Osteotomy vs No Osteotomy Second Ray

Transcription

1 Osteotomy vs No Osteotomy Second Ray Michael D. Dujela DPM, FACFAS Fellowship Trained Foot and Ankle Surgeon Washington Orthopaedic Center, Centralia, WA Chairman, Education and Scientific Affairs Committee American College of Foot and Ankle Surgeons

2 Weil Shortening Osteotomy Possible plantar plate repair Partial Met Head Resection Plantar Condylectomy Floating Toe Dorsal vs Plantar Approach Recurrence and Pain Transfer Lesions HISTORICAL TREATMENTS ARE INSUFFICIENT IS THERE A BETTER ALGORITHM?

3 Anatomic Considerations Dynamic MTP Instability Flexor tendons weak/imbalanced FLEXOR TENDONS PATHOLOGIC POSITION MEDIAL DISPLACEMENT OF THE PLANTAR PLATE ABNORMAL MET PROTRUSION???

4 Problem with AP View and defining what is Normal?? Static AP view only Frontal plane information? Adjacent met elevation? No truly defined normal Barouk 1996 Griffin Bone 2005 Fleischer et al. Foot Ankle Int. 2016

5 Abnormal Structure vs Function What about functional components? More than just abnormal length! Why don t we typically see plantar plate tears of MTP 3, 4??

6 Just do a soft tissue balancing! -Dr Hollawell Cannot Address a structural deformity through a soft tissue correction alone! Dr. Hollawell balancing act in China 2013 Flexor to extensor satisfaction? Variable.. 51% Satisfied Thompson F, Foot Ankle Int 1993 Myerson Foot Ankle Int 2005

7 64 Feet 2 nd MTP instability and PP dysfunction -Flexor tendon transfer with PIPJ arthrodesis Complications in 20/64 Feet Persistent MTP Dorsiflexion=37% Unhappy or Major Reservation=30% Although the function of the second toe improved in most patients as a result of pain relief, A substantial number of the patients in this study remained Myerson, Foot dissatisfied Ankle Int 2005

8 Why Weil? Reproducible Ease of execution Inherent stability Robust blood supply m High Patient Satisfaction!

9 30 Patients with MTP Contracture Level IV Evidence Weil Osteotomy n=25 22 month F/U Transfer lesions=zero Recurrent Metatarsalgia=Zero Non-Union=Zero 84% Complete reduction MTP dislocation Trnka, Myerson Foot Ankle Int 1999

10 24 patients 25 feet Level II evidence Good to Excellent results= 88% AOFAS scores Increased = The patients who didn t improve? All had prior Keller Arthroplasty Seven years PO Hoffstaetter et al. J. Bone Joint Surg. Br 2005

11 More Evidence? Excellent Results with Weil Osteotomy 81% Good/Excellent Results 58/59 pts decreased pressure Non Union=0 Recurrence=0 IF time add article titles Beech I. J. Foot Ankle Surg Vandeputte G. Foot Ankle Int Trnka HJ Acta Orthop Scand. 2002

12 What is the quality of evidence? There is grade B evidence to support Weil Osteotomy in central metatarsalgia Espinosa, N. Foot Ankle Int. 2008

13 30 % rate of floating toes Picture of floating toes PIPJ Arthrodesis may be part of the problem Floating toes are a common complication with PIPJ arthrodesis and fusion should be avoided when performing a Weil - Migues

14 Complications/Floating Toe Center of Rotation Change in COR with clawtoe deformity Change in COR with Weil osteotomy Migues A, Foot Ankle Int 2004

15 Triple Cut osteotomy Shortens without plantarflexion Anthony Perrera AOFAS Oral Presentation 6 pairs of FF Cadavers Espinosa, Maceira Foot Ankle Tech 2008 Perrera A. AOFAS Poster Presentation 2012

16 Courtesy J McAlister DPM, FACFAS Phoenix, AZ thecoreinstitute.com

17 Phoenix, AZ thecoreinstitute.com

18 Surgical Algorithm 1. Address Medial Column/Hindfoot 2. PIPJ Arthrodesis 3. MTP Open Repair 4. MT Osteotomy and Fixation 5. If Lachman (+), Then Plantar Plate 6. Revisions: Flexor Tendon Transfer Roukis TS. JFAS Rush SM et al. JFAS Doty JF, Coughlin MJ. Int Orthop

19 We all seek excellence. Some never find it. Problem Resolved Unsolved

20 Soft tissue corrections for Structural Deformity=FAILURE Severe Bunion Ankle instability hindfoot varus PTTD Stage II TAR Failing in Varus Why would we treat a plantar plate injury with structural deformity by a different standard??

21 Review Correct structural abnormality! Repair of plantar plate/st alone insufficient Center of Rotation must be restored to avoid contracture at MTP- Maceira, McAlister PIP fusion with Weil=Risk for floating toes Flexor Transfer reserved primarily for revisions It is difficult to counter nature and even more difficult to correct nature. Luke D. Cicchinelli, DPM

22 Thank You