Emerging Thinking About First MTPJ Salvage Procedures

Jennifer Spector, DPM:

Welcome back again to Podiatry Today Podcasts, where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. I'm Dr. Jennifer Spector, Assistant Editorial Director for Podiatry Today. In this installment. We're talking about first MTPJ salvage surgery with Dr. Joshua Sebag and Dr. Zachary Cavins, specifically diving into the procedure decision-making process, imaging, comorbidities, and fixation options. Both doctors are fellows of the American College of Foot and Ankle Surgeons and practice in the state of Florida. Welcome, and thank you so much for being with us today. So, I think the first question we'd like to start out with today is for both of you to describe for us in your practices, what's the typical patient that you see coming in for a first MTPJ revision and how does that contrast from the patients that are coming in for primary procedures?

Joshua Sebag, DPM:

So for me, the demographic most commonly coming in are going to be the geriatric folks, either with rigidity, someone who was treated with an arthritic bunion and some sort of Hemi or something, where there was a joint semi joint sparing or joint sparing procedure, or a completely failed implant.

Zachary Cavins, DPM:

I would kind of echo a lot of those similarities, especially when it comes to the revisions. The other thing I would see with these patients are previous bunionectomies or even incorrect bunionectomy procedures, where there was undercorrection, or there was even a malalignment secondary to correction. Now, we're seeing these patients three to five years out, and they're still having complications at that joint, but definitely, in terms of previously joint sparing and other procedures, age ranges can literally be anything. I would say most commonly 65 to mid-seventies, not really seeing too much younger than that from a revision salvage standpoint.

Jennifer Spector, DPM:

When you are coming up with your surgical plan for these revision patients, how aggressive are you?

Zachary Cavins, DPM:

For me? I'm definitely a fan of arthrodesis as a whole. I think we have a lot of data that supports arthrodesis and honestly, for me, it's really the gold standard and continues to kind of be so. I'm sure that in another provider's hands, there's an option for arthroplasty but when you look at the data, especially when you start looking at some of the literature that's out there on how patients tolerate these procedures postoperatively and how well they honestly do. Usually, I'm able to have these conversations with patients where I'm talking about arthrodesis. I can't say that I have never performed arthroplasty, but I would say the majority of time, these patients are coming to me for, especially when it comes to revision, they're looking for a solution. They're not looking for another possibility. They're looking for something that's going to get them out of pain. For me, I think I'm able to do that most successfully and most consistently with arthrodesis.

Jennifer Spector, DPM:

Dr. Sebag, is there anything you would like to add to that?

Joshua Sebag, DPM:

For me, it's not really much of a discussion. It would have to be a real unique scenario where maybe there were multiple fusions, distal, or proximal to the revision site for me to really entertain something that would be an arthroplasty or sort of an arthroplasty. Nine times out of 10, probably more, I'm looking for a predictable, durable, lifelong lasting option, and that's going to be a fusion and that's been born out in the literature pretty well now. If you read and you see what works long term, these folks are coming in, it's by definition a second, or maybe even a third option. The goal to be able to give them something that you know is going to be durable long term, I think is logical for me. So, I'm always leaning towards that.

Additionally, if I'm dealing mid-seventies year old person, who's had surgery on the first ray once or twice, or maybe more, I have to expect the soft tissues to be a concern, or at least with some evidence of scarring. And if I perform a fusion, I know that I can stabilize the soft tissue. So I'm also treating that soft tissue with a fusion and that to me is just more of a comfortable procedure versus encouraging motion around that scar site.

Jennifer Spector, DPM:

Now, what do you feel about advanced imaging? Do you ever order say an MRI for these patients preoperatively? Is there any benefit to that in your assessment?

Joshua Sebag, DPM:

Definitely. I think for one, if it's a revision, you could argue there's medico-legal reasons to just really make sure you're kind of covering yourself, get all the information you can. Advanced imaging has come a long way between weightbearing CTs, and thin cut MRIs and these multiple Tesla models that allow us to just get good good data. With MRI and hardware, obviously, there's going to be scatter and there's loss of definition, but I do think a weight-bearing CT, or even a non-weight-bearing CT gives us great information. If I'm going to be dealing with a revision, I have to expect cystic change or bone loss somewhere, maybe sesmoidal damage that was missed on the primary, which probably should have been treated with a fusion definitively then. So, for me, it just helps in lots of different ways, especially on that coronal cut, looking at it as a motion sesamoid axial, it's a lot better than a simple weight-bearing view.

