Hello all. I thought I would ask some seasoned podiatric surgeons about implants. What procedures are out there that require implants for foot and ankle surgery? Are their any problems with patient healthcare that could yield potential improvement if the material was altered in these implants due to increased strength and better biocompatibility?
Surgical Implants For Podiatric Surgery
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Implants are used in the first metatarsal phalangeal joint, and sometimes in the ankle joint or lesser met-phalangeal joints. To a lesser extent you will also see "implants" that are more of spacers than joint replacements in the 1st met phalangeal, lesser met phalangeal, interphalangeal, subtalar, and 4/5th met cuboid joints.
I don't think it's the materials so much as the biomechanics of locomotion that cause failure. The materials' durability has improved and reactivity has gone down; it used to be a lot of silicone, but now it's mostly stainless, cobalt chromium, occasional ceramics, etc... and UHMW Polyethylene if the joint is a total with a meniscal component. However, the implants still fail (or get infected... or shift position... or dislocate... or break altogether). The foot and ankle joints take many different angles of stress, but there are just so many joints in close proximity that any one of them just is not as anywhere near as essential to human locomotion as say, the human hip or knee joints. Arthrodesis of the foot joints, especially 1st met phalangeal and ankle joints, has been proven in the literature to be equal or better than implant replacement in terms of short, med, and long term outcomes.
There will always be those who continue looking to re-invent the wheel, especially in an area like surgery where it's sometimes art and science. Also, if given the choice, the vast vast majority of patients will pick "replacement" or "motion" when given the other option as "fusion" or "destruction" of the joint. A lot of docs want to be a hero to the patient... but sometimes you might need to use a healthy amount of parenteral judgement when you know the materials, costs, risks, and evidence based outcomes and the patient does not. I try to believe in everything when indicated, but the more I seem to read, the less implants in the foot and ankle seem to ever be indicated.
I don't think it's the materials so much as the biomechanics of locomotion that cause failure. The materials' durability has improved and reactivity has gone down; it used to be a lot of silicone, but now it's mostly stainless, cobalt chromium, occasional ceramics, etc... and UHMW Polyethylene if the joint is a total with a meniscal component. However, the implants still fail (or get infected... or shift position... or dislocate... or break altogether). The foot and ankle joints take many different angles of stress, but there are just so many joints in close proximity that any one of them just is not as anywhere near as essential to human locomotion as say, the human hip or knee joints. Arthrodesis of the foot joints, especially 1st met phalangeal and ankle joints, has been proven in the literature to be equal or better than implant replacement in terms of short, med, and long term outcomes.
There will always be those who continue looking to re-invent the wheel, especially in an area like surgery where it's sometimes art and science. Also, if given the choice, the vast vast majority of patients will pick "replacement" or "motion" when given the other option as "fusion" or "destruction" of the joint. A lot of docs want to be a hero to the patient... but sometimes you might need to use a healthy amount of parenteral judgement when you know the materials, costs, risks, and evidence based outcomes and the patient does not. I try to believe in everything when indicated, but the more I seem to read, the less implants in the foot and ankle seem to ever be indicated.
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Feli,
Excellent post. There are actually also digital implants. At the present time I have no personal experience with the use of ankle replacement implants, but as a general rule I'm not a big fan of implants, especially those utilized for the first MTPJ.
Although this is certainly a gross generalization, the majority of implants of the first MTPJ I've removed, were placed by surgeons that were more impressed with utilizing these because of the impression of being "high tech", although they did not appear to have a clue regarding the etiology of the deformity or have any understanding of biomechanics.
When evaluating the pre-operative radiographs of almost all the first MTPJ implants I removed, all the implants were doomed to fail without ancillary procedures being performed.
A monkey can be taught to PERFORM a surgery, but the true skill is actually understanding the etiology and how to correct the problem with the greatest long term results, with the least potential complications.
Decision making is paramount in residency/surgical training, or the training is grossly inadequate.
