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Good evening, everyone and welcome to this um webinar. Uh This session is part of our mastering orthopedic implant uh series. This is delivered to you by the orthopedic Academy and myself. Uh uh And now I'm the convenor of this course this evening. I have the pleasure of having Justin uh Mura with us. Justin is a Caribbean surgeon. So I hope that's sort of cover the majority of, of ankle arthroplasty. Um There'll be a lot of nuances and I guess we could discuss them in the, in the question and answer part at the end. Uh So we move on to first MTPJ Arthroplasty. So first MTPJ Arthroplasty, usually again for painful degenerative, limited range of motion, big toe um that has failed conservative treatment which would include weight loss, include stiff insoles, include physical therapy, um steroid and uh and local anesthetic injections. Um Usual treatments for these would be a fusion which has predictable good results. Um but you can do an arthroplasty and the benefits of arthroplasty. You know, you retain your range of motion, less chance of adjacent joint disease or trans metatarsalgia. Um A transude into the second metatarsal head. Um contraindications again, would be infection or poor bone stock, um vascular insufficiency, neuropathy, or inflammatory arthropathy. So, un unlike the ankle where you can do it on rheumatoid, you tend not to do it for patients with rheumatoid arthropathy for the foot MTY PJ. Um So treatment options before we get it, we won't go into too much detail. But uh you do subchondral drilling for, for small cyst autograft transfers. So you could take a bit of the femoral cartilage from lateral Condy of the femur. Um I'll put a link to that below. Um You could do ectomy where you just shave a bit of the bone off, off the top. Uh and the side of the metatarsal head as well as the front and the sides. You could do a dorsiflexion osteotomy to try and, and change the arc of motion of the first MTPJ. Um rheumatoid, you could do sin ectomy and then you have joint sacrificing procedures, um which could include resection of the joint, um and interposition arthroplasty. So you can borrow a bit of the extensor hoses where this muscle unplug it inside. Um, or you could do an arthrodesis and you have your, your, your various different mechanisms of fusing the big toe using plates and screws or two cross screws. Or we currently use two staples in Manchester at the moment and it works quite well. And then you have um, the options of hem and total arthroplasty, which we discuss a bit. Um So in terms of, of the, the designs of, of arthroplasty for the first MTPG, not hugely successful again as of the joints throughout the body. But it was described by Swans in 1952 we made a metal hemisphere called KA A ta but stem um which had some issues. Um He then went on in between 65 and uh and 67 to develop a Silastic be um double stem type implant um which had about a 90% survival rate. Um There was discussions on cases of osteolysis and silicosis um fracturing of the, the silicone implant. Um They tried later on to do metal designs with Cobalt chrome surfaces um for the proximal phalanx only, they went on to try um metatarsal type resurfacing. So it's a handicap type for the phalanx. So they had for the metatarsal and they had for the phalanx separately. Um just link below for this, this particular um studies review of joint implants quite good. So they went back, I think basically almost every couple of years since the fifties then. Now they had a new type of implant that they try and, and that has high, high risk of failures. Um uh over the years. Um They tried ceramic type implants, Emoji tried pyro carbon and again or or not really great. I think what generally stands stood, the test of time would be the um Swansons silicone type um spacer. Um get, get people using uh certain implants on like arth surface total arthroplasty and they get um reasonable midterm results. But in terms of robust long term studies, nothing is really within the test of time compared to maybe the joint spaces like the Swansons. Um In vogue, a couple of years ago, they started this uh cartiva, which is a polyval alcohol hydrogel synthetic cartilage implant. So they had it for different uses throughout the body in the knees, et cetera. And then they started it into the big toe. Um So treatment of OC DS, um essentially you, you, you shave in and prepare the joint surface on one side and it put in a tiny little this uh polyval alcohol plug into the metatarsal head. Um Initial studies were promising. Um However, um there's a lot of instances with loosening now and lysis within the joint um and a high revision rate at present. So, if you, if you currently put Cartiva into Google, you'll get links to a lot of um legal websites. And if you've had a had cartiva placed into, into your body and required infusion, please contact us. Now, uh we'll take your case up. So you have to be very cautious about those, those implants. Um So at at present, the current implants that we have would be we have the metal and poly um pre cemented. Um And we go through a bit of that coming up now. So in terms of the approach um this is again from the industry, um use a dorsal dorsomedial approach to the big toe and that avoids that uh dorsomedial cutaneous nerve. Um So I in the wound, your extensor hallucis longus tendon would be somewhere just on the, in that area there and your nerve would be on this side here. So you put that nerve will go medially and the tendon will go laterally in the wound once you safely dissect through the skin, subcutaneous tissue and, and fat and get down through the capsule will be directly down to bone. And from that point in, you just put some hormones in and retract either side and clear, clear all the soft tissues around the joint. It's quite AAA simple approach. You have cartilage on both sides. So this will be the metatarsal side and this will be the phalangeal side. So this particular um procedure here would be a hem arthroplasty that I'm showing you. So you would make your, you have a hole. So, and you make a sort of parallel cuts on your