Zachary Cavins, DPM:

When it comes to any revision, I want to know what else is going on within that bone, that surrounding structure and why are we seeing those cystic changes. A lot of times, if there is hardware previously in place, or if you're doing say, even a revision MTP fusion, those even definitely can come up. You don't always get the best visualization of that surrounding bone and with CT scans and thin cut CTs, we're definitely able to see that bone structure so much better. So, for me, it's almost a given if you're coming in and we're talking about revision, then we are for sure pursuing advanced imaging.

Jennifer Spector, DPM:

Were there ever any findings on that advanced imaging? You mentioned the sesamoid findings, perhaps, that really surprised you, that had a significant impact on your operative planning.

Zachary Cavins, DPM:

The sesamoids are definitely important to look at. Also, when it comes to structural grafting, sometimes we're looking at bone loss and you're not always seeing that, especially in those cases of those revision MTP fusions, where we're not always seeing that bone very clearly. And so you're going to see sometimes some bone losses, especially on whether it's the proximal phalanx base or on the first metatarsal head, that's not always predictable with plain film radiograph. So, having that CT definitely will let you know what you're getting yourself into. Revisions are never really predictable so we try to do as much as we can upfront. It does change sometimes my plans, if we are talking about doing the structural allograft or structural autograft or any at all, or we're just going to try to put bone back together, depending on the level of shortening. But having that information upfront, especially if there's a lot cystic changes and being prepared for additional bone loss, I think it's extremely important.

Joshua Sebag, DPM:

I would just say yes, for sure. There's benefit to it. The patients appreciate it. It gives me more information. So, yes.

Jennifer Spector, DPM:

Definitely. Well, speaking of more information and needing to take certain things into consideration, in these patients that need revisions, you mentioned some of them are of advanced age, but they probably are also dealing with some other comorbidities. Could you tell us a little bit about how this might affect your preoperative planning specifically, say a patient who smokes or who has diabetes or perhaps neuropathy?

Joshua Sebag, DPM:

If it's a neuropathic patient, this is something where they're not a candidate for an arthroplasty. So again, leaning towards fusion. Similar to how we would treat a total ankle, you might be a candidate until you don't feel well and if you're insensate, we lean towards fusion. I would go with the same logic here. So, for a neuropathic patient, they really are chosen by definition to get a fusion. And in terms of counseling a patient, it's easier to counsel them on smoking cessation protocols and stuff like that. and this is relatively elective. So, we do have the power as the surgeon to say no. And for a patient that has poor peripheral fusion or some sort of inherent biologic concerns that I can't control, I probably would lean towards a first ray extension or some sort of non-operative thing. If it's truly a symptomatic non-union or malunion or something that I genuinely believe I can't correct with an orthotic, I would have to counsel the patient.

I'm not super eager to operate on elective surgeries on smokers, though. So, I would totally refuse hindfoot surgery. The first MTP has fairly predictable fusion rates so I feel okay to do that, but I would probably go ahead and get a vascular evaluation if there was any concern about that.

Zachary Cavins, DPM:

How long do you make them stop smoking for?

Joshua Sebag, DPM:

I've been asked this and talk to other people and we all give different answers and I'm not sure it even matters. So, I would more rest my hat on having a vascular surgeon, evaluate them and document AVIs, TVIs, things that are going to give me information on their ability to profuse the limb versus a timeline which may be totally subjective. So, I don't really have a number, I guess.

Zachary Cavins, DPM:

I think we all have a subjective we're just going to pick, but how it actually matters, I'm not quite sure. Yeah, I'm right there behind you in terms of patients with neuropathy. If you can't fill you where you are in space, then usually we're seeing those patients not necessarily due to an issue at the joint. Usually there's a secondary, whether it's an ulceration or just a secondary infection, sometimes it will happen from increased pressure or they're pre ulcerative or they're callusing there. And that's just sometimes just secondary to that neuropathy, they can't feel the offload. So it's malpositioned from previous surgery plus a combination of neuropathy. So for me, that's an automatic fusion. Doesn't really matter what shoes they're wearing, they need to be more educated on what that disease process looks like for them. And what's going to be the most important thing for them, long-term success-wise, and trying to keep them with all their toes for the rest of their life.

