Real world: how do you feel about MPJ Hemi-implant ?

[DogSnoot]

In the real word, how often are you using Hemi-implant for the 1st MPJ? Is this a money grab, is an arthrodesis best or do implant work ?

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[Scrantonicity]

In the real word, how often are you using Hemi-implant for the 1st MPJ? Is this a money grab, is an arthrodesis best or do implant work ?

In my hands, the Arthrosurface (now Anika) implant, has always been my dependable go-to. Most patients, if given the option, would rather keep their motion. You do have to consider the patient of course. I fuse if there is a notable IM angle, or if the patient is old/not very active. If they're still jogging and/or walking any kind of daily distance, I lean toward implant. Recovery is pretty quick too, and I encourage very early weightbearing and motion to avoid adhesions...

I always have the proximal phalanx components in the room in case I do a total implant (if it's clearly gout related or if the proximal phalanx is just destroyed)

 

[DYK343]

I never do implants but I have to convert other peoples work to fusions a few times a year.
Grabbing a large chunk of bone from the calcaneus to fill the void is painful. Ive found the recovery for this is about 6 months. Also they ALL get sural neuritis (hate that nerve...)
IMO its not if implants will fail but when.
Once a patient gets over the idea of a fusion and has the procedure they typically love it.
Fusion is a reliable time tested procedure. Implants are not.

That said in my last job there was a guy who put a lot of them in early on. Swanson implants. Most of them were still functional 20ish years later.

 

[Scrantonicity]

...and so the debate rages on😂

 

[DYK343]

...and so the debate rages on😂

For what its worth I wouldnt put a TAR in either. Seen too many fail. Anything thats going to last 10 years at best IMO is a poor choice (unless elderly...). I would personally have an ankle fusion over a TAR. They funtion great with an ankle fusion. Cant even tell the joint is fused when they walk.

Maybe im just anti implant.

 

[icebreaker32]

Data shows there is fusion and everything else. In the everything else category nothing has been proven superior to cheilectomy. We can debate endlessly about all those options.

 

[icebreaker32]

For what its worth I wouldnt put a TAR in either. Seen too many fail. Anything thats going to last 10 years at best IMO is a poor choice (unless elderly...). I would personally have an ankle fusion over a TAR. They funtion great with an ankle fusion. Cant even tell the joint is fused when they walk.

Maybe im just anti implant.

Data is starting to show if at least 57 and healthy/active, reasonable BMI, then TAR is an excellent option.

 

[heybrother]

Patients who present for revision to fusion -never- have any ROM when they see me. I'm very skeptical they actually had any ROM to begin with. They routinely have hallux valgus, they still have joint pain, and they also have transfer type pain. Primary 1st MPJ fusion in the vast majority of patients can be walked on near immediately.

Every patient I have seen who had a 1st MPJ implant (haha, typoed that) hates the original surgeon. Obviously there's a selection bias here.

Interesting bone graft source - I did a 1st MPJ fusion / panmetatarsal head resection on a lady with an implant, Weil, tailor's bunion pain etc. The 2nd metatarsal head was trashed from arthritis/a screw, but I prepped the metatarsal heads of 3-5 to see who I'd like best and the bone quality for the graft was outstanding. Excellent quality / viable / firm / structural (?). The lady wouldn't stop walking on it for the first 3 weeks and she still healed.

 

[Shiyuan]

For the right patient/activety level/age... sure. But I always try Valenti first if possible.

One thing I have noticed for ones I have done (Integra BioMotion), is that in less than five years there’s already some subsidence... thankfully asymptomatic though.

 

[PatchAdamsFan]

1st MTP implant has no place in my practice, but I know many swear by it. Either bump or fusion for me. I have the opposite experience regarding activity level - my fusions walk day 1 and many are active runners with no limitations, actually the implant would probably fail much faster in the very active patient imo.

 

[PeaJay]

In my opinion, it is fusion unless there is a good reason not to fuse.

I have done silastic implants for low mobility geriatric patients and in the case of failed fusion in geriatric patient. The silastic implant can be used as a space to gain length avoiding non-Union risk and harvest site problems.

 

[wakaflocka88]

Fuse, cheilectomy or offer them an interpositional spacer utilizing the MTPJ capsule.

 

[Shiyuan]

So... any gummy bear (Cartiva) users out there? 🤪😅🥸

 

[air bud]

80 plus implant they will die before this is a problem.

