Dr. W. Hodges Davis discusses how to match the right patient with a Cheilectomy for hallux rigidus, along with setting expectations for this surgical option.
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it's It's a fascinating thing for me, Thio. See how Fassel we have come in this in this way to teach and how intimate this type of teaching can become. I love being on the call with with Michael and Jeremy guys who have gotten to know young, smart guys who are really focused on doing the right things for their patients. And, um so that fits with my philosophy. Um, as I told them early, I'm coming from Ah Park in Monaco, Wisconsin, and that's a longer story to tell you exactly why, but But it's all good. Um, so, um, we all know Alex Rijs, um, is an isolated arthritis of the big toe. The symptoms can be paying can be stiffness. We altered loading. So you see your kicking over to your lateral side activity modification and shoe fit limitations, and you can see here the clinical picture, and then when you open it up, sometimes the joint looks worse than you would even expect. It is the most common arthritic condition of the foot. It affects one in 40 um, people over the age of 50 which is really amazing, considering how many of those air out there. So the estimated is 2.2 million new cases per year. Um, 50 to 80% depending on what you read is bilateral. And it's interesting that 70% are women, which has certainly been my experience. Um, it is our belief that the cartilage issues to the MTB joint or a progressive continuum. The problem is that the X rays correlate poorly with patients, symptoms and Alex ridges, and our patients come in and they say, you know, reached the point where I got to do something, but I don't want to lose my motion. And this is an example of a patient in my practice who has continued to have really a significant amount of motion. But the pain had gotten worse. Um, the classifications system that has kind of become the standard is by my friends Mike Coughlin and Paul Sureness. Um, and the reason why this is such a good classifications system, is it? It is combines exam findings with radiographic findings in grade zero is really a normal X ray with some stiffness grade one extreme on the extremes of motion on Lee. Great to is kind of that in between grade three and four are getting pretty close to in stage where you're almost bone on bone on X ray. The surgical treatment options, at least the way that I approach it, are pretty consistent. Is that in the grade ones and to I like to collect me in the grades Two threes and four I'm trending towards Arthur Plastic. Excuse me towards fusion or cart Eva in my in my practice, Um, and and Mawr and Maurin. My practice, the threes and fours get an option for CART Eva Infusion. Now, this is an algorithm that Judy Bombers group came up with and so everyone gets non operative care. And then if they have persistent symptoms that are isolated dorsal with decent motion, you might consider a collect me plus or minus a proximal phalanx. Ost IATA me. Um, if you want to preserve function and help with pain on day, don't have no muscle issues or angular deformities, you might consider court IBRA polyvinyl alcohol implant with with possibly adding a proximal family exhaust IATA me and then final and definitive. Our first MP art reduces um, the evidence based analysis of the effectiveness of cart. Eva is a great. A fair evidence with Arthur DCIS and then the Kyle Ectomy is a bunch of non randomized retrospective studies. But but so a great see the top patient factors when selecting a surgical procedure. For Alex, rigidness is one. Reduce the pain to improve the motion or at least maintain the motion. Three. Get me back to my day to day activities quick and consistently, and then the other thing is to burn. No bridges. So have some different procedures. If if this fails, what else can I do? Um, and so what? I like to call this is a continuum of care and and we've been talking about it a lot at right medical as we talk about ankle arthritis and we now talk about big toe arthritis. And we're now talking about it in Halik, Val Ghous and all of these things. Air matching the right operation with the right patient, the patient who's failed non operative, their age, their expectations, their desire or not desire for motion, job or activity requirements. And so very often where they are on the continuum of of one, they're grading system, but also of their expectation and needs. So if you really want a motion sparing option, you really have to think about collecting me and cart Eva. The beauty of both of those operations is it doesn't burn bridges, and the pre op X rays don't necessarily correspond to the postoperative treatment. Empty fusion works well regardless of what the pre op X rays look like, and regardless of what the pre op motion is, but it is a definitive procedure, but we certainly know it has good functional outcomes. So in our practice, collectively is a tried and true technique. We have used it for years, both open and M. I s as a first line surgical treatment. It's inherently simple. It's easy to explain to. The patients were gonna just take the bump off and straighten the toe. It preserves joint motion, and it can reliably