Hello, my name is Alastair Younger and I'm from Vancouver in British Columbia. I'm going to talk about the use of the scope and minimally invasive surgery for chylectomy in the first MTP joint, small incisions and great results. Here are my disclosures. I do consult for Stryker and that is a potential conflict with this talk. The other conflicts I don't think are of major significance. So, how do these people present to you? Well, typically, hallux rigidus has an insidious onset. There's no sort of particular trauma and they will well localize the pain to the first MTP joint area. They will often report loss of motion and loss of function and sometimes have difficulty with shoe wear with the dorsal osteophyte. And they will have activity-related pain in the first MTP joint. So, usually, it's a pretty clear presentation, which is somewhat unusual in our foot and ankle practices. Once they've presented, if you examine them, you'll find typically a dorsal osteophyte on the first ray and they will have localized tenderness in that area and you'll often palpate the osteophyte. The standard imaging is an x-ray and you usually do not need anything more than a standing apian lateral of the foot. And this will give you an idea of where the osteophyte is. And it will also show you the degree of joint space narrowing they have in the first MTP joint. The indications for this procedure are a painful dorsal osteophyte, usually with joint space narrowing. And in general, the amount of joint space narrowing doesn't really relate to the imaging or the outcome or the complaints. So, I tend to offer them surgery pretty much regardless of how much joint space narrowing is present. They'll often have restriction of activity, typically in sports, definitely running. And the indication for surgery obviously is failed non-operative treatment, which tends to be rigid rockers or shoes, plus or minus a rigid plate in the shoe, physiotherapy, and in my practice, often injections. I wouldn't do a dorsal chialectomy in a patient who has advanced sesamoid arthritis, because this will simply prevent them from getting range of motion. So, this you can determine by palpation and CT, if you choose. If there's advanced degenerative change, there may be an argument not to do it. I tend to tell patients that I'll try, and if I fail, I'll go ahead and fuse them. But often you can get a result with this. If there's obviously too much bone loss or avascular process with the head, these are both contraindications to doing a dorsal chialectomy. It's worth examining the patient looking at other copathology. Sometimes you'll find patients with an elevated first ray, and in those patients, I'll have a discussion about whether or not we should treat it. They may also have a long first ray. The sesamoid arthritis, obviously, we've discussed the significance. They may have a gastrocnemius contracture, and you might consider doing a heel cord lengthening. They may have other hind foot malalignment, such as a planovalgus or cavus foot, that you might consider treatment at the same time if it's symptomatic. So this is a case of mine. It's a patient who has a dorsal osteophyte, and I consent them for this, plus MTP joint arthroscopy and debridement. I think that the arthroscopy is important, and in time, this has been shown to be an important factor in this, as if you don't take out the debris, then they tend to have a bad outcome. In our practices, where I am in Vancouver in Canada, we use a calf tourniquet. Sometimes folk advocate no tourniquet. You do need some form of irrigation if you have a tourniquet to make sure that you're not generating heat, and you need to think about the heat that the burr may be generating. We'll use a regional block, so basically, a popliteal block for this surgery, so the patient's awake. I will use a 3mm scope. You can also use a 2.9 scope, depending on the company providing it. A 3.5 shaver. The larger scope allows better field of view, and because you've taken out the bone, you'll have more space to work in, and you'll get better flow. I'll use either the 2x12 Shannon burr or the 3.1 wedge burr. It depends how much bone I'm taking out, and obviously, you need the console and all the arthroscopy equipment. The incisions I'll make is one just approximately in the metatarsal shaft, and I'll take two incisions over the joint line. It's important to realize that there are nerves in this area. There's two dorsal cutaneous nerves, and you want to not damage them, so you want a nick and spread technique, and you need to elevate the soft tissues of the bony prominence using an elevator. It's actually hard to damage the extensive tendons using these burrs, but you need to be cognizant of it as you're doing the surgery. The first thing I do is I make sure I'm getting my reflection in the right plane, so this is a wedge burr. I'm coming down the shaft and making my cut almost parallel to the shaft or slightly greater than the shaft direction, and check this on a C-arm to make sure that I'm getting my original cut in the right place, and this just shows how I'm doing it. You can see the incision point, and really important, I'm using my non-dominant hand to palpate where the burr is going so that I'm making my cut in the right plane, so because this is a three-dimensional deformity, using your non-dominant hand to feel the bones is critical, so you'll also notice I got my finger on the skin using the burr. That helps me to make sure that the burr is kept in the right plane. Once I've finished doing my dorsal debridement, I'll go both sides of the joint and remove the osteophyte in the dorsal side of the proximal phalanx, because patients don't like that being left behind. I'll then insert the scope and the shaver, and I'll remove the debris, and also check my resection margins, and I'll document the residual cartilage and assess range of motion. So this is what it looks like through the scope. We can see the resection margin here, we can see the proximal phalanx here, and you see appropriate removal of bone and a pretty clear-looking joint, and also some fairly advanced degenerative change on the dorsal side of the joint, which is to be expected. In this case, if we actually look through the joint, we can see that there is some cartilage left on the plantar side. It's worth documenting this, so should the patient have ongoing complaints, at least you can explain it. And I want all the debris out, so I'll go and chase it down, all the bits of cartilage, all the bits of bone, and all the bone fragments. So in this case, we can see on the image intensifier view, we can see appropriate resection