People run marathons with a 1st mpj fusion. For most people this should be their most performed surgery.

I have never been anyplace where their were a lot of cartiva, but now I am so looking forward to revising things.

Speaking of revision, or something like RA/gout where there is cystic bone at the joint. Paragon makes a great graft spanning recon plate that you can use to get fixation away from the joint. When doing pan met head resection don't need to worry about grafting so just use the plate. If revising something and need graft then use paragon plate and they have anatomic grafts as well. Here are some pics.

Also, I don't use crossing screw unless super obese and or non compliant. A plate is strong enough. Don't listen to feli and him being afraid of anything not stainless steel. And instead of crossing screw I have switched to staples from medial to lateral. Fast, orthogonal and fast.

The guy pictured here (have permission for x-rays) had terrible cystic RA bone. Didn't worry about shortening of 1st ray since met head resection. Plate and screws in good bone bypassing bad bone. Staple in not great bone but only for 2nd point of fixation. NWB 3 weeks with some bone graft from heel.


Normal 1at mpj fusions should be walking day 1. I do 1 week short boot then 5 weeks surgical shoe.

 

[Pronation]

Interesting staple placement

 

[Feli]

First Mpj implants don't work. The literature is robust. They are ok short term (wont move too well even 6 or 12mo after), bad mid term (pain Pain PAIN), terrible long term (fusion with bone grafts and/or shorten lessers).

The only candidates even remotely considered should be ones who the implant will outlive their activity level. Those should still be interpositional plasty or fusion with a dynamic fix construct. Never let the active and/or young patients pick "motion" when the EBM and common sense says "WRONG WAY."

The implant 'cash grab' part is long over... the first mpj implant arthroplasty code was changed years ago. Whether that was the reason for tons of misguided implants first mpj or not, it pays much less now (a bit less than arthrodesis).

Cheilectomy can work... but most patients are past the stage where that may help by the time they seek consult or consider surgery (they have too many erosions and osteophytes). Also, many surgeons pussyfoot around and don't take enough (think Valente resect/arthroplasty capsule tissue or EH capsularis for any meaningful help). I see a lot of "failed cheilectomy" just a year or two or three post-op.

Fuse, cheilectomy or offer them an interpositional spacer utilizing the MTPJ capsule.

Yea.. exactly.

And try to send the failed implants back to sender... even offer Fed Ex Air Express mail rates prn.

 

[HardRoadPaved]

I think decompression osteotomies when cartilage is still good work well. I see a lot of dorsiflexed 1st rays that had Cheilectomies that needed mechanics changed at the joint.

 

[PeaJay]

Let’s be honest no matter what you do there will not be long term motion.

Long term first mpj outcomes

Keep it simple for the inevitable fusion.

Cheilectomy —> Fusion

 

[Pronation]

lol @ "preserving" motion of the MTPJ...

 

[DYK343]

Cheilectomy can work... but most patients are past the stage where that may help by the time they seek consult or consider surgery

Ive been known to push the limits on cheilectomy. I am not super aggressive as im always planning for fusion and I discuss with patient its a 5-10 year fix at best (OK ignore my comments above about a 10 year surgery is bogus - but a well planned cheilectomy doesnt burn bridges like an arthroplasty does). I fenestrate the crap out of the 1st MTPJ arthritic areas and so far I have had really good results.

Im curious about @wakaflocka interpositional capsule spacer. Ive done this for painful freiburgs twice (usually they are asymptomatic but for the painful ones..) with good success. Never 1st MTPJ. Tell me more.

 

[air bud]

Interesting staple placement

I want 100 percent bone on bone and 2nd point of fixation so this works. Just started doing it. Don't do it on every one.

 

[Shiyuan]

I want 100 percent bone on bone and 2nd point of fixation so this works. Just started doing it. Don't do it on every one.

I use crossroads’ system which has a staple in the middle. Love that hardware!

 

[air bud]

I use crossroads’ system which has a staple in the middle. Love that hardware!

I would use it 100 percent of time if not for cost and our Stryker contract....

 

[DYK343]

I use crossroads’ system which has a staple in the middle. Love that hardware!

Synthes rep banging on my door twice a week trying to get me to use this system.
It looks really fast. I have no idea the cost. Do we ever know the cost? I have zero idea what im using cost wise daily.

 

[Shiyuan]

Samesies.

