Intermediate outcome of interpositional arthroplasty for the treatment of hallux rigidus. Anand Vora, MD

Transcription

1 Intermediate outcome of interpositional arthroplasty for the treatment of hallux rigidus Anand Vora, MD

2 CONFLICT TO DISCLOSE Intermediate outcome of interpositional arthroplasty for the treatment of hallux rigidus Anand Vora MD My disclosure is in the Final AOFAS Mobile App. I have a potential conflict with this presentation due to: Consultant: Arthrex

3 Introduction Arthrodesis remains gold standard for surgical treatment of advanced hallux rigidus Select patients may not be appropriate candidates for arthrodesis Perceived needs for 1 st MTP joint motion maintenance by both physician and patient for professional or recreational activity The purpose of this study was to assess a subgroup of patients with advanced, end stage hallux rigidus in whom arthrodesis was considered unacceptable who underwent hallux interpositional arthoplasty using an acellular dermis graft

4 Methods Retrospective review of prospective collected data Tegner scores, VAS scale, SF12, AOFAS Hallux score Minimum follow-up 2 years Inclusion criteria: Patient and physician perceived need for maintenance of joint motion for recreational or professional activity Refused arthrodesis Hallux rigidus advanced (grade 3, 4) Exclusion criteria Shoe wear or cosmesis concerns as perceived indication for joint preservation Significant associated additional surgery

5 Surgical Technique Dorsal approach with aggressive release of the medial and lateral collateral ligaments and tissue synovectomy to expose the first metatarsal head Aggressive cheilectomy and dorsal phalangeal exostectomy (Fig 1,2) Fig 1 Conical reaming of the metatarsal head to penetrate the subchondral bone to create a bleeding bony surface A 3.5cm x 3.5cm x 2mm acellular dermal regenerative tissue matrix graft (Arthroflex, Arthrex, Naples FL) was then prepared to match the metatarsal head dimensions Fig 2

6 Surgical Technique One centimeter proximal to the metatarsal head two dorsal to plantar bone tunnels are made with a 2.0mm drill bit (Fig 3) Fig 3 Suture passer is utilized to pass the graft dorsal to plantar with attention to assure the reticular layer of the graft is placed against the metatarsal head (Fig 4) Suture is then tied to the dorsal lip of graft to secure the parachuted graft and then further secured medially and laterally to the adjacent capsular tissue as needed (Fig 5,6) Fig 4 Fig 5 Fig 6

7 Surgical Technique Fig 7 The first metatarsophalangeal joint is placed through range of motion and stability is confirmed (Fig 7,8) Fig 8

8 Results 8 feet (7 patients) eligible were all available for follow-up 5 feet (1 bilateral) tennis 3 of 5 feet tennis pro instructors 2 feet soccer 1 foot professional MLS player 1 foot yoga instructor Ave age 42 yrs. (26-53) Ave follow-up 2.4 years (2-3.4) 2 feet additional procedure 1 foot 3 rd interspace interdigital neuroma resection 1 patient midfoot dorsal ostectomy

9 Results AOFAS Hallux score: 51 preop to 81 postop (p<0.05) VAS score 6.8 preop to 1.6 postop (p<0.05) Tegner score 8.5 preop to 8.5 postop (not significant) 1 professional soccer player returned to play same level MLS 2 tennis pros returned to same level tennis pro instruction All patients reported ability to return to preop activity / sport Range of motion (not significant) DF preop 12 degrees to 17 degrees postop PF preop 10 degrees to 12 degrees postop All patients would undergo surgery

10 Discussion 1 st study of which aware to assess return to sport / Tegner scores Avoid potential morbidity associated with autograft procedures Accelular dermal graft material may minimize concerns associated with graft reaction Motion is not reliably improved however pain relief and ability to return to previous level of athletic activity appears reliable Minimal bone resection may allow for uncomplicated 1 st MTP arthrodesis in future if necessary

11 Limitations Small sample size Very selective inclusion criteria of younger athletic individuals with narrow clinical criteria Limited follow-up Although outcome measures and physical exam parameters were collected prospectively, study is retrospective review

12 References Berlet, Gregory C., et al. "Interpositional arthroplasty of the first MTP joint using a regenerative tissue matrix for the treatment of advanced hallux rigidus." Foot & Berlet, Gregory C., et al. "A soft-tissue interpositional arthroplasty technique of the first metatarsophalangeal joint for the treatment of advanced hallux rigidus using a human acellular dermal regenerative tissue matrix." Techniques in Foot & Ankle Surgery 5.4 (2006): Cosentino, Gerald L. "The Cosentino modification for tendon interpositional arthroplasty." The Journal of foot and ankle surgery 34.5 (1995): Coughlin, Michael J., and Paul S. Shurnas. "Hallux rigidus grading and long-term results of operative treatment." The Journal of Bone & Joint Surgery (2003): Fitzgerald, J. A. W. "A review of long-term results of arthrodesis of the first metatarsophalangeal joint." J Bone Joint Surg Br 51.3 (1969): Galli, Melissa M., and Christopher F. Hyer. "Hallux rigidus: what lies beyond fusion, resectional arthroplasty, and implants." Clinics in podiatric medicine and surgery 28.2 (2011): Hyer, Christopher F., et al. "Interpositional Arthroplasty of the First Metatarsophalangeal Joint Using a Regenerative Tissue Matrix for the Treatment of Advanced Hallux Rigidus 5-Year Case Series Follow-up." Foot & ankle specialist 5.4 (2012): Lombardi, Charles M., et al. "First metatarsophalangeal arthrodesis for treatment of hallux rigidus: a retrospective study." The Journal of foot and ankle surgery 40.3 (2001): Mann, Roger A., Michael J. Coughlin, and Henri L. Duvries. "Hallux rigidus: a review of the literature and a method of treatment." Clinical orthopaedics and related research 142 (1979):