Free Gracilis Interposition Arthroplasty for Severe Hallux...
4
121 Bulletin • Hospital for Joint Diseases Volume 62, Numbers 3 & 4 2005 Abstract Surgery for the management of hallux rigidus aims to relieve pain and improve function. Arthrodesis, though reliable in terms of pain relief, may encounter some resistance from patients reluctant to have a fusion. Re- sults of other techniques, such as silastic implants, may give poor long-term results. Excisional arthroplasty and cheilectomy are also routinely used. Interposition arthroplasty has been used with some success in other joints. We describe a technique of autologous inter- position arthroplasty using a free ipsilateral gracilis tendon graft for patients with severe hallux rigidus with moderate to high activity levels and who do not wish to undergo fusion. S urgical management of severe hallux rigidus is controversial. Many procedures have been de- scribed, but few yield good long-term results. Arthrodesis seems to give the most reliable long-term results. 1,2 Some patients, however, are unhappy with the restricted motion and with the fact that, if female, they may not be able to wear high heel shoes. 3 Other techniques have been described. Excision ar- throplasty is normally undertaken in elderly or sedentary patients, given the loss of flexion strength of the first metatarsophalangeal joint and the possibility of trans- fer metatarsalgia in active patients. 4,5 Silastic implants may produce synovitis, and implant failure has been described. 6,7 Cheilectomy has had some success, but results are better with less severe hallux rigidus. 8,9 Interposition arthroplasty has been described in other joints with good long-term results, especially in the hand. 10-12 In hallux rigidus, interposition with the capsule and a portion of flexor hallucis brevis and extensor digi- torum brevis tendons has been described. 13,14 Coughlin described soft tissue interposition for hallux rigidus in a group of seven patients. 3 The aims of the technique are to decompress the joint, provide a stable arthroplasty, retain plantar intrinsic attachment, and preserve digit strength. 3 Range of motion is also improved. Indications and Contraindications We use this technique to correct severe hallux rigidus in active biologically young patients with severe hallux rigidus. Preoperative Planning Complete past medical history and physical and radio- graphic examinations are necessary. Standard radio- graphs, including anteroposterior and lateral weightbear- ing views of the forefoot, allow the assessment of the severity of degenerative joint disease. Technique The operation is performed using the anaesthetic tech- nique of choice with the patient supine. The whole of the lower limb is prepared in the standard fashion and exsanguinated. A thigh tourniquet is used. A dorsal longitudinal skin incision is used over the first meta- tarsophalangeal (MTP) joint (Fig. 1A). The incision is deepened through the skin, subcutaneous tissue, and through the medial aspect of the extensor hallucis longus tendon. The first MTP joint is then exposed (Fig. 1B). Free Gracilis Interposition Arthroplasty for Severe Hallux Rigidus David Miller, M.R.C.S., and Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Orth.) David Miller, M.R.C.S., and Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Orth.), are in the Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, Hartshill, Stoke- on-Trent, Staffordshire, England. Correspondence: Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Orth.), Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, North Staffordshire Hospital, Thornburrow Drive, Hartshill, Stoke on Trent, Staffordshire ST4 7QB England.
Transcript of Free Gracilis Interposition Arthroplasty for Severe Hallux...
121 Bulletin• Hospital for Joint Diseases Volume62,Numbers3&4 2005
Abstract
Surgery for the management of hallux rigidus aims to relieve pain and improve function. Arthrodesis, though reliable in terms of pain relief, may encounter some resistance from patients reluctant to have a fusion. Re-sults of other techniques, such as silastic implants, may give poor long-term results. Excisional arthroplasty and cheilectomy are also routinely used. Interposition arthroplasty has been used with some success in other joints. We describe a technique of autologous inter-position arthroplasty using a free ipsilateral gracilis tendon graft for patients with severe hallux rigidus with moderate to high activity levels and who do not wish to undergo fusion.
Surgical management of severe hallux rigidus iscontroversial. Many procedures have been de-scribed, but few yield good long-term results.