 

[wakaflocka88]

@DYK343
There was an article that came out a while ago (I think FAI or JBJS, can’t recall) but I found this one from 2020. Actually goes into nice detail with pictures too.

Capsular Interposition Arthroplasty With Percutaneous Suture Anchoring: A Pragmatic and Novel Surgical Technique for Hallux Rigidus

There is support for the use of capsular interposition arthroplasty (CIA) as an alternative to arthrodesis in the surgical treatment of hallux rigidus. In this technical report, the authors describe novel technical variations to the traditional capsular ...

www.ncbi.nlm.nih.gov

The tricky part is if they have poor capsular tissue then no go. My ortho colleague use hamstring autograft to do it sometimes.

It’s not perfect but combined with a cheilectomy they get some ROM back and more importantly no pain. So far so good and can’t beat autogenous graft and not burning any bridges. I just run like 2-3 straight needle sutures out the bottom of the foot and tie it down on bulky dressing for at least 3 weeks to ensure the capsular sandwich stays in place and scar down.

 

[DYK343]

I would use it 100 percent of time if not for cost and our Stryker contract....

I hate the concept of contracts. I get that hospitals save $$$ but the surgeon should be able to use what works in their own hands.
Most screws are screws and most plates are plates.
But I love the Arthrex speedbridge for haglunds and I cant use it becasue of a stupid contract.

 

[wakaflocka88]

For what its worth I wouldnt put a TAR in either. Seen too many fail. Anything thats going to last 10 years at best IMO is a poor choice (unless elderly...). I would personally have an ankle fusion over a TAR. They funtion great with an ankle fusion. Cant even tell the joint is fused when they walk.

Maybe im just anti implant.

Hintermann implant going well far longer than any other implant on the market. Yes there are still 15-20% failure rate but it’s an option. I like it, simple straight forward system.

I laugh when I see these studies telling us about “midterm” or “2 year” “4 year” survivorship with a small N. What a joke. Ya, I’m looking at you ACFAS fellows that rinse and recycle your directors garbage data.

 

[DYK343]

@DYK343
There was an article that came out a while ago (I think FAI or JBJS, can’t recall) but I found this one from 2020. Actually goes into nice detail with pictures too.

Capsular Interposition Arthroplasty With Percutaneous Suture Anchoring: A Pragmatic and Novel Surgical Technique for Hallux Rigidus

There is support for the use of capsular interposition arthroplasty (CIA) as an alternative to arthrodesis in the surgical treatment of hallux rigidus. In this technical report, the authors describe novel technical variations to the traditional capsular ...

www.ncbi.nlm.nih.gov

The tricky part is if they have poor capsular tissue then no go. My ortho colleague use hamstring autograft to do it sometimes.

It’s not perfect but combined with a cheilectomy they get some ROM back and more importantly no pain. So far so good and can’t beat autogenous graft and not burning any bridges. I just run like 2-3 straight needle sutures out the bottom of the foot and tie it down on bulky dressing for at least 3 weeks to ensure the capsular sandwich stays in place and scar down.

More or less what I do with freiburgs.

 

[Utvolsdpm]

Barry Block must be a lurker

Todays PM News: Medical Malpractice Lawsuit Over Cartiva Toe Implant Surgery Allowed To Proceed - AboutLawsuits.com

 

[AttackNME]

@DYK343
There was an article that came out a while ago (I think FAI or JBJS, can’t recall) but I found this one from 2020. Actually goes into nice detail with pictures too.

Capsular Interposition Arthroplasty With Percutaneous Suture Anchoring: A Pragmatic and Novel Surgical Technique for Hallux Rigidus

There is support for the use of capsular interposition arthroplasty (CIA) as an alternative to arthrodesis in the surgical treatment of hallux rigidus. In this technical report, the authors describe novel technical variations to the traditional capsular ...

www.ncbi.nlm.nih.gov

The tricky part is if they have poor capsular tissue then no go. My ortho colleague use hamstring autograft to do it sometimes.

It’s not perfect but combined with a cheilectomy they get some ROM back and more importantly no pain. So far so good and can’t beat autogenous graft and not burning any bridges. I just run like 2-3 straight needle sutures out the bottom of the foot and tie it down on bulky dressing for at least 3 weeks to ensure the capsular sandwich stays in place and scar down.

