Download Great Toe Resurfacing System

Great Toe Resurfacing System
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Indications
Anatomy
Treatment Options
Arthrosurface System
Indications
• Degenerative and Posttraumatic arthritis in the first
metatarsal joint in the
presence of good bone stock
• Hallux Rigidus / Limitus
• Hallux Valgus*
• Unstable or painful
metatarsal / phalangeal
(MTP) joint
* In combination with corrective
osteotomy
Disarticulated bones of the foot
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From above (The talus and
calcaneus remain articulated)
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1 Calcaneus
2 Talus
3 Navicular
4 Medial cuneiform
5 Intermediate cuneiform
6 Lateral cuneiform
7 Cuboid
8 First metatarsal
9 Second metatarsal
10 Third metatarsal
11 Fourth metatarsal
12 Fifth metatarsal
13 Proximal phalanx of great toe
14 Distal phalanx of great toe
15 Proximal phalanx of second toe
16 Middle phalanx of second toe
17 Distal phalanx of second toe
Metatarsophalangeal MTP Joint
• The 1st MTP is the most
complex joint of the foot,
where bones, tendons
and ligaments work
together to transmit and
distribute the body’s
weight, especially during
movement.
• First MTP-related
problems occur from
repetitive trauma and
arthritis.
Foot Function– Truss and Tie-Rod
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Walking generates a force in the forefoot equal to 80% of the body’s
weight. Running increases it to 250% of body weight.
Calcaneous and talus serving as the posterior strut, the remainder of
the tarsals and the metatarsals serving as the anterior strut, and the
plantar aponeurosis serving as a tensed tie-rod. Weighting of the foot
will compress the struts and create additional tension in the tie-rod.
The plantar aponeurosis holds together the anterior and posterior
struts when the body weight is loaded on the triangle.
First MTP Joint
Three surfaces: metatarsal, phalangeal and sesamoid
Sesamoids Gliding Over Implant
Sesamoids Gliding Over Implant
Sesamoids Gliding Over Implant
Extension and Flexion
• Arthritis reduces the
natural extension and
flexion of the great toe
• The 1st MTP joint is
instrumental in all sports
that involve foot contact
with the ground.
• The Great Toe is the final
structure in contact with
the ground on push-off.
First MTP Arthritis
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Hallux Rigidus/Limitus
Hallux Valgus
Rheumatoid arthritis
Bunions
Gout
Post traumatic arthritis
Hallux Rigidus
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Males mostly ages 20 – 60 years old
Progressive arthritis from top to bottom
Staged I, II or III depending on severity
Sesamoid complex is last to be involved
The Pain of Beauty
• Shoes should be low
heeled, stiff soled with
a wide square shaped
toe box.
NOT
• Women today are
wearing shoes that
clearly do not fit the
profile
Hallux Valgus
• >85% Females; ages 40 – 60 years old
• Pain in joint when active, especially on
push-off
• Swelling around the joint
• Deformed mechanical axis
• A bump, like a bunion or callus, that
develops on the top & side of the foot
• Stiffness in the great toe and an inability to
bend it up or down
Surgical Options:
• Cheilectomy: (ky-lek-toe-me) Mild to moderate
damage. Removes bone spurs
• Arthrodesis (Fusion): Fusing the bones together
(arthrodesis) has often been recommended when the
damage to the cartilage is severe. Pins, screws, or a
plate are used to fix the joint in a permanent position.
• Arthroplasty: The joint surfaces are removed and an
artificial joint is implanted. This procedure may relieve
pain and preserve joint motion.
