arthrex dorsal midfoot plate. So we've got two provisional wires outside the footprint of the plate. Now I've dropped the plate on top. I'm going to go intraoperatively and make sure I've got this aligned well. I think the best view to do this is the lateral oblique view that kind of shows the orientation of the plate as it relates to the second and third metatarsals most accurately. Sometimes a little bit of fiddle factor to rotate or translate the plate. And that works out really quite nicely. Here's an example of the plate being placed. Again. Lock the screws down proximally, and most times I'll take a template off the pack system. And most of these patients you can kind of predict the length of screws. I don't have to measure any of these screws at all. They're all locked, so I don't have to use both cortices. Usually 20 to 22mm in length on the proximal side 1618 on the on the distal side. Here's the example of showing that load screw. You may get some value out of that by releasing this, but I think by and large, you want to make sure you really have a great dynamic compression across the area. Here we are here. Final construct. All right. Closure. Again backing out. Db. Muscle close over the plate nicely. You then recruit your tendons back into anatomic position. Close the deep fashion as a layer and you've got again control of neurovascular structures. You haven't damaged anything. And it's a clean operation with hopefully less risk of wound problems. Final construct here. Again evaluate for proximal extension. This particular case is pretty obvious. So I have a pretty low threshold on this type of heavy set guy who's a kind of a beer keg softball player type of personality to fuze that primarily. Eric talked about that in the IV, which we've gone to. Here's an example of fuzing the Cartiform joint primarily, and then using the TightRope again to reposition the second TMT joint and the inter inter osseous ligament across the lisfranc joint, the true Lisfranc joint, in order to secure this. And this is an example of him three years post-op. So I've had excellent results in this context with the TightRope button system stack screws on an NC joint just to finalize. Again, this is a little more difficult, but this is an example of using stack screws to maintain mechanics over the tension side of the joint. So I try to bias the internal fixation on the medial side of the joint. That's where the business end is. Here's an example of the relatively modified medial utility incision. Again, the joint is just underneath the tibialis anterior tendon that's lifted up dorsally. You don't want to traverse or cut this. Incidentally there's the joint. Here's the distraction device to kind of open that up. Bottom right corner is really the best way to see it. You've got good access. And I always try to prepare the medial and central cuneiform and even to some extent the lateral cuneiform on deformity correction. You can kind of see across here pretty well. Here's the joint being prepared. Here's the joint being compressed and provisionally fixated. And then we'll slowly show you some solutions. Stacked screws. Again you want to relocate this middle column downwards. So I'm going to try to use this device to kind of bring it down. Here's the screws going from across the board like a set of rebar in concrete for reinforcement. And again, they're stacked from bottom to top to kind of help reduce the tension side mechanics with solid screws. Closure. Simple case here. Again Arthrex has a medial column plate. This is a plate that's designed for the navicular cuneiform joint. This was again applied in the same construct. Again fixed angle constructs, if the joint is not well positioned is not going to lead to significant improvement. So you've got to you'll get a lot of nonunions if you use lock plates with a GAP because it's going to hold that gap out. You have normal physiology of bone healing where you get resorption as the first stage and you're screwed. So you've got to make sure you do something dynamically to get those small joint positions adequate. And this is one way here's an example of her at about six months. And then again I took the plate out in this case. But you can see a nice primary fusion across this region. Mid-foot Osteotomies I think are helpful. Here's an example of a patient with a fairly significant deformity. And this is old school stainless steel staples. So again with the technology, the DynaNite, I think that's going to be the next phase of treatment. We've already gone through the DynaNite staples. It just came out in in December. I've just started using them in our system. And I'll have more information over a period of a year to show you some outcomes. There's no outcomes at two months, so I don't even want to talk about it yet. Nonetheless, we know the power and the value of the staple line. So bottom line is you got to distract it. You got to prepare it well. You got to visualize the depth of the joint. You got to get it back together in close approximation. And again, whatever you use for provisional fixation, just make sure that you understand the basics of getting this really well opposed. So I hope that's helpful. So again the staple line is probably going to be the value added proposition. That's one of the I think the areas of anatomy that these staples are really well designed for. And that's all I have today. Thank you.

Multilevel Midfoot Arthrodesis: Tips for Preventing Nonunion

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