More Thoughts on 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. Hopefully you caught the last episode where we will continue the discussion today starting out with post-operative considerations. In these cases, both doctors are fellows of the American College of Foot and Ankle Surgeons and practice in the state of Florida. We're so grateful to have you back to continue the conversation. Thank you so much for being here. I think we left off last time at the end of the procedure. So, why don't we kick off today by starting a little bit with post-op protocols.

Joshua Sebag, DPM:

For me, again, it's going to depend on the size of the void. So, if this is simply just a patient who had to make pride and we're calling it a revision and now it's a primary fusion but it's a revision surgery, then I would treat that as a primary arthrodesis and I would let them weight-bear as tolerated in a boot as soon as the skin is healed. So, really my only limiting factor would be the soft tissues. So, say 14, 21 days later based on their biology, I'd let them weight-bear in a boot.

If it's a true revision where there's a fusion that was failed, extracted hardware, whatever I needed to do to restore the first ray length, then I treat that a little different. So, for that true revision with a spanning graft, that's going to be a minimum of six weeks and I would probably introduce a full thread screw across it at some point if I can just from a real estate standpoint to add to stability. But I would still place six weeks minimum on the patients for them to even commit to that type of timeline before I would let them weight-bear.

Zachary Cavins, DPM:

I differ a little bit. One, it's kind of typically for me based on age and what the demand of that patient is. If I've got that mid 70s grandma that's coming in that needs a revision that is minimally ambulatory, I'm letting them weight-bear right off the table in a protective boot. I'm not having them go to the grocery store. I'm definitely telling them they need to kind of take it easy around the house. But that's a little bit different than when I first started. I was a little more cautious early on. Patients teach you a lot of things over the years and if my patient's younger, they are definitely more limited. So, if I have the 48-year-old patient that's coming in or that mid 50s active person that you can tell they're just going to get after it no matter what, then I'm making them have a period of non-weight-bearing at least four weeks.

I want to have pretty good bony, basically a start of some bony knit happening on that fusion mass before I let them start to weight-bear in a protected boot. And I really educate them on the bone biology and bone healing that really goes on into that and the benefits of stability and letting things heal and the military's effects of motion, even with the attempt of fusion, it can definitely happen.

So, I really educate them as heavy as I can on that right there with Josh though, where we completely agree, I'm putting any sort of graft spanning of whether it's especially a structural allograft. I do not let them weight-bear at all until six weeks out. I want to make sure that that site is as solid as possible before I let them really do any sort of real activity based on x-ray findings and swelling and obviously skin, but transition to shoe hopefully for the majority of people at that six-week mark. And then for my graphs, somewhere between eight to 10, they're a little bit more swollen because they're down for a little bit longer. But usually, eight to 10 is when I'm seeing to get them back into sneakers.

Jennifer Spector, DPM:

So, in what setting are both of you usually performing these revision procedures? Especially now that we're hearing more and more about cost effectiveness and cost consciousness across the surgical field? Has that affected your choices at all or tell me a little bit about that.

Zachary Cavins, DPM:

I'm a hospital group employee, so a 100% of my surgeries today occur at a hospital facility. If I was doing primary arthrodesis then I would... Depending on insurance and yeah, we could do them at ASCs previously, anything that requires a graft is definitely going to need to go to the hospital from a cost perspective.

Joshua Sebag, DPM:

The world that we're in now with cost conscious ASC stuff, I think is a big deal. I do bring the vast majority of these outpatient. Now, I understand there's issues with Medicare folks and we said the vast majority of these may be older. So, if there's truly an older patient that's going to need a bulk allograft, then I'll bring that elsewhere if I can't get it done at the ASC. But more and more I've been doing them at the ASC and I'm not a huge proponent of the biologics and I'm not a huge proponent of buying into some of the mantra that there's donor site morbidity with autographs. So, the calcaneus and the distal tibia are right there for the taking. So, I would just assume procure the bone and use the autograft and fill the allograft plug if needed to restore the length. But I would do this outpatient if I could try to avoid the unnecessary use of biologics.

Zachary Cavins, DPM:

If you are using a bulk allograft or a structural allograft, are you using biologics then or are you just putting that graft then?

Joshua Sebag, DPM:

I've done it both ways and I can't say it made a whole bit of difference. So, I'm really leaning towards autograft, I would go to the calcaneus. There's good amount of literature that says that we can harvest enough bone from the dorsal calcaneus or the distal tibia. So yeah, I'm taking autogenous bone and mixing that as needed to back up the fusion site.

