Midfoot Arthrodesis Donald R. Bohay, MD, FACS Professor, Michigan State University College of Human Medicine Private Practice: Orthopaedic Associates of Michigan, PC Director, Grand Rapids Orthopaedic Foot and Ankle Fellowship Grand Rapids, MI Midfoot Arthrodesis Introduction Common procedure among foot and ankle surgeons Indications include : Osteoarthritis Post-traumatic arthritis Rheumatoid arthritis Conservative treatment Activity modifications NSAID Lisfranc Injuries Diagnosis Tender, swollen midfoot Pain with weight bearing Surgical Treatment Options Fusion 1st tarsometatarsal (TMT) joint Can be applied to: Hallux valgus Pes planus Hypermobile first ray treatment Instability of first TMT joint Cause for symptoms Fusion joint Difficulties of Midfoot Arthodesis Technically challenging Plagued with complications Shortening first ray MTP stiffness Criticism High non-union rate (10-12%) First TMT joint
Psoriatic arthritis Deformity Medial column instability Longitudinal arch supports +/- injection
Plantar ecchymosis
Arthritis
Modified Lapidus procedure Correct deformity
Dorsal malunion Recurrence
Single Joint Midfoot Arthrodesis: Technique Tips Be sure to denude the entire joint. Do not miss the plantar joint surface. 30 mm deep Avoid shortening of the first metatarsal
Postoperative Course Splint 2 weeks NWB Cast 4 weeks Weight of leg Fracture boot 4 weeks Progressive weight bearing Total 10 weeks immobilized More complex foot reconstructions require 8 weeks NWB In the literature: FAI 2005 Sep:26(9):698-703, Thompson IM, Bohay DR, Anderson JG Union rate 96% Non-union 4% 50% previous surgery Revision rate 2% 1st TMT Fusion: Important Points/Summary Early weightbearing Predispose to nonunion Achilles contracture ↑ stress midfoot Surgical technique/Post op protocol Safe Effective
Predictable & acceptable union rates Few complications
Previous bunion surgery May increase risk for non-union? Medial Column Stabilization Solution for midfoot sag Hypermobility Concurrent bunion deformity Medial Column Stabilization: Technique Notes Tarsometatrsal/Naviculocuneiform joints Screws and/or Plates Stress relief bone graft Pocket / Countersink “Manoli” Hole Prevents dorsal cortical breakout as screw head engages Os calcis osteotomy Lateral column lengthening Neuropathic Midfoot Collapse Complicated by other co -morbidities i.e obesity,diabetes,vascular insufficiency Usually significant deformity refractory to conservative measure Surgical indications include: Non-healing ulcer Unbraceable deformity Pending ulcer Pain Instability
Neuropathic Midfoot Collapse: Patient Case 35 y/o female 2 month history foot pain and deformity No known neuropathy Surgical correction o TMTJ 1-3 , ICJ, NCJ fusions with LCL and gastrocnemius recession Research Report: Midfoot Reconstruction for Primary Atraumatic Arthritis: Analysis of Outcomes Hypothesis: Midfoot arthrodesis is an excellent procedure for primary midfoot arthritis and can achieve good results with acceptable rate of complications. Retrospective Chart Review: Methods 95 patients (104 feet) Mean age 61 (20 – 80) Male/female (18/77) 297 total joints fused 77.9% gastroc recession 55.8% forefoot Results 92.4% union rate 3.8% major complication 99% union rate after 25% hardware removal revision (7 patients) Statistical Significance (p < 0.05): o VAS improvement : 6.9 pre-op 2.3 post-op o AOFAS improvement : 32 pre-op 79 post-op o Satisfaction: BMI ≥ 30 7/35 & BMI < 30 1/39 Conclusions Limitations o Retrospective study o 28% loss to followup o Did not correlate outcome to correction achieved Hypothesis is sound Lis Franc: Mechanism of Injury Direct loading Load parallel to joint surfaces Significant soft tissue disruption Indirect loading Axial load along metatarsals Variable bony fracture involved To fuse or not to fuse? The “gold standard” of ORIF has been based on the assumption that the patients “all do well” In reality a fair percentage develop a chronic disability despite anatomic reduction, early treatment and accurate diagnosis Be careful in your decision making; significant instability, articular damage, higher energy, ligamentous lisfrancs and complex fracture dislocations may do better with ORIF with fusion