margins, we can see some debris left behind, so you can see where the arrows are that we got all of this out. You can also see where the resection is on the metatarsal and the proximal phalanx. This just demonstrates the range of motion, so you can see we've got the toes straight, and you can see the appropriate resection margin on the dorsal side, and how much range of motion you can gain. So we can see on the, through the scope, you can actually see the toe coming up and down. And this is kind of what your x-ray needs to look like afterwards. You want to remove not only the dorsal osteophyte, you want to remove the medial and lateral. Now sometimes when I've been taking out the bone fragments, they got held behind in the skin, and I've had to go back and remove it later, so make sure you get all the fragments out. So what's your options? Well, you can go for an implant arthroplasty such as this, you can do the dorsal chialectomy, or you can do a fusion. This is one of the pathologies that really is up to the patient to decide, and it's really them to decide their goals. So if you do an arthroscopic debridement like this, you've got preservation of motion, you get good pain relief, and it's pretty much fairly immediate and a short recovery, and you can always convert it to fusion or implant arthroplasty later should the patient have failure of symptom relief. An arthroscopic fusion is my preference if I have to do it. I do my fusions arthroscopically, and there's loss of motion, there's good pain relief, there's no risk of non-union, and the benefit of this is that it will give you good long-term result in a patient who's not so concerned about the loss of range of motion. The final thing is implant arthroplasty. This requires fairly extensive dissection to get into the joint. As a result, the range of motion return is longer, but it is definitely an alternative in the treatment, and ultimately it's a matter of talking to the patient, finding out what their goals are, and then offering them the operation they choose. If they want motion and minimal incisions with a short recovery, a dorsal chiolectomy, which is an arthroscopic assisted, I find to be a really reliable operation, and there's some evidence as well, which I'll discuss later. You do want to avoid nerve injury. This is a really nice dissection, which shows where the nerves are likely to be, and where you need to make your incisions, ideally to avoid them. This is another patient of mine with previous lapidus procedure done a considerable time ago, who's developed dorsal osteophytes and some hallux rigidus. So this demonstrates the resection plane, and the removal of the bone. In this case, I also did a medial eminence resection, and got an arthroscopic washout done, and it was a good result. This is another case. You can see the dorsal osteophyte. Again, the resection margin, we can see also here that we've got resection both on the dorsal end of the metatarsal, and the dorsal side of the proximal phalanx. So what I'll do is I'll take the burr down, flex the toe until I got the right point of entry into the dorsal side of the proximal phalanx, and then I'll confirm range of motion on the image intensifier, as well as confirm debris removal. This is a patient with diabetes who underwent an arch reconstruction, plus a debridement of the first MTP joint, which is a fairly advanced degree of arthritis you can see on these x-rays. So a patient underwent a calcaneal osteotomy done percutaneously, a percutaneous first TMT fusion, as well as a dorsal chiolectomy and medial eminence resection. So this is the percutaneous lapidus that was done at the same time. To restore his arch, having diabetes, I was more concerned about wound healing, and this demonstrates how we did the chiolectomy. So I used an elevator and a first web space incision using the beaver blade to identify this lateral mass of bone, palpated it with a blunt instrument, and then placed the burr across this, both across the base of the metatarsal lesion and then across into the proximal phalanx area. We then did the dorsal ossified excision. You can see that I'm using the 2x12 Shannon burr in this case, and once I've confirmed this, I'll then flex the proximal phalanx a bit and go across that joint, and this shows the excision and the range of motion in this case, and this is what it looks like after I've done the debridement. So fairly extensive osteophyte formation, actually a joint space that's preserved when we've actually got rid of all the osteophyte. This just demonstrates my hand position, and this is a video just showing how I go through this. I like to come down the metatarsal shaft. I've felt this, I've loosened this off, and I'm just going to go down and get into the joint, the breast MTP joint, and feel myself penetrate across the joint, and that gives me my plane for the resection of the dorsal osteophyte or dorsal pyelectomy. Okay, awesome, thank you. So this is what it looks like on CT, and this is just a 3D CT showing a resection margin. I can see, despite my best efforts, a couple of bits of bone got left behind, but anyway. So this is a paper just outlining the technique of using the scope, and basically reiterates the need for removal of the extra debris with the scope. This is Australian paper with good results with scope debridement with 33 patients, and a larger series is published in Foot & Ankle International of 88 patients, and of note a 12% conversion to fusion, and also still some nerve injuries, which is really the main concern as you trade wound issues from an open procedure to potential issues with nerves, so be careful with your technique. This is a paper just describing doing this now in the office setting with a needle arthroscope, and this won't work in Canada, but if it works in your country, it's a technique you can use. So in summary, I think that arthroscopic debridement is important. It's what my patients basically choose. When I explained to them the options and how it's rigidous, the burr has been a game changer since its introduction in July of 2017 in Canada and the U.S. The nice thing about this operation, it's salvageable, it's short recovery, and we allow early mobilization and early range of motion. So more information if you want to learn how to do this, obviously attend AOFAS courses, or go to one of the MEFAS courses. It's the best way of learning MIS surgery, so I would recommend doing cadaver work first and going to courses before you attempt this and get familiar with the burrs before you use them. Thank you very much.

arthroscopic debridement

hallux rigidus

big toe joint

X-rays

dorsal chilectomy