Jennifer Spector, DPM:

What about you Dr. Cavins? Are you using biologics at all?

Zachary Cavins, DPM:

I am definitely using biologics when I'm using structural allograft that is upwards of eight to 10 millimeters. There are companies out there that make a cup and cone shape that allows me to fit in that mirrors the head of what we're trying to do. Because a lot of us when we do these fusions are using cup and comb reamers or we're reaming these out. And so, there are devices that allow us to address that similar length issue to help restore the length of ray but then also use a graft to help get us there and not necessarily be reliant upon say posterior superior lateral calcaneus to just give you a more of a square shaped graph. So, whenever I'm using anything that's eight to 10 millimeters in length in terms of those discs, then I am using biologics.

I think that just really just to help stimulate some of the whatever goes across that site. For the smaller ones not as common. I guess it depends on that patient and what those comorbidities are. But I would say more frequently, especially now with the reamers and things that exist from that foot from the Cal cancer, we're able to do, it's right there for the taking and it adds three minutes to your procedure, which is the same time it takes it probably make the stuff we're trying to make.

So, if you have a patient with a pretty good protoplasm and a good propensity to want to heal, then giving the patient their own ability to do that I think makes a lot of sense. It's more for me based on if I'm having to use one of those larger discs before I'm pulling the trigger to use those orthobiologics.

Joshua Sebag, DPM:

So, do you think it makes sense to maybe lean towards a shorter allograft even if the perfect toe parabola isn't achieved in a salvage case and then to that point de lesser metatarsal osteotomies make sense in the same scenario?

Zachary Cavins, DPM:

Yeah. I guess we could have that conversation about is less more and then have a second incision. I mean I could put the other side of that coin and now say, well if I just restore the parabola, yes it's a little more expensive but now haven't created a second or a third surgical site, what are those chances of those while going on? And now, I've increased more risk on those lesser metatarsal osteotomies as less risky as they honestly are. They're still now I'm creating additional incisions and putting in things there. And if you're drilling and you're using hardware, is there still a cost associated with that now? Not on the magnitude of course of the work of biologic, but I wouldn't say it's not without it. If I'm doing an MTP fusion and I'm sure I'm putting over and I need the length, I'll put it there. Now, if I'm super short and I had one of these, oh God, not that long ago where I was short and I probably needed 18, it was bad.

It was really bad. They were structurally short I think to begin with and then they got an implant, so they were even shorter. And then I ended up doing subsequent wiles with that. When I think about the procedure as it of itself and it's just in the entirety, typical revision medial column first MTP, I would say I'm probably not leaning towards going to something shorter and then doing additional procedures. And I think that's a patient conversation too. I mean I think that's, "Hey, my problem is here," and I go, "Okay, that's great. But I can fix this, but I also need to fix this and this as well." You have to have a patient that also wants to agree to that. Not that we can't explain that now that we can't take the 10 minutes to do it and make them understand the parabola and lesser nostalgia and those procedures. But I would say as a whole for me, I'm probably leaning more towards just addressing that primary issue if I can and just one single setting and on that one surgical site.

Jennifer Spector, DPM:

So, since plating seem to be the consensus among all of us as far as fixation choice, are there any particular pearls that you've come across in your work about using that type of fixation that you wanted to share with the audience?

Joshua Sebag, DPM:

Yeah. Definitely. So, I think Roukis who did a pretty good systematic review and one of the biggest issues, it was maybe near 8% or so, 7% was malunion and a dorsal malunion is just a bad problem. And subsequent IPJ flexion deformities that follow and all the other issues that can go on with the malunion. So, for me, I looked at my own 40, my first 40 I think in private practice. And when I was critical with my own work, I found that I had a low rate, but I did when I was honest with myself, find myself with a little dorsal malunion sometimes and I thought of course, that I was doing a good job. But then I evaluated it and I found that a small percentage of these patients were not necessarily complaining about their position, but that they were somewhat malunited.