Arthrodesis seems togive themost reliable long-termresults.1,2Somepatients,however,areunhappywiththerestrictedmotionandwiththefactthat,iffemale,theymaynotbeabletowearhighheelshoes.3
Other techniqueshavebeendescribed.Excisionar-throplastyisnormallyundertakeninelderlyorsedentarypatients, given the loss of flexion strength of the firstmetatarsophalangeal joint and thepossibilityof trans-fermetatarsalgia inactivepatients.4,5Silastic implants
may produce synovitis, and implant failure has beendescribed.6,7 Cheilectomy has had some success, butresultsarebetterwithlessseverehalluxrigidus.8,9
Interpositionarthroplastyhasbeendescribedinotherjoints with good long-term results, especially in thehand.10-12Inhalluxrigidus,interpositionwiththecapsuleandaportionofflexorhallucisbrevisandextensordigi-torumbrevistendonshasbeendescribed.13,14Coughlindescribedsofttissueinterpositionforhalluxrigidusinagroupofsevenpatients.3Theaimsofthetechniqueareto decompress the joint, provide a stable arthroplasty,retain plantar intrinsic attachment, and preserve digitstrength.3Rangeofmotionisalsoimproved.
Indications and ContraindicationsWeuse this technique to correct severehallux rigidusinactivebiologicallyyoungpatientswithseverehalluxrigidus.
Preoperative PlanningCompletepastmedicalhistoryandphysicalandradio-graphic examinations are necessary. Standard radio-graphs,includinganteroposteriorandlateralweightbear-ingviewsof the forefoot, allow theassessmentof theseverityofdegenerativejointdisease.
TechniqueTheoperationisperformedusingtheanaesthetictech-niqueofchoicewith thepatient supine.Thewholeofthelowerlimbispreparedinthestandardfashionandexsanguinated.A thigh tourniquet is used.A dorsallongitudinal skin incision is used over the first meta-tarsophalangeal(MTP)joint(Fig.1A).Theincisionisdeepened through the skin, subcutaneous tissue, andthroughthemedialaspectoftheextensorhallucislongustendon.ThefirstMTPjointisthenexposed(Fig.1B).
Free Gracilis Interposition Arthroplasty for Severe Hallux Rigidus
David Miller, M.R.C.S., and Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Orth.)
DavidMiller,M.R.C.S.,andNicolaMaffulli,M.D.,M.S.,Ph.D.,F.R.C.S.(Orth.),areintheDepartmentofTraumaandOrthopaedicSurgery,KeeleUniversitySchoolofMedicine,Hartshill,Stoke-on-Trent,Staffordshire,England.Correspondence: Nicola Maffulli, M.D., M.S., Ph.D.,F.R.C.S.(Orth.),DepartmentofTraumaandOrthopaedicSurgery,KeeleUniversitySchoolofMedicine,NorthStaffordshireHospital,ThornburrowDrive,Hartshill,StokeonTrent,StaffordshireST47QBEngland.
122 Bulletin• Hospital for Joint Diseases Volume62,Numbers3&4 2005
Osteophytesareremoved(Fig.1CandD)anda1.6mmKirschnerwireisinserteddistallyalongthemedullarycanalof theproximalphalanx(Fig.1E).Asmall jointOstek reamer (Hillsborough,Oregon,USA;16,20,or24mmaccordingtothediameterofthefirstmetatarsalheadandbaseoftheproximalphalanx)isthenusedtoproduce a convex surface at the base of the proximalphalanxof thehallux(Fig.1F).TheKirschnerwire isthenremovedandinsertedintothemedullarycanalofthefirstmetatarsalinadistaltoproximaldirection(Fig.1G).Aconcavesurfaceofequalsizeis thenproducedusingthesmalljointreamer(Fig.1H).Thewireisthenremovedandtheareadebrided,takingcaretoleavetheplantarintrinsicligamentsintact. Thetendonofgracilisisharvestedthroughavertical2.5 cm incisionover thepes anserinus (Fig. 2A).Thesartorius fascia is identified and incised between the
gracilisandthesemitendiosusinlinewiththeirfibers.Thesartoriusfasciaisthendissectedoffthesurfaceofthesemitendinosusandthegracilis.Theinsertionofthegracilisonthetibiaisidentified,andaclampisplacedonthedistalendofthetendon.Thetendonisthenpulledwiththeclamptodeliverasmuchofthetendonoutsidethewound. Thetendonisthenpalpatedproximallytomakesurethatthereisnoremainingattachmentsoradhesions.Thetendon stripper is passed in line with the tendon.Thetendon is thendeliveredoutof thewound,strippedofallmuscletissueanddetachedfromitsinsertiononthetibia.15
Thefreegraftisthensuturedusingabsorbablesutureintoaballabout1.5cmindiameter(Fig.2B).This istheninsertedintothefirstmetatarsophalangealjoint,andactsasabiologicalspacer(Fig.2CandD).Thecapsule
Figure 1A,Preoperative:55-year-oldpatientwithseverehalluxrigidus.Onlyminimalpainfuldorsiflexionwaspossiblebothactivelyandpassively.B,Dorsalincisionoverfirstmetatarsophalangealjointandretractionofextensorhallucislongusmedi-ally.C,Dorsalcheilectomy.D,Medialexostosectomy.E,Kirschnerwireinsertedintometatarsalmedullarycanalinadistaltoproximaldirection.F,APowerOstekreamercreatesaconvexproximalsurfacetofirstmetatarsal.G,Kirschnerwireinsertedintoproximalphalanxinaproximaldistaldirection.H,Concavesurfacecreatedonproximalphalanxwithpowerreamers.