Research Report: Primary Open Reduction Internal Fixation vs. Primary Arthrodesis of Lisfranc Joint Injuries: A Prospective Randomized Trial Introduction/Purpose Lisfranc/TMT joint injuries are associated with long-term disability subsequent painful osteoarthritis and residual deformity, surgical management is Primary ORIF (PORIF) The purpose of this study is to compare standard PORIF to salvage primary arthrodesis (PA) Prospective Randomized Study: Methods PA: 17% 3 HW removals 40 patients (32 complete) PORIF: 114% req. addtl. PORIF/PA (14/18) Surgery Results PORIF o No infections, loss of fixation, neural injury, or malalignment were noted PA o 1 delayed union associated with a broken first TMT joint screw, healed at the six month mark o 1 non-union of a first TMT joint was treated non-operatively o No deep infections Surgical Evaluation Category PORIF PA Anatomic Reduction 14/14 (110%) 17/18 (94%) Solid Fusion N/A 17/18 (94%) Addtl. Surgery 15 (114%)* 3 (17%)* Delayed/Non-Union 0 2 Hardware Failure 0 1 *p < 0.05 SF-36 & SMFA o No statistical difference between ORIF and PA at 3, 6, 12,or 24 months Phone survey: 21/32 patients were very satisfied or satisfied Results/Discussion PA may lead to less revision surgery than PORIF PA: viable treatment option, investigator’s next steps: o Possible longer follow-up analyses o Adjacent arthritis o Gait analysis Lisfranc Fractures: To fuse or not to fuse? When treating a closed displaced and unstable fracture of the tarsometatarsal joints, management includes all but one of the following:
anatomic ORIF delayed surgical treatment secondary to soft tissue constraints preoperative evaluation including radiographs and CT scan consider EUA anatomic ORIF with fusion
Conclusion Safe procedure with excellent union rate High patient satisfaction and acceptable complication rate Outcomes/ satisfaction reduced with complications Elevated BMI may correlate with poor outcomes Final Tips/Notes Recreate the “tripod” Address bony deformity Spare the essential joints
IF IT LOOKS LIKE A FOOT, IT WILL WORK LIKE A FOOT! 1.
Jahss MH. Dr. Paul W. Lapidus (1893-1981). Bull Hosp Jt Dis Orthop Inst. 1987; 47(2):100-102.
2.
Hansen ST Jr. Hallux valgus surgery. Morton and Lapidus were right! Clin Podiatr Med Surg. 1996; 13(3):347-354.
3.
Horton G. Tarsometatarsal arthrodesis for the treatment of hallux valgus. Foot Ank Clin. 1997; 2:685-698.
4.
Lapidus PW. A quarter of a century of experience with the operative correction of the metatarsus varus primus in hallux valgus. Bull Hosp Joint Dis. 1956; 17(2):404421.
5.
Saffo G, Wooster MF, Stevens M, Desnoyers R, Catanzaritis AR. First Metatarsocuniform Joint Arthrodesis: A Five Year Retrospective Analysis. J Foot Surg. 1989; Sep-Oct;28(5):459-65
6.
Cantanzariti AR, Mendicino RW, Lee MS, Gallina MR.The Modified Lapidus Arthrodesis: A Retrospective Analysis. J Foot Ankle Surg. 1999;Sep-Oct;38(5):32232
7.
Sangeorzan BJ, Hansen ST Jr. Modified Lapidus Procedure for Hallux Valgus. Foot Ankle Int. 1989;Jun9(6):262-6
8.
Myerson MS, Badekas A. Hypermobility of the First Ray. Foot Ankle Clin. 2000 Sep;5(3):469-84.
9.
Habbu, R.A., Holthusen, S.M., Anderson, J.G., Bohay, D.R. Operative Correction of Arch Collapse with Forefoot Deformity: A Retrospective Analysis of Outcomes.
Foot & Ankle International 32(8): 764-773, August 2011. 10.
Anderson, J.G., Bohay, D.R., Eller, E.B., Witt, B.L., Gastrocnemius Recession. Foot Ankle Clinics 2014 19(4): 767-793.
11.
Henning JA, Jones CB, Bohay DR, Anderson DR, Sietsma DL. Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009 Oct;30(10):913-22.
12.
Rink-Brüne O. Lapidus arthrodesis for management of hallux valgus--a retrospective review of 106 cases. J Foot Ankle Surg. 2004; 43(5):290-295.
13.
Thompson IM, Bohay DR, Anderson JG. Fusion rate of first tarsometatarsal arthrodesis in the modified Lapidus procedure and flatfoot reconstruction. Foot Ankle Int. 2005; 26(9):698-703.