Um, I am chief of the division of foot and ankle at Atlanta WellStar Atlanta Medical Center and director of the Surgeons Foot and Ankle Center. And it's my pleasure to talk about chelectomies with you today. We're going to discuss open and some MIS technique. Here are my disclosures. So chelectomy, why are we even talking about this in the great toe? Well, it's for the diagnosis of hallux rigidus. Um, some of the symptoms of hallux rigidus are the crease motion to that great toe, pain, and then you can eventually start developing osteophytes, um, and even, uh, more stiffness. And in general, we don't jump directly to surgery from this, um, treatment includes anti-inflammatories and form of NSAIDs, um, inarticular steroid injections. We can talk about orthotics in the shoes and even a Morton's extension, um, to limit some of the motion to the great toe. And then you start getting into things such as activity avoidance, um, and then you can order an extra depth wide toe box shoe to accommodate any dorsal spur, because sometimes it's that dorsal spur that causes discomfort. And that's mainly why we ended up doing a chelectomy. We'll talk about that further. Clear our classification systems. You've got your Hattrop and Johnson and your Coughlin. The Hattrop and Johnson is really based largely on radiographic findings. Um, and so you'll hear about that a lot in research and, um, this Coughlin landmark article in which some clinical findings were added to as well, I think, uh, really flows in terms of communication, uh, between doc. So chelectomy, I'm not talking about fusion today. Um, so we're going to talk about a chelectomy and you can see in this picture here where there's a dorsal spur, um, and when you have that dorsal spur anecdotally, that's when I really find that it works best. Um, when you can do your physical examination and you palpate that spur and they say, Hey, this is what's causing pain. It's when the shoe is contacting that spur. You don't have that axial load pain to such a degree, or at least minimally in a negative grind test, kind of alerting to you that mid range of motion isn't really the big problem. This is when I find that a chelectomy really works well and you really have to discuss what the expectations will be after this. So really in terms of chelectomy, we're talking about a debridement of that osteophyte as you can see on this picture here and removing approximately a quarter to 32% of the articular cartilage. Chelectomy, we'll see that old school works. I have this picture here of Tim Duncan. He's also known as Big Fundamental, um, all world basketball player, hall of famer, who just did all the right things on the court, um, which led to him winning numerous titles. The same thing with the chelectomy, it works. Um, you know, if you have the right indications, um, the, there's a couple of articles here we talked about. There are no limitations. The ADLs of almost 90% of the patients, um, own an 8.8% revision rate. This article here and in Coughlin's landmark article of 93 feet, 92% success and pain relief with this. And it's not necessarily just for some of the earlier stages. There've been some data kind of correlating, uh, foot and ankle ability measures, ADL scores and radiographic grade of how it's rigidous. And so, you know, if clinically and radiographically, sometimes you can get away with something that looks worse on x-ray and have some good symptomatic relief. And it's been shown that you can add a Moberg osteotomy, um, which is a dorsiflexion type osteotomy of the proximal thighs of the great toe. And you add that with, um, kind of a, an Aiken type procedure and correcting any deformity. And that has been shown that you can have some improvement in range of motion and pain. Now, some of these are level three and level four studies, uh, but anecdotally they work. So in general, when you think about a chelectomy, you think about this dorsal approach as you should, as we show here, um, we go just medial to the EHL, we've sacked about 25 to 30% of the bone with either an osteotomy or a saw. This allows you to do a synovectomy as well, really can release some of the sesamoids openly. And then you can use your Ranjour, remove any remaining osteophytes medially or laterally, um, and get a good capsule at least if necessary. Now I put this picture of Questlove here because to be honest with you, I did, I thought a pretty good literature search and it wasn't until I talked to one of my partners, uh, about this medial approach to a dorsal chelectomy. So I kind of felt like I was digging in the crates here, but these smart guys, Dr. Easley, Dr. Davis, and Dr. Anderson did a study in, it looks like in the late nineties, 57 patients, medial approach, um, 63 months followup. And that AOFAS score improved from 45 to 85, dorsal flexion, Ranjour motion, 1939, um, Ranjour motion in general improved 30 degrees and they were able to excise the osteophytes and even do a plantar capsule release. Um, and my partner, um, who gave me these pictures, cause he does a medial approach which is even a dude can do kind of a Moberg, Moberg-Akin type procedure with his, and he's done this since he read that article in the late nineties. And so, um, I thank him for letting me know about this. And he says, you're able to reach plantar to the metatarsal head and do a lateral capsule release. Now in open, they all don't do well. And so in general for a Hattrick grade three or a Coughlin four, you know, those usually go on orthodesis. And there's some of this literature is discussing that. And I think it's important, you know, for us to really, you know, manage some of the expectations of the patient, you know, they think they're going to, you know, be able to, uh, with a grade three and four, just removing kind of the, uh, chelectomy that, um, dorsal osteophyte, where we know there's kind of, um, more extensive disease, um, really kind of having a long conversation and discussing what the right surgery will be with the patient is important. And this literature bears this out. Let's talk about MIS chelectomy. Here's a new type of big man, right? Um, the process per se, Joel Embiid. And we'll talk a little bit more in detail on some of these articles. Um, the minimally invasive, you know, it does work. I mean, there is a little slightly higher vision rate should be done for grades two and grade three, um, um, in a Coughlin classification, but more studies need to be done. And there is an increased relative visceral reoperation, but let's talk though, right? Like