It's all about the position, this is the buzzword, it's all about the position and it's very, very easy to find yourself with the toe facing, the nail plates north and transverse plane. We're happy, there's no cigar sign, but then sure enough your sagittal plane's off or vice versa where other things are, right. So, it's really difficult to get them all straight. So, what I've trended towards anyway is what the osseous study put out. It might have been 2007 or so, but he did some, I think pretty good work and evaluated the general position of the first ray. And if you take into account the first ray metatarsal declination angle, you really shouldn't have a plate probably more than maybe five-degrees of dorsiflexion that puts the MTP in about 25 degrees of dorsiflexion with a five-degree max extension on the plate.

And I thought that was just really profound. And when you start to look at some of the manufacturers that we, of course a lot of them have upwards of 10, 15, maybe even more options. And I think that that's just allowing us to make this mistake. So, I've pretty much gravitated towards a neutral plate. I do take down the dorsal condyles on the base, the proximal failings as well as the metatarsal head with almost like a back brush technique. And that's allowed me to counter sink the plate, so to speak. Also, decrease the soft tissue tension when closed in that area. So, I would say for me, it's five-degrees max and I'm switching almost always to a neutral plate. If I do the bi plantar approach then I just have to be more critical of my work because I don't have that plate template, but the plate templates really help. So, that's something that I think is important.

Zachary Cavins, DPM:

I'm right there with you in terms of neutral plating, zero degrees is kind of where I want to keep everybody, some of the women that would come in, there's definitely concern about range of motion, and then can I go into my heels? And a lot of that just has to speak to patient expectation. Luckily for me in these scenarios, I'm the second or third person they're coming to, so I can go look, everyone else tried to give you what you were open for and I'm going to give you something that doesn't hurt or at least try to, I kind of lean that way.

But going back to what we first even talked on was that when you really look into literature into the data about the outcomes of these procedures and the pain afterwards and how little it really is and how pleased these patients are, especially even when coming from arthroplasty then to arthrodesis, I think that really speaks to the procedure and you just educate them on that and you spend a little bit of time on that to really help them understand and give them the why of what you're doing.

And I think once you do that, that helps guide those patients so you can then as the surgeon that has the understanding of the pathophysiology and the path of mechanics that are going on and then the subsequent mechanics that are there after you have intervened. I think that it really helps aid in that. So for me, I definitely, I'm a huge fan of the zero plating. I'm a cup and cone reamer person where I really try to maintain that more physiologic shape I do. So, I would say sometimes tend to leave the medial side of that proximal failing as a... It was like a landing zone as I am typically using a screw going across there. And that screw orientation is from that distal medial to proximal lateral aspect. I really am trying to put the poster to the wall.

I'm not really a fan of reversing that around and going putting the wall to the poster as the analogy that we all like to give. So, I like the idea of taking that proximal family and putting it onto the first metatarsal head. I definitely have had times where I've had to flip it and even last week, I didn't have any space on the medial side, so I ended up actually making an inner space incision along the lateral side of the first toe and was able to put a screw that way and that had pretty good success, but I definitely am more of a fan for that. But I do try sometimes keep that medial flare. But definitely, getting all that cartilage denuded following the same principles and going back to early on in school and our line residency and rotations, but a 100% it's all about position at the end of the day.

You want to make sure that that toes up and the alignments there. And that would really be the biggest thing that I really try to think about. And a lot of these companies have foot plates and things like that to make sure that things aren't really elevated. So, that's for me, before I start putting in my internal fixation and utilizing these templates, I do try to work on alignment and I work on that footplate and bring that footplate out or the lid off of one of your trays just to make sure that your alignment is where you're wanting to be and when you load that foot that there is purchase and that it's not sitting off the ground.

Jennifer Spector, DPM:

Somebody mentioned it a little bit earlier and I'd love to hear a little bit more about your thoughts, eccentric reaming. What have you encountered, what do you feel the impact is on these procedures?

Joshua Sebag, DPM:

I think it's a really forward-thinking way to address a bad problem. It's a little technical and it's not easy necessarily, but if we have the benefit of a cup and cone system, and we can do this with flat cuts, but we're limited in how many planes we can adjust. So, with the cup and cone system, and I think there may be a new article coming out in the Fast Track journal actually out of Minnesota that I was reading. There's some authors now who were talking about it and I think some of us are probably doing it anyway and now it's being published.

But the idea of being able to correct a bony loss or correct a deformity in the way of the reaming allows us to do both sides and then almost reintroduce a more rectus position just because we're removing the deforming factors. So, whether or not it's the metatarsal head or the phalangeal base or the combination, I think that it's a powerful tool and if we pick the appropriate size reamer, we can actually correct the MTP overall.