phalangeal side to take out this this cartilage here and you, you size the pharynx for an implant and then you'd use um so you have different types of reamers. So you use what called co and con. So for the fall side, you have this will take all this sort of concave shape. And then if you were doing a total arthroplasty on, on the metatarsal side, you'll have the opposite um type Remer. So you get a nice cone fit as opposed to flat cuts. Um And then you, you know, you as any other implant, you Broch it uh you broach the intra canal of the pharynx impact it. Um in this particular implant, they ha you take a suture through the flexor, hallucis s boot, um the medial and lateral heads and then you put that directly through the implant and cause there's a little space for it to go through and then you snot that down into the joint. So this is a hemiarthroplasty um on the phalangeal side. Um Again, this can be replicated on the metatarsal side would be a similar sort of procedure. So you, you could do it either on the phalangeal side or you could do it on the metatarsal side and in terms of arthroplasty. So this is from industry um arth surface to motion. Um a similar procedure. But in terms of the approach, you just have to be a little bit wary about the position of the implants in it on the side of pain in particular. So you make sure that the patient have enough dorsiflexion and plant flexion at the end of the procedure. Um and the body is sort of built in into this component. Um So a lot of surgeons in London, in particular, I had good midterm results with these implants, uh low revision rate, but there, there aren't many robust studies in the literature that would promote this. My understanding is the Silastic types, joint spaces work the best and have the best um longterm results followed by the he followed by the total. So this is the Swans that we were talking about. So this was the initial um initial type, first generation silicone type spacer. And now this is the more up to date one with the silicone type spacer and metals to help with for bone sheathing or stress shooting in the bone. Um A study by Mister Tim Clough in 2020. He is describing his results at his center and he had 97% survivorship in five years. Um So, uh again, this in particular, is not a formal arthroplasty and it should be made known to the patient and it is a sort of a two spacer rather than arthroplasty. Um The approach again would be similar that dorsal dorsomedial approach and you make this one will make flat cuts and then this would be a spacer that you implant and this can be done for the first or even the lesser metatarsals because you have different sizes to choose from. Interestingly, you still get a decent range of motion. Um With this implant, the patient, patients get a reasonable dorsiflexion implant, flexion after with this and it has a, a good survivorship. Um in, in the long term, this is the cartiva that we're speaking about is a, a very small implant that goes just in the metatarsal head there, but I don't think it's no longer involving any of the centers that I've worked in. So, in summary, um again, you want to just pay attention to the factors contributing to the disease of the patients. You wanna look, see if it's arthritis versus um you know, for treatment and you so they can make an informed decision on, you know, if they would like to do things like have an arthrodesis or fusion versus an arthroplasty. Um You want to discuss if they need to have, you know, um one stage or two-stage operation, you wanna discuss during the operation, if you have to do concomitant procedures such as um we, I was particularly talking about the varus valgus malalignment, but you may also have to do things like a heel shift. So patients have, you know, a flat foot deformity, you can do a medial or lateral um displacing Calcaneal osteotomy. You may have to do ligamentous um releases or ligamentous reconstruction. So you, you can do things like brostrom or ligamentous tightening on the lateral side and you can do things like releases on the medial side. Um So you have to discuss that with the patient. Uh uh and you have to discuss things like bone grafts and whatnot. I if it has to be used. Um And, and you know, in the long, long run, you have to always mention to the patient, look, you know, our backup plan. What are our backup plans? You know, if it doesn't work, we may have to consider Arthrodesis. If it doesn't work, we may have to consider, um, you know, sorry, uh, revision and then Arthrodesis and, you know, worst case scenario, you know, what's, what's you have to discuss the, you know, things like amputations and whatnot. It's slightly scary in that sense. But, um, in, in orthopedics and in, in arthroplasty, nothing is really particularly straightforward, I would say, thank you very much, Justin. That was wonderful. Yeah. Very enlightening. Really. Especially for me as um I'm not a foot and ankle surgeon. So, um uh I very uh you know, rarely hear about these um, implants. The question uh to you uh Justin. Um So what, why is it that um, ankle and foot arthroplasty is, is not as successful as the hip and knee is, is just a ma it just because it's just in concept is developing, um, or is there more particular issues um that's affecting it because uh you know, let's say now for hip hip replacement, hip replacement has become the gold standard of treatment. Yeah. And arthrodesis is now almost obsolete. Yeah, it's a, it's a, it's a, it's a really good question and I do think there is a straightforward answer that I think we, we know for sure the most successful operation in the world I is the, the total hip replacement. Um And, and definitely in orthopedics. That's one of our most successful arthroplasty. Um, I think it's just based on the biomechanics to me of the foot and ankle and I just don't think it's the way it's designed and, and the way the load is transferred to the, to the joints in particular, um, to the first metatarsophalangeal joint and the ankle, it's just not designed to, to, to be replaced. Um, uh, and the implants that we have just can't see that function as good as, as the hip, you