4/22/2017 ADVENTURES IN FOREFOOT RECONSTRUCTIVE SURGERY WHAT IS FOREFOOT RECONSTRUCTION? HALLUX VALGUS CORRECTION

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1 4/22/217 ADVENTURES IN FOREFOOT RECONSTRUCTIVE SURGERY ERIN E. KLEIN, DPM, MS Associate Director of Research, Weil Foot & Ankle Institute Clinical Instructor, Dr William M Scholl College of Podiatric Medicine Des Plaines, Lake Forest, Libertyville eek@weil4feet.com WHAT IS FOREFOOT RECONSTRUCTION? 1st ray deformity repair Hallux valgus Hallux limitus/rigidus Digital deformity repair Plantar plate repair Metatarsal osteotomies Tailor s bunions HALLUX VALGUS CORRECTION Goals of surgical procedure: Joint realignment Decrease the IM angle Decreased the HV angle Realign the sesamoids Decrease the interphalangeus 1

2 THE OPTIMAL PROCEDURE SHOULD Versatility of correction Bilateral correction Immediate guarded weight bearing Return to gym shoes at 1 week post op Early physical therapy Reproducibility Straighten the toe Allow return to sports Heal as quickly as possible Long term predictability Cosmetic result Have a toe that moves afterward (generally speaking) THE OPTIMAL PROCEDURE SHOULD SURGEON PERSPECTIVE Versatility of correction Bilateral correction Early physical therapy Reproducibility Long term predictability PATIENT PERSPECTIVE Straighten the toe Have a toe that moves afterward (generally speaking) Cosmetic result Immediate guarded weight bearing Return to gym shoes at 1 week Allow return to sports Heal as quickly as possible THE OPTIMAL PROCEDURE SHOULD SURGEON PERSPECTIVE Versatility of correction Bilateral correction Early physical therapy Reproducibility Long term predictability PATIENT PERSPECTIVE Straighten the toe Have a toe that moves afterward (generally speaking) Cosmetic result Immediate guarded weight bearing Return to gym shoes at 1 week Allow return to sports Heal as quickly as possible THIS PROCEDURE MAY OR MAY NOT ACTUALLY EXIST. 2

3 PRE-OP PLANNING What is the position of the 1 st ray? Is there joint related pathology at the 1 st MTP joint? What it the metatarsus adductus angle? Is there an elongated 2 nd metatarsal? Is the 2 nd MTP joint unstable? PRE-OP PLANNING What is the position of the 1 st ray? Is there joint related pathology at the 1 st MTP joint? What is the metatarsus adductus angle? Is there an elongated 2 nd metatarsal? Is the 2 nd MTP joint unstable? PRE-OP PLANNING What is the position of the 1 st ray? Is there joint related pathology at the 1 st MTP joint? What it the metatarsus adductus angle? Is there an elongated 2 nd metatarsal? Is the 2 nd MTP joint unstable? 3

4 PRE-OP PLANNING What is the position of the 1 st ray? Is there joint related pathology at the 1 st MTP joint? What is the metatarsus adductus angle? Is there an elongated 2 nd metatarsal? Is the 2 nd MTP joint unstable? METATARSUS ADDUCTUS METATARSUS ADDUCTUS 4

5 PRE-OP PLANNING What is the position of the 1 st ray? Is there joint related pathology at the 1 st MTP joint? What is the metatarsus adductus angle? Is there an elongated 2 nd metatarsal? Is the 2 nd MTP joint unstable? PRE-OP PLANNING What is the position of the 1 st ray? Is there joint related pathology at the 1 st MTP joint? What is the metatarsus adductus angle? Is there an elongated 2 nd metatarsal? Is the 2 nd MTP joint unstable? HOW DO YOU ADDRESS 1 ST RAY PATHOLOGY? HALLUX VALGUS HALLUX RIGIDUS 1 ST MC JOINT INSTABILITY 5

6 Not technically demanding Versatile Stable CHEVRON BUNIONECTOMY Easily amenable to fixation Reproducible results Heretherington VJ, JFAS, Metatarsal head width LIMITATIONS Capsular reefing does not alter post operative results May not correct the IM angle May not correct the sesamoid position/rotation. Heretherington VJ, JFAS, SCARF CUT Woodworking term to describe interlocking joints Stability Versatility Predictability Ease of fixation 6

7 4/22/217 SCARF OSTEOTOMY Head-shaft procedure Distal osteotomy starts in the cancellous head Distal cut at 7-9o with apex in metaphyseal bone 1/3 1/3 Distal arm in dorsal 1/3 Proximal arm in plantar 1/3 THE SCARF OSTEOTOMY POST OPERATIVE One week post-operative Bathing Return to closed athletic shoes Night Bracing Begin physical therapy 7