decrease or eliminate pain. It rarely gives them a perfect big toe, and it's easy to revise if it fails to another procedure. So why am I on this symposium? I've been talking about Kai lacking me for years, and you could see on the left Um, this is an open procedure from from what we did for years, right on the right. You can see me doing it with an M. I s technique. And so I've always believed Henry Ford's adage that anyone who stops learning is old. Whether they're 20 or 80 anyone who's keeps learning stays young. And the greatest thing in life is to keep your mind young. So when the m. I s stuff came out and pro step really came on the market, um, I felt that this is something that I might want to give a try. And in fact, my first cases work. I elect Amis. Um, I really I've always liked small incisions. And those of us who have been doing this for a while know how arthroscopy has changed the way that we look at things and do things. Laparoscopic surgery has changed general surgery for sure. We use mental incision for Achilles and fracture treatment. And robotics has changed that. Also, small incisions can be transformative, but it's been around for a while. Martin Polakoff, an innovative podiatrist, reported a system of sub journal dermal office surgery with no power tools. Power tools came in the sixties, and in the seventies there was a textbook with curriculum and training institutions. In the nineties, there was an increased popularity with my ass bunion surgery driven by the Italians in Bologna, done with the Saw and Fixed with and I AM K Wire. But then a couple of damning articles came out this one, and from F I I f I I. In 2000 and seven, Mark Morrison's group had 13 patients with 70% non union Mallya Union using the gin. Any technique in a different in a different edition in 2000 and five, a perky Tania's distal metatarsal, Osti Ami for Alex Ridges had a 25% rate of postoperative mala alignment despite reporting a 70% satisfaction rate. So at that point, everything died. But like most things that it's often worth revisiting ideas. And here's a picture in of of Becky, Cerrado and Mercy. Who would tell you that that she's not sure how she became a bunion surgery? But when she started doing in my ass, that's what she does. So what's the difference? The difference is the burgers. Power box imaging techniques are better, fixation is better, and the education is better. So what about the birds? Each procedure has a specialized Burr. In addition, the hand in the box provide us with low speed, high torque option which eats away bone without burning things around it, including nerves and skin. And finally, many cr miss so much better now than it was back when I first started practicing the nineties. But even back in the eighties, when M. I s was popular before, the technique is well defined and the things that we can do extra articular are great. The intra articular things that we do like an m I s collect me, um, also provide, um, an advantage with smaller incisions. Finally, our fixation is better. We kind of know where it needs to be. And the training, um, that the pro step franchise has rolled out has changed our approach to this. So what about literature and support of this iteration of M i s, um Here's one from Tom Sherman and Greg Guyton, who's been a real proponent. Here is 1/5 metatarsal ost IATA me for Bunia Nets. And here is a great review of dorsal collecting me for Hallett ridges. Eso How do you engage on a low strips way for both? Both the surgeon in the practice. Well, the key is to get used to the burr and taking bumps off is really nice. In addition, you learn that you've gotta let the burr do the work and you pivot rather than push. And the correct burr for the right procedure really makes a difference. Um, X ray position and related to your dominant hand is key. I found out for 4 ft surgery. The X ray always needs to come from the patient's right side for Kyle. Act Amis. I use a three by 13 wedge burger, and then I use these these soft tissue instruments that will release the soft tissue over the top of the bump and allow us to get to it. You can see the goals air exactly the same as an open procedure. Um, you get the burr in the right direction, uber cross it, and you get the the loose piece up and then you bird bird towards the skin, which takes the piece off so you can see the angle. Uh, the ossified penetrates the joint and then use your thumb for tactile feedback, and you bear towards your thumb to get rid of the ossified. You never want to plant a flex because the h L under stress can be cut. You could stay here. I'm still working on this and really getting all of the proximal phalanx off. There's a serape did instrument that allows you to get some of these pieces off the end. It's easy to get the ossified off. The first metatarsal is well, is the proximal failing and that's what we're doing here. And you can see we've got the proximal phalanx ossified and the the metatarsal had ossified. And it looks like you've done an open procedure with the burr. Um, Joe Vanua and his group looked at this, and they reported that 86% of patients returned to ordinary footwear. Normal daily activity or employment closed off. What I would say is, it's still foot surgery, so I