So for me, neuropathy, especially if it's subsequent to diabetes, that's almost an automatic fusion. The diabetes numbers, when I first graduated, that A1C number used to be 8% and we've seen that number start to drop down lower and lower now. So, I think most recently, we're talking about it somewhere, they're likely to be around 7% now. I do my best to educate patients on those risks and concerns, and really try to work with endocrine to make sure we're getting them as optimized as possible. And definitely on my diabetic patients as well, they're getting pre-vascular workup and making sure we have as much blood flow going to that area as possible, especially in these revision patients, as we're going back into the bone and taking more bone. And even more important if we're going to start grafting and doing things like that as well.

Joshua Sebag, DPM:

At least in my area, it seems I'm personally not treating as many diabetics as I thought I might, but a ton of my patients are on biologics for all sorts of disease-modifying anti-rheumatic things or patients with kind of loose diagnoses of scleroderma and just these unbelievable autoimmune conditions. When I discuss the multidisciplinary approach with the rheumatologist or with someone else, the more and more I talk to them, they're telling me that we're actually treating them. I used to take a drug holiday, we would take a holiday between the DMARDs and now we're kind of just riding it out. And I can't say, at least anecdotally, that I'm seeing a huge difference. So, I've actually switched to doing that.

Jennifer Spector, DPM:

That's super interesting because I think those medications have really blown up and awareness of those conditions has really increased too. So, it makes sense that your patient population is representing that more as well, but I'm not aware of any studies specifically that talk about that. Dr. Cavins, have you had any experience there?

Zachary Cavins, DPM:

No. I mean, I think a lot of it also depends on the rheumatologist in your area. Who I'm talking to now, I'm still seeing them with the recommendation of a holiday. Tapping on a medico-legal standpoint, it's kind of the same thing. I don't want to sit here and say, "Well, I need you to see all these different specialists." Because I tell them, "You need to go get cleared by your rheumatologist. You got to get cleared by whoever else." And you list your 19 doctors that they have to see. And then they come in and they go, "Well, we're going to stop their DMARDs." And I go, "Well, you really don't need to do that. You're probably okay with some of these advanced biologics to stop that."

Joshua Sebag, DPM:

Well, I'm having them stop prednisone and steroids, but I'm not having them stop Humira, things like that. So the DMARDs themselves, the biologics themselves, they're continuing. The steroids, the things that have clear soft tissue concerns or healing concerns that are more, I think identifiable and legitimately a concern, I'm having them stop those and they seem to be okay with it. And the rheumatologist seems to be okay with it, but I'm not requesting and the rheumatologist is not encouraging DMARD cessation.

Zachary Cavins, DPM:

I'm hopeful that they just continue to document that way for you, that's all. Obviously, from a steroid standpoint, we talk about from a skin and chronic steroid use and what did that, the hostility of the skin and just everything else that goes along from a healing standpoint and you need information from a healing perspective. So, I don't disagree with you at all. It's just, I'll tell you, I've seen the documentation come through for request and my guys up here still have their holiday. Patients ask me, "Well, what do you think I should do?" And I go, "I think you should listen to the guy that you see." I don't want to be the one that says, "Hey, go ahead and keep on your Humira." And then all of a sudden we don't and there's obviously a secondary issue and the rheumatologist is going, "Well, I told him to stop, but Cavins said to keep him rolling." And now we're staring at exposed plate or something, who knows.

Jennifer Spector, DPM:

Well, hopefully we're not staring at exposed plates, but we all have our preferred methods of fixation for first MTP arthrodesis and I was curious if both of you could share how you like to approach the fixation aspect?

Zachary Cavins, DPM:

Nine times out of 10, it's a dorsal plate with an interfrag or a crossing screw underneath. I have fixated other ways as well, but I would say more routinely it is a interfrag or compression style screw with a dorsal plate to help some of those forces.

Joshua Sebag, DPM:

I would say that it depends on the size of the void. So, if I'm dealing with a revision and there was something that was required in order for me to correct deformity and then maybe an allograft plug or an autogenous piece of bone, I'd probably have to measure it and then make a determination if I could bridge it appropriately. But what I have been doing for these that works pretty well, actually, is more of a biplanar approach where I can get multiple points of fixation dorsally immediately. Almost always it's that construct. Similar to how we're seeing a lot of literature support fusion in the TMT and that seems to work well and also avoid the need for a thick plate in an area of concerning soft tissues.

Jennifer Spector, DPM:

Both of our thought-leading surgeons today have more to say about revision first MTP surgery, and we'll continue our discussion in our next episode. Thanks to both of them for joining us and to the listeners for tuning in. Be sure to explore previous podcast topics at Podiatry Today dot com and your favorite podcast platforms.