Excellent post. There are actually also digital implants. At the present time I have no personal experience with the use of ankle replacement implants, but as a general rule I'm not a big fan of implants, especially those utilized for the first MTPJ.
Although this is certainly a gross generalization, the majority of implants of the first MTPJ I've removed, were placed by surgeons that were more impressed with utilizing these because of the impression of being "high tech", although they did not appear to have a clue regarding the etiology of the deformity or have any understanding of biomechanics.
When evaluating the pre-operative radiographs of almost all the first MTPJ implants I removed, all the implants were doomed to fail without ancillary procedures being performed.
A monkey can be taught to PERFORM a surgery, but the true skill is actually understanding the etiology and how to correct the problem with the greatest long term results, with the least potential complications.
Decision making is paramount in residency/surgical training, or the training is grossly inadequate.
Thank you for the responses so far surgeons. Your detailed answers have been helpful. Are there any procedures not mentioned which are common for implants? Are so called cosmetic foot surgeries utilizing implants?
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I agree. Everyone wants to be on the cutting edge, and reps also provide a lot ego massage (and consultant or kickback payments?) to many attendings for using the latest and greatest implant, skin graft sub, plate and screws, ex fix, etc. I think the surgeon's sense of bravado definitely comes into play when they get it into their head that "I'm gonna be the first in town to use this" or "the company thinks I'm so good that I should be a paid lecturer if I use their implants."
Surgical procedure selection should be with the plan that it will alleviate pain or fix the deformity... not because it's the newest, because it looked cool in the pamphlet, because the rep gave you dinner or a bonus, or because the surgeon wants to find a patient to "try it out" on. There's many ways to skin the cat in surgery, but when we think about things other than the pathology, then that's when I think we start creating indications for our surgical, wound care, etc "toys" which the reps are bombarding us with.
I really like how most of the PI surgeons repeat "technique over technology" in their lectures and teaching. Camasta also likes to say "you don't want to be the first guy or the last doing a procedure." When I asked one attending there which fixation he would be using for the next day's procedure, he looked at me and told me that there is only one fixation company. He stuck with $30 basic AO screws instead of cannulated titanium space age screw staple sets that cost ten times that much, and I respect that. At the end of the day, his dissections and post op XRs were definitely as good or better than most who used the newer devices.
I'd be extremely happy if I can get through residency with the skills to perform 95% of surgeries with the basic Synthes screw and plate sets. The locking sets, ex fix, orthobiologics, tissue subs, etc are nice tools to be aware of, but you have to pick your spots. I think too many people view them as the magic bullet that will make the surgery go well instead of simply a tool that cannot and will not substitute for good pre-op eval and pt selection, good technical OR skill, and good follow up care.
It will be pretty interesting to see how the new govt health plan covers the high cost surgical implants, ex fix, biologics, etc which many surgeons use almost routinely use in large hospitals (but very rarely use in physician owned surg centers).
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Feli,
You are correct again. The PI doctors are often very conservative with their use of "gadgets" (though I know of a few exceptions) and are very strong proponents of the basic AO set and principles.
Yes, the use of cannulated systems has made it much simpler and at times quicker, though it does not truly adhere to AO principles. I must admit, I do find myself gravitating to the cannulated sets as the rule and not the exception.
I've also gravitated away from the use of frames whenever possible, because of the time, potential complications and "fear factor" when presented to the patient. When I first started with these systems, I felt very macho, but realized the burden and psychological impact it often had on the patient.
Ironically, I had a patient a few weeks ago who I performed an "Austin" on about 20 years ago when I first started out, and used a simple K-wire. Fortunately her foot turned out great and she returned to me for her contra-lateral foot. Well, she refused a screw (not really refused) and asked me why I couldn't use the same "wire" I used a long time ago.
There was no REAL rational reason, so I performed the surgery, shot in a Kwire which took all of 30 seconds and wrappped her up good and tight and placed her in a CamWalker. The cost of fixation was probably about a buck, and her foot turned out as good as any of my couple of hundred dollar high tech screws!