Cheilectomy
Resection arthroplasty (Keller)
Arthrodesis
(fusion)
Arthroplasty
(implant)
Cheilectomy
• PRO:
– Keeps joint motion
– No implants needed
– Fast and easy to perform
• CON
– Only good in stage I with little joint involvement
– 30% of patients will progress in arthritis
– Quite often x-rays underestimate extent of disease
Cheilectomy
Resection arthroplasty (Keller)
Arthrodesis
(fusion)
Arthroplasty
(implant)
Resection arthroplasty (Keller)
• PRO:
– Good for severe stages of arthritis (sesamoid arthritis)
– Good relief of pain control
– May weight bear immediately
• CON:
– High (40%) risk of deformity (varus/valgus/cock-up)
– Severe loss of push-off strength
– Only indicated for elderly and sedentary patients
Arthrodesis - Fusion
Arthrodesis
• PRO:
– Good relief of pain control
– Good for sesamoid arthritis
• CON:
– Limits shoe wear for women
– Increases stress on next joint
– Hard to get patients to accept fusion
– Long recovery from fusion (awaiting fusion)
– Malpositioning is difficult to deal with
BioPro
Hemiarthroplasty
Implant arthroplasty (hemi)
• PRO:
– Easy to perform
– Good relief of arthritis pain
– May weight bear immediately
• CON:
– Only for the proximal phalanyx
– Does not work in sesamoid arthritis
– Variable success rates
Implant arthroplasty (total)
• PRO:
– Easy to perform
– Good relief of arthritis pain
– Allows immediate weight bearing
– Either silastic or metal
• Reflection – osteomed – accumed
• CON:
– Silastic has high failure rate and complications
– Does not work in sesamoid arthritis, or loss of push
off
– Salvage/fusion is very difficult from bone loss
– Joint subluxation is big problem (soft tissue balance)
– success rates
Interpositional arthroplasty
• PRO:
– Good relief of pain control
– No artificial surfaces
– Allows immediate weight bearing
• CON:
– Not for sesamoid arthritis
– Causes significant stiffness and loss of motion
– Variable success rates
– High risk of postoperative deformity
PRE/POST OP X-RAY
HemiCAP Device
• PRO:
– Good relief of pain control
– Addresses both sides of arthritis
– Allows immediate weight bearing
– Low incidence of postoperative deformity
• CON:
– Does not address sesamoid arthritis
– No long term outcome studies yet
Why this implant?
• Very little bone resection so salvage (fusion) is
much easier if fails.
• Does not affect sesamoid complex so push off is
normal.
• With “Hasselman’s technique” both sides of the
joint are resurfaced.
• Allows women to wear their “other shoes”
without sacrificing strength or pushoff.
• Very easy to perform, no problems with
instability or deformity because of soft tissue
balance
Algorithm by Age
Conservative Tx
Cheilectomy
Age:
<35
Bridging the Gap
Hemi/Total Joint
Replacement
Fusion
35 - 60
>60
PRE/POST OP X-RAY
INTRA-OP X-RAY
PRE/POST OP X-RAY
HemiCAP™ System
Osteophytes
No Cartilage
Trial Reduction to
assess Joint Space
Main Objections
„ How can the patients get pain relief with
OA on both sides of the joint
„ No joint space so how will HemiCAP™
address motion
„ No cartilage left so how do you map
surface
„ Can you still do a fusion after this
How can the patients get pain relief
with OA on both sides of the joint?
„ Majority of pain comes from superior
Metatarsal osteophytes & exposed bone
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New weight bearing surface
Painful osteophytes are removed
Joint space recreated
Phalangeal cheilectomy/interpositional graft
How will HemiCAP™ address motion?
„ Stiffness a result of osteophytes & pain
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Osteophyte removal for dorsiflexion
New joint surface eliminates pain
Phalangeal Chielectomy/Moburg osteotomy
Joint line can be recessed
No cartilage left so how do you map
surface?
„ Cartilage loss goes Superior→Inferior
„ Use inferior and M/L cartilage references
„ If no cartilage then boney references become
the new surface elevations and joint will still
be congruent with joint line slightly posterior
Can you still do a fusion after this?
„ Yes
„ Remove implant and fixation component, then
bone graft for screw arthrodesis
„ Future possibility: remove implant and then
use K-wire through fixation component to fuse