know, the hip. Uh and the knee can uh I don't know, you see, it's sort of the planar of like, for instance, the first metatarsophalangeal joint, the weight bearing portion is in the metatarsal head and then you have implants running in the opposite direction as opposed to the hip or in the US directly, you know, actually loading into the joint. Um And uh and the main problem I is just loosening. Aseptic loosing is number one cause of failure. I in, in the implants in both the ankle and in the first metatarsophalangeal joint, all aseptic loosening. And, and they have been re revising the implants for many years. So one of the links I had an article on, on the history of it basically um from 19 fifties, 19 onwards, every couple of years, they revise the implants, revise the implants and like everything in orthopedics, it became in vogue and everyone is talking about it and everyone is trying it and then after two or three years is it starts coming and the results come in and they all fallen out a fever and then they, they start the cycle over again, the front of the implant. This, this is a difficult one to see, but I think it will just boil on the biomechanics. Basically all the joint functions well done. Yeah. So patient with end-stage arthritis with a a virus deformity Again, this is may not be exactly 30 but it's just an example. Um And it's for, it's for osses. So that's debate, arthrodesis or whatnot. Um So I agree. I think this is, is the correct way forward. So for, for VARA, so I'll just give you an idea. So your options for Varus, you could have um a laterally base uh Calcaneal osteotomy. So this could go laterally, you could have a deltoid ligament release. Um You could have a medial ulus osteotomy. You could have lateral ligament reconstruction because you know, the lateral ligament will be stretched if it's in this direction, rather uh an in rooted, rather than in its normal place. Um You could do cutter debridements. Um uh you could do dorsiflexion, osteotomies of your first metatarsal and you could do tendon transfers. Um So there's a lot of things you could do to sort of correct um deformities prior to starting. You could even do uh supra malar osteotomies as well and you could do them uh with bone grafting. So one of the cases I went to Switzerland uh recently, uh it was a two stage where a supra osteotomy was performed with the iliac crest bone graft and held by a screw. And, and at the beginning of the surgery, we removed the screw and the bone was nicely uh in there and then we proceeded with all cuts and a nice flat cut. So, yeah, well done for everyone who chose the end. I think that was the correct thing guys. Yeah, let's move on next one, please. So 50 year construction will go with a BM I of 30 which it's neither here nor there. I probably have a BM I of close to that um limited range of motion and pain in the first MTPG field, non surgical treatment. So again, II, I agree, I agree with that. So I guess I'm I'm very happy that the take home message was well received. So, although it was on arthroplasty, um right. Candidate selection, right, in right indication for surgery. So II, I put the, didn't put a heavy BM I person, but I put 50 year construction workers. So we, we know if we replace that joint and overload that first meal joint with the arthroplasty, we know it's it's just gonna fail by tic loose. So arthroplasty arthrodesis, sorry would be the treatment of choice and you could use any, any form of arthrodesis that you have currently at your hospital. Um and that would be a good, good result. This last one is a bit wordy, true, false. Um, might be a bit of a trick question. Let me see how people responded. It's painful end-stage arthritis in your foot and ankle. So, for painful end-stage arthritis, what should we do? We might as well just offer our patients and arthroplasty in the first instance and, you know, give them the best chance of motion. Um, And you know, the uh the backup plan would be just gonna with the fusion if it doesn't work. What do you think? True or false? I purposely didn't give any demographics. Uh In this case, I just want general concept to be felt. II, I think it, I, I will went to force on this because I, I think it's not just to give, you know, just go have a go at arthroplasty and, and you have backup options. I, I think you really need to, to choose your, your candidates properly. Um And you have to have the right indications um because it, you know, it's a lot of consequences for fi arthroplasty. I think uh you could have, you know, the risk of, of, of having revision surgery, the risk of converting to, you know, arthrodesis, risk of amputation and it can be very restricting um for the patient to have multiple procedures, have risk of, of infection and all that. So I, I would go forward with this one in particular, and um you know, have proper patient selection and if you, if the right choices they give the patient an arthrodesis, then that's just the right choice for that patient. Uh That's what I would think but um I'll leave it up to you. Um When you see your patient and you make your, and you make your plans with them, you are some of my resources. Um pretty good link article there. If you need to go back and check anything, I check anything. But from my point of view, I think, you know, the take home messages would, would be um you know, Red Tava trial in particular um for uncle um and for the M the first MTPJ, there aren't any very good robust trials for the first MTPG. But my, my take on my understanding is the hemings do better than the totals and of the totals, the Silastic swans and Silastic does does the best overall. So that's my take on it. Thank you very much Mr Mura for this wonderful presentation spot on one hour. Uh good timing. It was really comprehensive and covered uh quite a lot of aspects about ankle replacements really more than I thought you could cover within this limited time. Um Thank you, I really appreciate it. Um uh So thank you very much. Um Justin, I know you are very busy with your foot and anchor fellowship in Manchester, but uh thank you uh for, for taking your time. Yeah, it was great.