8 POST OPERATIVE 6-8 weeks post op Return to all activities to tolerance Return to all shoes to tolerance 2-3 months post op Doing significantly better Edema is much less WHAT IF THE PATIENT NEEDS MORE THAN A SCARF? LET S TALK LAPIDUS! Fusion of the 1 st metatarsal cuneiform joint LAPIDUS Indications: Large IM angle Metatarsal rotation Instability Arthritis Revision surgery 8

9 THE LAPIDUS POST OP COURSE Somewhat variable by surgeon Strict NWB for 2 6 weeks in a cast or CAM walker Gradual return to weight bearing ROM of the 1 st MTP joint is variable Incision and capsulorraphy Move it in the cast? RISK/BENEFIT RATIO Risk MTP joint doesn t move after surgery Non/delayed union Is the position obtained correct? Benefit Definitive procedure Significant IM correction Rotational component realigns the sesamoid complex 9

10 OKAY. WE HAVE FIXED THE 1 ST RAY. NOW WHAT? CAN T LEAVE THAT 2 ND MTP LIKE IT IS!!!!!! 2 ND MTP JOINT INSTABILITY Plantar plate Collateral ligaments Capsular structures Base of phalanx Plantar plate Met head Cruveilhier. The anatomy of the human body, Sarafian. Anatomy of the foot and ankle, Sarafian. JBJS-Am, Stainsby. Annals, ND MTP JOINT INSTABILITY Flexor tendons Intimate association with the plantar plate The flexor tendons provide an indirect plantar flexion at the MTP joint Plantar fascia Deep slips of the plantar fascia create the sheath that allows the flexor tendons to provide flexion at the MTP joint Met head Plantar plate Deep slips of plantar fascia Proximal phalanx Cruveilhier. The anatomy of the human body, Sarafian. Anatomy of the foot and ankle, Sarafian. JBJS-Am, Stainsby. Annals,

11 4/22/217 PROGRESSIVE UNDERSTANDING Early signs Pain Edema Positive drawer Splaying of the 2nd and 3rd toes Late deformity Less pain Minimal edema Fixed deformity Multiple joint involvement PATIENT HISTORY PARAMETERS Parameter Incidence (%) Sensitivity Specificity Positive Predictive Value Negative Predictive Value Odds Ratio Sudden onset Gradual onset 7% NA 93% Pain >6 months 69% Previous 1st ray surgery 18% NA Previous cortisone injection 21% Neuroma? 9% Klein, et al. FAI, 214. PATIENT HISTORY PARAMETERS Parameter Incidence (%) Sensitivity Sudden onset 7% Gradual onset 93% 93 Pain >6 months 69% Previous 1st ray surgery 18% Joint 7 line Previous 21% cortisone If a patient has injection Specificity 1 Positive Predictive Value Joint 1line Negative Predictive Value Odds Ratio 8.9 NA NA Digital Nerve been diagnosed with a second interspace neuroma that Neuroma? 9% 91.7has not 93.4responded 27.8 to treatment, it may not be a neuroma. Klein, et al. FAI,

12 PATIENT CLINICAL PARAMETERS Parameter Incidence Sensitivity Specificity Positive Predictive Value Pain - 2 nd metatarsal head Edema - 2 nd metatarsal head Positive drawer sign Negative Predictive Value Odds Ratio 98% % % Pain with 2 nd 28% MTP joint ROM When pain, edema and a positive drawer sign are Crossover combined, 8% this 8.will identify % 88.9 of plantar 8. plate tears..696 toes Klein, et al. FAI, 214. PATIENT CLINICAL PARAMETERS Parameter Incidence Sensitivity Specificity Positive Predictive Value Pain - 2 nd metatarsal head Edema - 2 nd metatarsal head Positive drawer sign Pain with 2 nd MTP joint ROM Crossover toes Negative Predictive Value Odds Ratio 98% % % % % Klein, et al. FAI, 214. MULTIFACTORIAL ETIOLOGY Shoe gear Activity level Congenital syndromes/issues Inflammatory processes Underlying systemic disease Osseous/soft tissue imbalance Structural Elongated 2 nd ray Shortened 1 st ray Functional Insufficient 1 st ray Waverly, et al. In publication process. Fleischer, et al. FAI, 216. Klein, et al. FAS,