Zachary Cavins, DPM:

Yeah, I think that a lot of us, we look at it and we do it without necessarily knowing that we're doing it as we look for that alignment. The cup and cone reamers definitely give us a lot of flexibility to do a lot of that, but doing something that's eccentric outside of just MTP, right? You have another joint just distal to that and you got that IPJ, and so you can sometimes correct, I think some interphalangeal is that may exist there by doing that eccentric reaming, so you can correct a couple of problems with one swing and that's maybe look a little bit different when you're start doing it to some of the people in the room, but when it comes out they go, "Oh, it looks pretty good." And you go, "Yep." And I think that's part of just being in the surgeon that's in there too, is not necessarily is understanding one what you're trying to accomplish, but also more of that art form that feeds into surgery.

Jennifer Spector, DPM:

So, what other kind of challenges and hurdles do you feel are commonly encountered with revisional first MTP surgery?

Zachary Cavins, DPM:

I would say the biggest hurdle would just be patient understanding and patient expectation. Providers, surgeons, they ultimately try to perform what they think is the right procedure. Things happen in surgery, complications are a known risk, it's not perfect, this isn't an easy bake oven, there's no cookbook. As much as we try to study and understand things inevitably can happen if they even select me to be their surgeon to do the revision, that there's still a possibility that things still may go wrong.

Especially, if we're talking about arthrodesis and as good as we think we are with fenestration. And even if you want to bring in biologics and we're talking about all the different things that we add into these procedures, I think that the biggest thing that I would say upfront that even from a non-surgical perspective is patient understanding and it has to deal with the patient expectations are, I would say, bony loss deformities. You know, you get into a situation where everything may look good, but AVN is a big one.

Sometimes you miss an AVN on whether it's actually you miss an AVN, even on CT where it doesn't always pick it up. The structurally things may look there, but it isn't necessarily alive. MRI would be great to have, but with scatter it makes things hard to see, obviously, right by definition. So, what are those soft tissues look like? What is the anatomy going on? What's happening with those osseous structures that are there? Do you have previous hardware? Do you have broken hardware? What are those things that you really have to start to encounter, when starting to take on these revision surgeries and you're starting to enter into that realm, just being prepared for the unexpected, kind of working that procedure through your head and making sure that your team is ready and making sure that you're, if you're working with vendors, that your vendors are ready, that they have what you think you may need and that they may encounter and that they've got stuff available for you, for the unexpected.

Jennifer Spector, DPM:

Anything else that either of you would like to add about this topic? It sounds like there's still several episodes in the future that we could go into on various aspects of it, but is there anything specifically that you'd like to leave the audience with today?

Joshua Sebag, DPM:

You got to choose your patience wisely, obviously. And the most unpredictable factor is often biology. We can pick a patient with a bad problem and have a good plan, but the times that I can think about that things didn't work out or are usually biologic things. So, we can't put enough emphasis on workup and making sure these patients are at the point where they can heal a fusion and MTP is fairly reliable to heal, which is nice, but the biology is a big challenge.

So, I would just encourage the biology evaluation and try and over plan that part, make sure that you're really good at that. And then the fixation choices, not all the hardware is made the same and I've leaned towards multiple small screws for a revision fusion versus a handful of big screws. So although, it may be stronger in appearance, I think that the rest of orthopedics has shown us that lots of periarticular screws are good for fractures and for fusions elsewhere in the body and they seem to work well. So, I've gravitated towards lots of points of fixation versus just a handful of big points of fixation for these revision cases.

Zachary Cavins, DPM:

With these fusions, the idea of vitamin D and calcium and supplementation, is there a place, as we talk about biology, I mean you have some of these patients, I've got great examples of terrible, terrible protoplasm that you're like, "This is never going to work." And terrible situations of A1Cs that are really high, and they end up doing great.

So, I think that it's definitely an art. I think it's definitely an evolving science and always a changing science for all of us. So, we do the best we can, what you have and educate your patients on what those expectations are and what those outcomes may be, and just move forward and do good work and go from there.

Jennifer Spector, DPM:

Thank you so much to each of these docs for being with us today to talk more about this important topic. We hope that you'll join us for future episodes of Podiatry Today Podcasts on speaker, podiatrytoday.com, and your favorite podcast platforms.