if there's a way to kind of minimize your incision from something like this and it still have good results, I think it's worthy of something to look at. And so here's an example of one of my MIS incisions, um, and here's a big dorsal incision here. With MIS chelectomy, you can see radiographically, um, the disease is not horrible, right? Um, you can still see that there's some cartilage, um, in this joint, um, referenced by the joint space. Um, but you can also see that there's a dorsal osteophyte that may be taken care of. And on my physical examination, I did just that and really isolated that a lot of the pain was coming from that dorsal osteophyte. And although it may look smaller there, um, clinically it was much bigger. And so what you do is you have to do kind of a small nick and you really have to be careful because you have to watch out for that dorsal medial tetanus nerve. And so I use kind of like a nick and spread method, like when you're doing your arthroscopy portals, um, to avoid that nerve. And I believe that's important and you need to use a elevator to kind of elevate that soft tissue, also the metatarsal head. Um, and then you can use your burr, uh, to shave it down as we did here. Now, I think we did pretty good here. Um, I think we removed all the bone that's necessary. Now, what I'd like you to do is look very closely at that x-ray and you can see where, um, there's some bony debris there. Um, and so we really, sometimes you really have to take your time to remove that bony debris. And I thought we had a good range of motion, um, in OR. Here are some of the tips when doing MIS. And I think, you know, we really need to, to think about these things. You know, you don't want to injure the EHL, which means you really have to make sure you elevate that soft tissue off. And you want to hold that hallux in neutral or even some slight dorsal flexion to put that EHL on relaxation, um, because it's, it's really easy as you start trying to move that burr to just kind of, as you're trying to use some tactile pressure, um, with your contralateral hand, as you use the burr in the other, um, to kind of plantar flex that great toe. And that puts that EHL in a position of vulnerability. And also, as I alluded to earlier, when I talked about some of that bony debris, when you do an MIS procedure and you're removing that dorsal osteophyte, there's quite a bit of bone paste, um, that we cause kind of like after you burr that material, and you really have to be conscious to express that bone paste fully. And then you have to irrigate until it is completely clear. Um, you don't want to leave it kind of pinkish. You want it to be clear because you're really trying to flush out that bone debris. There's also some tools in terms of rasps and palpation that you have to do, because sometimes you can leave a little sliver of bone, um, in there based on how you're doing this. And sometimes you have to widen that incision just a bit to move that bony piece where you break it up. And again, you want to use C-Harm, um, to help guide you in where you're moving your burr and also to help you and aid you in looking for some of that material in the joint. All right, so a little comparison of MIS versus open. Um, now granted, um, this is a relatively, uh, new procedure. And so, you know, maybe there's a learning curve in there, maybe not. But when you do it openly, um, you can visualize your joint surfaces. You can really assess and treat any conjural defect. And it allows for an extensive soft tissue release. MIS, there's a perceived less insult to the soft tissue. And so, the idea is that you have some earlier mobilization, return to function. There's not a big wound to worry about. Um, and hopefully you'll have less scarring. And so, you can, uh, I let those patients walk immediately and do range of motion, you know, um, the first day as we use our block and try to get as much motion as possible and maintain as much motion. In this study here, as I was kind of alluding to, as I was talking about MIS versus open, this study, 38 open, 133 MIS, showed a reoperation rate in the open of 2.6 and MIS is 12.8. And the complication was only one in the open and 15 in MIS. Now, granted, there is a significant difference in the comparison of the number of open and the number of MIS. But here are some of the, the, the complications that you'd see. Um, return, return to operation. Now, you can see there wasn't many wound infections in the MIS. Uh, I don't see any listed here and there was in the open, um, but there was some residual stiffness, some ectopic bone in the area. There was even a CRPS, which happens from time to time. And unfortunately, an EHL rupture and a dorsal renal continuous nerve injury. Um, so, uh, we definitely need to, uh, take a close look at what we're doing in our MIS. And then here's a study, um, of, it was a cadaver study where, um, some orthopedic surgeons were kind of learning how to do the MIS, uh, chelectomy and they showed a 15% dorsal renal continuous nerve injury. Now, granted it's a cadaver, um, and the tissues are different in a cadaver, but, and this is also part of a learning curve, um, that I alluded to earlier. Again, I know I'm saying alluding to, because I think this is a new, um, procedure and there, there are things that just still kind of need to be worked out, but I do believe it works and we just need to keep kind of trying to move this forward because that incision is much less, um, and patients do like it when it goes well. And so here's one idea, um, that may help with MIS and, um, anything that may be remaining in the joint and that's to use a scope. Um, on their arthroscopic evaluation, there's 100% bone debris and 100% Sinusitis, um, that was remained when they looked at the scope. Um, how much of that is clinically relevant is important. Um, some loose bodies were seen and even cartilage flaps. So again, um, there's more work to be done as we develop MIS chelectomy. And so here's a picture from that study, um, where you can see here where there is a loose body in the joint, um, as well as some residual debris and even a cartilage flap. So in conclusion, chelectomy works and is reliable. I believe MIS has its place. I think that there is a learning curve involved, um, and you really have to stick to some of the principles. And it may be that you want to add, uh, an arthroscopy, um, if you are going to do MIS. Um, uh, here's some additional references. Thank you very much.

chelectomies

hallux rigidus

stiffness

pain

big toe