Do you feel autologous soft tissue grafts for interpositional arthroplasty is superior to like graftjacket (I.e. Berlet procedure)? I mean it’s being ground down anyway like a poly in total replacements

 

[wakaflocka88]

Do you feel autologous soft tissue grafts for interpositional arthroplasty is superior to like graftjacket (I.e. Berlet procedure)? I mean it’s being ground down anyway like a poly in total replacements

I’ve seen and revised a few graftjacket failures where it just eroded into the bone. I tell the patients it’s just a procedure to buy time and preserve motion. They seem happy. It’s cost effective and I’m not burning any bridges by implanting something in there prior to a future fusion.

 

[Boba Foot]

In my hands, the Arthrosurface (now Anika) implant, has always been my dependable go-to. Most patients, if given the option, would rather keep their motion. You do have to consider the patient of course. I fuse if there is a notable IM angle, or if the patient is old/not very active. If they're still jogging and/or walking any kind of daily distance, I lean toward implant. Recovery is pretty quick too, and I encourage very early weightbearing and motion to avoid adhesions...

I always have the proximal phalanx components in the room in case I do a total implant (if it's clearly gout related or if the proximal phalanx is just destroyed)

I did one of these as well last fall. So far so good.

 

[DogSnoot]

Hintermann implant going well far longer than any other implant on the market. Yes there are still 15-20% failure rate but it’s an option. I like it, simple straight forward system.

I laugh when I see these studies telling us about “midterm” or “2 year” “4 year” survivorship with a small N. What a joke. Ya, I’m looking at you ACFAS fellows that rinse and recycle your directors garbage data.

Could I ask to what degree do the revision rates affect the length ? How much of the bone are you actually taking ? I’ve read the standard is 5-7 mm of the base of the phalanx or met head is resected prior to implant placement. Is that a real word number ?

 

[Feli]

Could I ask to what degree do the revision rates affect the length ? How much of the bone are you actually taking ? I’ve read the standard is 5-7 mm of the base of the phalanx or met head is resected prior to implant placement. Is that a real word number ?

Hintermann is a total ankle model.

Ankle is debatable since it's the most essential of the joints in F&A (I'd still say either no or needs more data for TAR). The people who pub on it are largely those who want it to work, and when it goes bad it is game over (deep infect = BKA or ridiculously complicated salvage, which might be BKA soon anyway). So, you Basically see TAR fan boys making the indications narrower and narrower to say, "see, it works." Ankle fusions work fine, they're cheaper, and it can be applied to a much wider pt and indications population.

...First mpj has been around awhile... not an essential joint, didn't work then, doesn't work now. The only arguments for them are "patients want motion" and "new implant models will be different." Basically, EBM is EBM. Some people read, some use common sense, some have to see for themselves. So, once you've seen mpj1 fusions going strong after decades and you've revised a few failed implants to fusion, you will think they're pretty dumb also.

At the end of the day, when something X is the bail-out or revision option for something Y, you are typically better off just doing non-op care and then doing X from the start (surgically). The 'set-up' and 'staged' operations have their rare place, but indications are paper-thin, and those are mostly for heavy volume surgeons doing salvage or highly complicated work. Surgery is tougher and tougher to get good results on since more revision equals more scar tissue, more vascular damages (bone, skin, everything), more nerve damage and pain, more edema, more pt convalescence (depression, job loss, weight gain, etc), more meds to take, etc. Don't be one of those guys who operates just for the sake of operating.

 

[msuDPM]

Do you feel autologous soft tissue grafts for interpositional arthroplasty is superior to like graftjacket (I.e. Berlet procedure)? I mean it’s being ground down anyway like a poly in total replacements

I have a robust N=2 case series of young (early 30s) patients with a badly elevated 1st ray and significant cartilage loss in which I performed a plantarflexory base osteotomy, lightly prep/resurfaced both sides of the joint with conical reamers and used Arthrex Arthroflex for interpositional arthroplasty. 4 corner the graft, parachute it over the met head, pass sutures plantar to dorsal through bone tunnels and tie on top. Of course had the conversation that they will likely need fusion down the road. At worst it put the met in better position for that. Overall worked pretty well. No complaints a 1-1.5 years out when I last saw them. Maybe 30 degrees of dorsiflexion if I recall. I have since moved from the area, but they were 3+years out when I moved on, so who knows.

