PTTD Reconstruction-Turning Failure into Your Guide to Success Michael D. Dujela DPM, FACFAS Visiting Fellowship Alumnus, Orthopedic Foot and Ankle Center A.O. Fellowship Orthopaedic Foot and Ankle Alumnus Combined German Swiss Orthopaedic Fellowship Alumnus Director of Foot and Ankle Reconstruction/Trauma Providence Hospitals, WA, USA
Decision Making in TPD Reconstruction Stage 1 Generally straight forward Stage 2 Generates most controversy Stage 3,4 Generally requires arthrodesis -Johnson and Strom, CORR, Feb 1989
Destined to Fail? Can we identify ahead of time who will fail TPD reconstruction? More than likely Yes! 1) Gross Hypermobility/Laxity 2) Obese/ High BMI 3) Don t Ignore the warning signs
Systematic Approach Must Assess- Ligamentous stability? Competent Syndesmosis? Tibial plafond?
Evaluation of AAFS Weight Bearing Radiographs Don t Forget Ankle! Hindfoot alignment Views Pics Ankle valgus xray, salzman view medial column collapse -Where is the Instability? First TMT? N-C? Syndesmosis Widening? Talar Uncovering
Advanced Assessment Things to Consider SevereValgus? Neurologic symptoms Posterior Ankle instability.?avn risk Significant Degeneration? -Beware neuropathic patient!
Success: Avoiding Lost Opportunity Conservative Treatment Duration? Don t cost patient an opportunity for joint preservation Reevaluate periodically.. Are they truly still pain free? 6 months? Yearly? 9 months later
Surgical Failures Failure in Decision? Failure in Planning? Failure in Execution?
Failure of Procedure or Judgement? Don t Rely on One Procedure set Around the World Procedure isn t the answer for all patients FDL transfer, MCDO, GSR Michelson J Orthop T. Relat Res. 1992. 50% failure of FDL transfer at 2 years MCDO/FDL transfer is not a deformity operation - Only 4% perceived significant deformity correction Guyton FAI 2001
Success: Addressing the Medial Column Restore Medial ColumnStability Stress/Simulate WB on the table Type IIC? Forefoot varus Consider TMT Arthrodesis
Successful Management of Forefoot Varus Options for Varus Cotton Procedure NC derotation arthrodesis First TMT plantar flexion arthrodesis For patient who needs a little more stability
Failure to Recognize need for Fusion The Reality Check Goal is to maintain motion but Some patients benefit from fusion Clearly-Stage 3,4 High BMI Less Clear-Spring Ligament Laxity
Pearls from Past Struggles and Failure Some things to Consider in AAFS TNJ capsule tight laterally/dorsolaterally in longstanding deformity Difficult to do lateral column lengthening- need to release the tight capsule
Positioning Bump ipsilateral hip Toes up position Thigh Tourniquet Knee Flexed for AP views Prep to knee Visiting Fellowship Alumnus
Medial Column/TMT Approach-Incisions Direct Medial Approach Typically combined with 1-2 dorsal incisions Between 2/3 Met 4 th /5 th TMT for Lat Column Tibialis Anterior Tendon? Repair, Anchor, tack down with plate Must address! Visiting Fellowship Alumnus
Joint Preparation Joints are mobilized, prepped for arthrodesis Always the Same Sequence! ¼ inch curved osteotome Curette Drill Fenestration ¼ inch curved osteotome cross-hatch Visiting Fellowship Alumnus
Sequence Subtalar Joint Prep TN Joint Prep Provisional fixation ST -How to position Provisional fixation TNJ -How to position Equinus Correction Preference but Visiting Fellowship Alumnus
Additional STJ Fixation pearls
Fixation of the TN Joint Derotate the forefoot, eliminate Varus TNJ fixation 4.5, 5.0, 5.5 screw/staple Pearl:Countersink- Stress riser Visiting Fellowship Alumnus
Moving Forward: Reflecting on Past Failures General Concepts Joint Preservation in high BMI/Laxity/Elderly unpredictable Fusion is not failure Assess the Patient not just the deformity Forefoot Varus? Equinus? Flexible Stage II becomes Rigid Stage III.
Conclusion Recognize Ligamentous instability Fusion isn t Failure Don t miss their opportunity No Shortcuts.. No simple solutions to complex Problems Visiting Fellowship Alumnus