tell the patients they can walk, but they need to be careful because they will get some swelling. Um, and here's the functional outcome out of a group, um by Dr Morgan and showed significant improvement and foot pain function and social aspect of the M s group compared to the open group using for open and m. I asked Kyle academies. I also would tell you that you need to consider a proximal phalanx Ost iata me. Um what coffin insurance when they were looking coffins, patients with Alex ridges discovered is that there was significant Alex August Inter phalanges in particular in the grade threes and fours. And so back then we started thinking, Maybe this is a lateral collapse, but also maybe we want to unload the lateral side by straightening the toe because our patients like straight toes. In addition, Moe Berg described a door silly based wedge which, when closed down and fix, can give you, uh, Cem increased dorsal flexion and helps. This is the description of the family exhaust IATA me, Moe Berg really popularized in 79. Bob Anderson likes to call it a pseudo Dorsa flexion, but it definitely puts less stress on the hallak. It improves your your fixation. Uh, the indications are running athlete, regardless of severity. Um, and in my opinion, if you've got Alex Valda center phalanges, I'm going to do approximate lost iata me for collecting me as well as cart Eva. So you see here and this is what it looks like. Loud described 21 of 24 ft with 90% satisfaction. And he used a K wire to fix his. So the Mohican procedure is easier to do m i s than it is to do open. It's a biplane, a rosti autumn E in the proximal phalanx to realign the Alex and add this pseudo dorsal flexion. You do it after you've done the chi like to me, and this is what it looks like. You do in oblique cut. You don't go through the far side or the lateral side, and you close it down and fix it with a headed headless grew, Um, you take 10 2 to 4 millimeters wedge, and you can take mawr Dorsey Lee than planner quite easily. Um, so the increased doors reflection in a straighter toe, in my opinion increases my patient satisfaction. I do this procedure with the collective me and I use the iceberg to do it with cart. Eva, Um and I I really if they don't have a straight toe, I'm adding this procedure, so keep learning. Keep your mind young. M. I s is here to stay in my opinion, and you need to take on new things that collecting is an ideal way to get started. And the Mohican procedure is much easier, M i s than it is open, which is saying something. Um, I used to collect me in grade ones and twos. In certain grade threes. I add a proximal phalanx estimate cost IATA me quite often. All right, Michael, I'm gonna give it to you. I'll stop sharing. Hey, Hodges, while while he's pulling up his talk Just a question. A technical question. When you do in the collective, particularly some of those images you showed, there's a fair amount of bone spur on the dorsal part of that metatarsal head. What happens to that bone? Um, does the water running through kind of allow it to run out? You're making small incisions. Do you have toe the consciousness that you ever need a counter incision? Just some technical thoughts about how toe that boned up out of there. I used to sometimes at a lateral incision if the if the spur was more over there. But I've stopped doing that. It creates a paste almost, and you've got to get water in there. Some guys using using arthroscope to get water toe get all of the Dietrich. It's out. Um, there is a serrated instrument in the disposable instruments that you can that you can sweep it in, and the bone pieces will come with it. I don't use a a, um, an arthroscope just is. It's one more big set up, but I But I do irrigated with a with a a syringe with a with a, you know, 18 gauge, 16 gauge that really gets water flowing through there. You really have to do that. And then about the learning curve, which I think is really important here, you're showing cases with Kyle luck to me, which I think make make good sense to start. What was the learning curve like for you? When did you feel comfortable doing this on a patient is compared toa training in a lab. Just maybe a few thoughts on that, You know, I think collect me is one of those things that you could you could do on a sawbones and do it in a patient. Um, I really do believe that some of the bunion stuff that we're doing, um a, um, a cadaver really makes a difference, but But if you do it on a saw bone and kind of get a feel for cutting across and then blurring towards the bone. Um, then you really do do have that. But the first probably five or six m I asked procedures I did were bump act Amis and diabetics. And you get a feel for how the borough works when you're just taking a bump off, which is different than a nasty autumn e the ost iata me like I showed the aching Moe Berg is so simple because you go straight all the way across you go up, you go down and then with the with the Mo Berg, you come up again and you squeeze it down a little bit. You come up again and then you put a little screw in there and you're done. So I think the aching of the Aussie autumn ease that we do is the easiest one to do. Yeah, thanks.
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