You are correct again. The PI doctors are often very conservative with their use of "gadgets" (though I know of a few exceptions) and are very strong proponents of the basic AO set and principles.
Yes, the use of cannulated systems has made it much simpler and at times quicker, though it does not truly adhere to AO principles. I must admit, I do find myself gravitating to the cannulated sets as the rule and not the exception.
I've also gravitated away from the use of frames whenever possible, because of the time, potential complications and "fear factor" when presented to the patient. When I first started with these systems, I felt very macho, but realized the burden and psychological impact it often had on the patient.
Ironically, I had a patient a few weeks ago who I performed an "Austin" on about 20 years ago when I first started out, and used a simple K-wire. Fortunately her foot turned out great and she returned to me for her contra-lateral foot. Well, she refused a screw (not really refused) and asked me why I couldn't use the same "wire" I used a long time ago.
There was no REAL rational reason, so I performed the surgery, shot in a Kwire which took all of 30 seconds and wrappped her up good and tight and placed her in a CamWalker. The cost of fixation was probably about a buck, and her foot turned out as good as any of my couple of hundred dollar high tech screws!
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I love the cannulated screws. The Arthrex screw actually costs less than the Synthes version (at least out here).
One other odd complaint I've heard a couple of times is that the stainless steel screw conducts cold. Winter sets in deep and the bone gets cold pain. The titanium screw apparently does not, at least per a couple of patients who had one of each type of metal in their feet.
One other odd complaint I've heard a couple of times is that the stainless steel screw conducts cold. Winter sets in deep and the bone gets cold pain. The titanium screw apparently does not, at least per a couple of patients who had one of each type of metal in their feet.
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Well, I do live out in the country...You're apparently very low tech. I use thermostatically controlled screws to allow for temperature changes.
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I'll have to remember to send you a couple of old Sears catalogs for when you have to trek out to that outhouse. Of course those catalogs come in handy when you run of of Charmin/Cottonelle or when the budget gets tight with the high cost of those Arthrex screws!
The other day it got a little embarassing. I had the Arthrex rep, Wright surgical rep and Osteomed rep all show up in my office at the same time, each toting a screw set in hand.
I'm on staff at several facilities, and some of the facilities prefer certain vendors, therefore I sometimes utilize those vendors to keep everyone happy as long as I don't feel it's compromising care. That's why all 3 companies showed up in my office, since I utilize products that they all make.
The other day it got a little embarassing. I had the Arthrex rep, Wright surgical rep and Osteomed rep all show up in my office at the same time, each toting a screw set in hand.
I'm on staff at several facilities, and some of the facilities prefer certain vendors, therefore I sometimes utilize those vendors to keep everyone happy as long as I don't feel it's compromising care. That's why all 3 companies showed up in my office, since I utilize products that they all make.
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Ha! Good one.
I know how that goes. It's like keeping your girlfriends from running into one another (or so I would imagine).
A few years ago I had the Orthofix rep in a case with the OrthoPro rep standing behind her touting his equivalent (but superior, of course) instrument. Awkward, but amusing.
I would like to know if polymers are being applied to different areas of foot surgery (Screws, implants, etc.)? In addition is there any data out there about some of these polymer applications? Also is there some general published data on using metals? Thank you for your help surgeons.
Can you give me some brands out there which utilize screws with polymers for foot/ankle surgery.
Any feedback on polylevolactic acid or plla screws?
Can you give me some brands out there which utilize screws with polymers for foot/ankle surgery.
Any feedback on polylevolactic acid or plla screws?
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The general consensus is that they couse edema and inflammatory reaction. Every rep will tell you their absorbable pin/screw is "next generation" and that swelling and inflammation is "a thing of the past."