ED
CBA
HG
F
123 Bulletin• Hospital for Joint Diseases Volume62,Numbers3&4 2005
Figure 2A,Theharvestedipsilateralgracilistendon.B,Gracilissuturedtoformaball.C,Firstmetatarsophalangealjoint(MTPJ)gapforinsertionofbiologicalspacerwithintactplantarintrinsicligaments.D,Gracilis“ball”inserted.EandF,MovementofMTPJdemonstrated.G,Theskinissuturedusing3-0absorbablesubcuticularsuturematerial.
EDC
BA
GF
issuturedtothegraftandthecapsuleclosed.Theskinisclosedwithabsorbablesuture(Fig.2G).
Postoperative ManagementAt theendof theoperation,acompressivebandage isapplied.Walkingisallowedimmediatelyandthepatientisadvisedtowalkonhisheel.Footelevationisadvisedwhenatrest.
ComplicationsDeepveinthrombosisispreventedbyearlymobilization.Mildtransfermetatarsalgiaandcock-updeformitymaybeencountered.Donorsitemorbidityisalsopossible.
ConclusionsThistechniquecanbeusedforthemanagementofseverehalluxrigidusinactivepatientsandforpatientswhoareconcernedwithmaintainingtheactivemotionofthefirstmetatarsophalangealjoint.
References1. Coughlin M:Arthrodesis of the first metatarsophalan-
geal joint with mini-fragment plate fixation. Orthopaedics1990;13:1037-44.
2. Coughlin M,Abdo R:Arthrodesis of the first metatarso-phalangeal joint withVitallium plate fixation. FootAnkle1994;15:18-28.
3. CoughlinMJ,ShurmasPJ:Softtissuearthroplastyforhalluxrigidus.FootAnkleInt2003;24(9):661-72.
4. ClevelandM,WinantE:Anend-result studyof theKelleroperation.JBoneJointSurgAm1950;32:163-75.
5. JordanH,BrodskyA:Kelleroperationforhalluxvalgusandhalluxrigidus;anendresultstudy.ArchSurg1951;62:586-95.
6. PerlmanM,SchorA,GoldM:ImplantFailurewithparticulatesynovitis(detriticsynovitis).JFootAnkleSurg1990;29:584-8.
7. GranberryW,NobleP,BishopJ:Useofahingedsiliconeprosthesis for replacementof thefirstmetatarsophalangealjoint.JBoneJointSurgAm1991;73:1453-9.
124 Bulletin• Hospital for Joint Diseases Volume62,Numbers3&4 2005
8. LauJT,DanielsTR:Outcomesfollowingcheilectomyandinterpositionalarthroplastyinhalluxrigidus.FootAnkleInt2001;22(6):462-70.
9. MackayD,BlythM,RymaszawskiL:Theroleofcheilec-tomyinthetreatmentofhalluxrigidus.JFootAnkleSurg1997;36:337-40.
10. Boeckstyns ME, Kjaer L, Busch P: Soft tissue interposi-tion arthroplasty for scaphoid non-union. J Hand Surg1985;10(1):109-14.
11. LuchtU,VangPS,MunckJ:SoftTissueinterpositionarthro-plastyforosteoarthritisofthecarpometacarpaljointofthethumb.ActaOrthopScand1980;51(5):767-71.
12. CiteraG,EspadaG,GayliardiSA,MaldonaldCoccoJA:Hiparthroplastybysofttissueinterpositioninjuvenilerheumatoidarthritis.JRheumatol1993;20(5):914-6.
13. HamiltonWG,O’MalleyMJ,ThompsonFM:Capsularin-terpositionarthroplastyforseverehalluxrigidus.FootAnkleInt1997;18(2):68-70.
14. CosentinoGL:TheCosentinomodificationfortendoninter-positionalarthroplasty.FootAnkle1995;34(5):501-8.
15. Deehan DJ, Pinczewski LA: Endoscopic anterior cruciateligamentreconstructionusingafourstrandhamstringtendonconstruct.JRCollSurgEdinb2002;47:428-36.