Otherwise, 95% fusions. I've done exactly one implant in 6.5 years and it was a conversion of an old awful failed fusion/non-union in an active 85 year old that settled in dorsiflexion and was causing a recurrent hallux ipj wound. I just took the hardware out and popped a silastic in there.

I'll do the occasional cheilectomy, but honestly I just don't see that much grade 1/2 hallux rigidus in sub 60 year olds that can't be managed conservatively.

 

[PlainsPod]

i used to do it all. Now I just do cheilectomies or fusions. Everybody is happier .

 

[Scrantonicity]

Well guess I’m in the minority here, but that’s OK lol. Works for me…

 

[PointyNippers]

If I were to consider an implant, Swanson is always my go to. I usually tell the patient that down the road some may need revision/fusion, and have them keep realistic expectations on their function and outcomes. They're usually happy campers as long as they know what to expect

 

[Feli]

If I were to consider an implant, Swanson is always my go to. I usually tell the patient that down the road some may need revision/fusion, and have them keep realistic expectations on their function and outcomes. They're usually happy campers as long as they know what to expect

Just do first MPJ scopes, brah. They be 🔥❤️‍🔥🔥👨‍🚒🔥

 

[DYK343]

If I were to consider an implant, Swanson is always my go to. I usually tell the patient that down the road some may need revision/fusion, and have them keep realistic expectations on their function and outcomes. They're usually happy campers as long as they know what to expect

Like I said above ive seen swansons last a long time. If I were to put one in this would be what I would choose too.
But do they really have any push off strength in the hallux?
Not really

 

[NatCh]

I did about ten Cartivas before I bailed off that sinking ship. I did one GraftJacket interpositional arthroplasty and she still loves the results many years later. I did a bunch of Arthrosurface but several of them had bony overgrowth a few years later, plus none of them had the normal motion that everyone had hoped for (never give a patient the expectation that an implant will restore normal motion). I've seen too many x-rays of silicone implants that fell apart years later so I won't even consider those. I'll consider a cheilectomy for the appropriate person but nowadays I love the reliability of a fusion.

 

[Pronation]

Just do first MPJ scopes, brah. They be 🔥❤️‍🔥🔥👨‍🚒🔥

What’s the CPT for this crap?

 

[Feli]

What’s the CPT for this crap?

Straight cash, homie.

Bonus point$ if you own the out-of-network "surgery center" (aka exam room 3) or if you can put in a mpj scope cartiva.

 

[PointyNippers]

Just do first MPJ scopes, brah. They be 🔥❤️‍🔥🔥👨‍🚒🔥

lol yall must be throwing implants into the wrong patient or something. I've had pretty good outcomes

any scope other than an ankle or fasciotomy is a scam though

 

[Pronation]

I need to know how many RVUs I can get for an MTP scope before I decide if it’s a scam or not.

 

[GreenHousePub]

lol yall must be throwing implants into the wrong patient or something. I've had pretty good outcomes

That's the problem with 1st MPJ implants though. Patients absolutely love them for 5-8 years. Then they start hurting and it is an absolute mess to revise them to a fusion.

 

[heybrother]

I don't think that patients can have a realistic expectation about what a revision fusion will consist of.

And now for the most ridiculous story ever.

#1 A patient had some sort of bunion surgery - I believe a 1st MPJ fusion. It non-unioned or something weird.
#2 An orthopedist in my town revises it but fused it supposedly in too much dorsiflexion. She always felt it was pointing up.
#3 She went to a fancy fellowship trained podiatrist in Dallas. They revised her fusion to a 1st MPJ implant.
And the toe is still overly dorsiflexed and hurts and she hates it.

She then went to the most revered foot and ankle orthopedist in my town. They told her she had made a huge mistake and should never have had the 1st MPJ implant (edited) put in.

And then she came to me... And I'm dropping her insurance. I will say it caused a myriad of feelings for me. I do like to get my fusion on. And I do like to help people with weird problems that are within my wheelhouse. But this screams disaster.

 

[NatCh]

That's the problem with 1st MPJ implants though. Patients absolutely love them for 5-8 years. Then they start hurting and it is an absolute mess to revise them to a fusion.

That was my experience with implants way back (other than Graft Jacket, if you want to consider that an implant). You have to wonder in the back of your mind how many of your implant patients needed a revision but went elsewhere to get it and you never heard about it, leading you to think, "I've had great results!" when in actuality your patients decided to never go back to you.