Arthrex has TrimIt absorbable pins which are marketed for hammertoes; I took one out... soft tissues around it looked terrible with a lot of yellow/gray/brown scar and granuloma-esque tissue. Most of the literature you will find on them, or other absorbable implants, either reports a fair amount of inflammatory granulomas... or is sponsored by the companies that manufacture and market the products...
http://www.ncbi.nlm.nih.gov/pubmed/12449404
http://www.ncbi.nlm.nih.gov/pubmed/16257673
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I've placed several absorbable screws and pins and I've been disappointed in the amount of inflammation associated with all of them, regardless of manufacturer. I've pretty much abandoned bioabsorbables completely.
Is the polymer screw, or PLA, definitely a negative for use in bunion surgery versus metal screws? For the ankle, would polymer screws be okay? Is this inflammation typical of most procedures, or was it related to the material?
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I can't say it's definitely a negative, although I believe it is based upon my own anecdotal results. I know a bunch of surgeons use bios.
Inflammation is a part of pretty much any surgery but the bio materials cause more than metals (again, based on my own anecdotal results).
Arthrex has a polymer product they call PEEK that is non-absorbable:
Edit: pdf file is too big to upload. Search the Arthrex site for the "New Materials In Sports Medicine" white papers. Or, I can email the pdf directly to you if you PM me your email addy.
http://www.arthrex.com/myarthrex/wh.../commonspot/security/getfile.cfm&pageid=26345
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For those of you who previously responded to my post, it is appreciated, I like to hear from podiatric surgeons as to what they are feeling in general about polymers for implants. My next question, is if any of you have had experience with poly-lactic-acid hydroxyapatite (PLA-HA) type screws/implants, or if you have any feelings about them? I also want to know if there is any literature out regarding patient success or other technical specifications with this material. Thank you for the professionalism on the board.
I guess they are Ok but I rarely use them. IMO they are not as good for compression, occasionally create a sterile abscess when the degrade, and can not be visualized if they enter a joint proximal or distal from where you are working.
Where they may make some sense is where you need fixation that would need to be removed before allowing a patient to walk. For example in an ankle diastasis or an ORIF of a Lis Francs dislocation. But I rarely use them
I agree with the Lis Francs comment. Ankle syndesmosis is another thing I have been looking into. Specifically have you tried any of the PLA-HA, or just polymers in general?
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I use bio absorbable fixation in only two situations.
First, I hate using metal anchors and use bioabsorbable anchors when performs tenosuspensions.
The other application is in Syndesmotic Diastasis repairs. This precludes me from having to remove a screw before allowing a patient to ambulate.
I was trained on using bioabsorbable pins for fixation in bunion repairs and saw so many complications with this in residency that I have never used it since.
First, I hate using metal anchors and use bioabsorbable anchors when performs tenosuspensions.
The other application is in Syndesmotic Diastasis repairs. This precludes me from having to remove a screw before allowing a patient to ambulate.
I was trained on using bioabsorbable pins for fixation in bunion repairs and saw so many complications with this in residency that I have never used it since.
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This was a great information that you shared in between .Podiatrist.. It will be very much helpful for all who are in foot and ankle sugery medicine.
Hey foot doctor, it's interesting that you got on this forum, I had not been on in so long and started this thread. Foot and ankle surgery is really a fascinating part of medicine and there should be many advances in the coming years as technology gets better. The experience of the surgeon is the most important thing, as many age old questions regarding technology cannot be "optimized" so to speak. However, the surgeon should stay abreast of the latest advances and be well read for the benefit of the patient.
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Has anyone else tried HyProCure's stent for TalTarsal Dislocation? I have used it in 7 procedures so far with great results. Any comments on long term results is what I'm looking for because all mine are recent (within 6 months).
Oh a "master surgeon". An arthroeresis is an arthroeresis. I find that those who take the Graham course IMO are usually overutilizing the procedure. I have seen patients who are told they need one to prevent a bunion or other potential foot problems. Even the term "internal orthotic" has been used. Crazy..................................
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