13 RADIOGRAPHS Parameters Incidence Sensitivity Specificity PPV NPV Odds Ratio intermetatarsal angle 47.1% 51.5% 66.7% 94.3% 11.3% First >12 Metatarsus adductus angle >15 7.7% 77.3% 22.2% 91.5% 8.3%.974 Hardy & Clapham +/- 2 mm 5.% 54.4% 5.% 92.5% 8.9% nd metatarsal protrusion distance 9.2% 97.9% % 92.% % >2mm Maestro 1 st Metatarsal <1 mm 36.2% 39.4% 62.5% 92.5% 8.1% 1.81 Maestro 2 nd Metatarsal >13 mm 65.3% 71.% 5.% 94.3% 12.9% Maestro 3 rd Metatarsal <9 mm 48.% 52.1% 5.% 92.5% 8.2% 1.89 First metatarsal declination >2 82.5% 9.4% 11.1% 91.4% 1% MPE >8mm 17.8% 19.5% 75.% 88.9% 8.3%.727 Second metatarsal 87.3% 95.7% % 9.8% % declination >2 Klein, et al. FAS, 213. METATARSAL LENGTH Metatarsal parabola evaluation is critical Underlying osseous deformity Soft tissue imbalance Nilsonne s Method Coughlin s Method Metatarsal Break Angle Maestro s Method Waverly, et al. In publication process. ETIOLOGY METATARSAL LENGTH Retrospective Case-Control study Exempt determination, ICF waver 3 subjects, 2 controls per 1 case Cases Non-acute, isolated 2 nd MTP joint pain Intra-op confirmation of plantar plate injury Controls Pain outside of the forefoot (e.g., plantar fasciitis, tendonitis) Matched on age (+/- 2 yrs), gender, and year of presentation Fleischer, et al. FAI,

14 ETIOLOGY METATARSAL LENGTH Fleischer, et al. FAI, 216. CONCLUSIONS OF STUDY Long 2 nd metatarsal was the only risk factor associated with plantar plate injury in both univariate and multivariate analyses: nearly 2.5x greater risk Metatarsal length exhibited a positive dose-response: patients with longer 2nd metatarsals were increasingly more likely to present with plantar plate injuries. (Mantel-Hantzel test χ , p=.27) Fleischer, et al. FAI, D SHARC Typically stagittal images.2 mm slices = 1 images of metatarsal heads A hypointense structure that has a stout distal attachment with a proximal attachment that blends with the periosteum of the metatarsal Base of proximal phalanx Metatarsal head Long flexor tendon Plantar plate Base of proximal phalanx Metatarsal head Long flexor tendon Plantar plate Sung W, et al. J Foot Ankle Surg,

15 4/22/217 DORSAL APPROACH REPAIR ANATOMIC PLANTAR PLATE REPAIR USING THE W EIL METATARSAL OSTEOTOMY APPROACH. W EIL L JR, SUNG W, W EIL LS SR, MALINOSKI K. FOOT ANKLE SPEC. 211 JUN;4(3): POST OP PROTOCOL Post op day #7-1 Post op day #1 Partial weight bearing in a surgical shoe Gym shoe Physical therapy Night time bracing 1 YEAR POST OP 15

16 * Noted at final follow up examination w hich w as performed after all procedures w ere undertaken (i.e. after T&C/manipulation if this w as needed) 4/22/217 WHAT DO OUR OUTCOME STUDIES SUGGEST? PATIENTS DO HAVE IMPROVEMENT IN SYMPTOMS WITH THIS PROCEDURE. 2 YEAR OUTCOME STUDY 53 consecutive patients Average age VAS Pain Edema Positive Decreased Drawer Sign Strength Decreased Range of Motion* Pre-surgical % 97% 8% 75% Post-surgical % 2.3% 2% 35% Klein, et al. In publication process. 2 YEAR OUTCOME STUDY Average time to final FAOS score: years Foot and ankle outcome scores 1. * * * 9. * Pain Symptoms ADL S&R QOL Pre-operatively Post-operatively Klein, et al. In publication process. 16

17 COMPLICATIONS - ARTHROFIBROSIS Arthrofibrosis did occur in these patients Possible explanation: Biopsychosocial patient parameters Physical therapist Genetic composition of the patient (i.e. scar tissue former) This complication is not yet well understood and currently being investigated in more detail Klein, et al. In publication process. PHYSICAL THERAPY CONSIDERATIONS DISCLAIMER: I AM A PICKY PAIN IN THE GLUTEUS MAXIMUS. NOT EVERYONE DOES THINGS THIS WAY. Developed over time Trial and error Multiple surgeon input PROTOCOL DEVELOPMENT Noted difference between PTs 17

18 PLEASE DON T EVER BE AFRAID TO CALL THE SURGEON. GOOD INTERDISCIPLINARY COMMUNICATION CAN TRULY BENEFIT THE PATIENT. IF YOU SEE SOMETHING, SAY SOMETHING. MY PHYSICAL THERAPISTS HAVE A NOSE TO TOES LICENSE. I DON T. IF YOU NOTICE PROXIMAL PATHOLOGY, PLEASE TELL US AND THEN FIX IT (IF YOU CAN). 18