Good afternoon, ladies and gentlemen, and thank you for joining our talk today. My name is Amitabh Iyer, and I am Division Chief for Foot and Ankle at Johns Hopkins University. Today, we will be discussing Hallux rigidus, evolution of minimally invasive techniques. Here are my disclosures. I want to extend a special thanks to all of you for being here today, and also to Dr. Clifford Jang, Dr. Tyler Gonzalez, and Dr. Jonathan Kaplan for their assistance with slides and some of the case presentations that are available here today. Thank you to all of them. Our general outline is that we'll be discussing the etiology of Hallux rigidus, discussions of chiolectomy as well as arthrodesis, and what has led to the evolution to incorporating minimally invasive techniques, if you will. The etiology for Hallux rigidus is really a multifold, and it may be related to degenerative processes, including arthritis, inflammatory or wear and tear patterns, gout, or post-traumatic, as is often the case in the setting of foot and ankle arthritic pathology. Additionally, flattening of the metatarsal head, osteochondral defects, turf toe injuries, flat-footedness, and trauma are all risk factors as well that one needs to be aware of. Interestingly, metatarsus elevatus in the past has been thought to have been a risk factor, but other data has said that it's really not a risk factor for arthritis specifically of the great toe. It's important to recognize that the Hallux itself is particularly important for dorsal flexion during gait, and up to 60 degrees is really of importance, and is what occurs during the gait cycle. Arthritis or Hallux rigidus is common in older patients, and most commonly, the dorsal aspect of the metatarsal head has cartilaginous loss. You may often see dorsolateral osteophytes, not just on the metatarsal head, but also on the phalanx as well. Certainly, the big bump that's seen in this photo is no stranger to those of us taking care of this pathology. This was in a paper back in 2003 by Dr. Coughlin, demonstrated that elevatus was not associated with this pathology in particular, but it was more common to see either a chevron-shaped head or even a flat head as it were. Conservative measures include using a stiffer soled shoe, including a carbon fiber insole or carbon fiber plate with a Mordent's extension, non-steroidal anti-inflammatories, or even steroid injections, the latter of which may be hard to do considering the concave convex nature of the joint surface or the curved nature of the joint surface, and challenge in terms of getting a smaller needle into a very tight joint space at baseline. When we think about traditional methodologies for handling helix rigidus, especially when we think about chiolectomy or taking back that bone spur, this is often accomplished by an open approach that leads to removal of the bone spur with a chiolectomy. Additionally, this may be accompanied by a Moberg or a dorsiflexion osteotomy of the proximal phalanx. Then certainly, the additional management of the arthritis may be treated with an interposition arthroplasty, joint replacements, which have been done over the years, as well as arthrodesis. More specifically today, as far as minimally invasive techniques are concerned, we'll be focusing our efforts or interest on chiolectomy and arthrodesis in particular. When we look at the data surrounding chiolectomy, it's often been pretty successful as a whole, going in, making that dorsal incision, protecting your EHL, getting to the osteophytic metatarsal head and removing it, has definitely shown demonstrations, has demonstrated improvements in pain, as demonstrated in the literature described here. And certainly, patients do better if they're older. And there's certainly improvement with time as well in terms of how patients do. But of course, some of this oral literature, it doesn't account for the soft tissue dissection, and perhaps that's part of the reason and the scarring that ensues that may be part of the reason why this may not work long-term or may not be a long-term solution. Although in some patients, it still can be. However, if we think about the evolution of minimally invasive techniques, we know that with minimally invasive hallux valgus correction, we have certainly seen improved post-operative pain, reduced operative time, blood loss, and even wound healing complications. And the lack of soft tissue disruption or minimal soft tissue disruption certainly allows for accelerated rehab and patient satisfaction. So if we think about minimally invasive chiolectomy in particular, this is a paper by two of my colleagues, Dr. Gonzalez and Dr. Kaplan, both of whom were involved with this retrospective series of 20 patients where there was a follow-up of just shy of two years with improved scores, improved range of motion. But unfortunately, two patients had to be converted to effusion about three years after the index procedure. And when the arthroscopically evaluated the patients, 100% of the patients had bone debris, inflammation, and many had large cartilaginous flaps as described here within the joint itself. This is another study that came out recently demonstrating just shy of 100 patients that were retrospectively reviewed between 2011 and 2016 with increases and improvements in not only their patient reported outcome scores, but also the VAS pain scores. Ultimately, two had wound infections, two had delayed wound healing, and 12 patients in total end up having revision surgery, seven of which ended up going on to a hallux fusion. However, the patients who had a more severe Coughlin grade of arthritis ended up having a greater risk of revision to arthrodesis in particular. So what are the indications for MIS chiolectomy? It's really the same as the open. And if you've got a patient who's got a grade one or a grade two hallux rigidus, if they have pain, especially with the extremes of dorsal flexion, no specific grind test, maybe minimal pain in the mid-arch of motion, then that would certainly be a candidate for a minimally invasive approach as opposed to the open one. Your principles are the same. Let's get rid of the spur more than anything and try to also address intraarticular pathology that may be happening at the same time. And so here are a couple of cases demonstrating location of the burr at that, location of the burr, which is high torque, low speed with the goal of limiting the disruption to the soft tissue, but also limiting the amount of thermal energy or heat imparted to the bone to limit risk of thermal necrosis. So using chilled saline has been recently popularized in data by Dr. Oliver Shipper. It demonstrates the value proposition that the chilled saline often affords. However, doing this without a tourniquet is additionally beneficial to limit risk of complication. At least that's one perspective to keep in mind. Some folks out there do use a tourniquet while they're doing this, but at least in my experience, humbly, I prefer to keep the tourniquet off while I'm actually doing the chiolectomy or any minimally invasive work with the burr as a whole. So we take the spur down and you can see the flattening of the dorsal aspect of the mid-torso head and the improvements in range of motion as visualized on this fluoroscopy image. And if you arthroscopically evaluate, you can really get into the joint, see the synovitis that's there, debride any of that at the same time. I've gone from doing an arthroscopy to doing a dorsal incision or small one that allows me to flush out the joint, remove any of that debris that was quoted in Dr. Gonzalez's and Dr. Kaplan's paper. And that to me is an additional way of doing it while still minimizing the risk of disruption to the soft tissues as a whole. You can see the metatarsal head having had the chiolectomy done and certainly the proximal phalanx at the same time. These are your incisions and these are really quite small and a lot of work can be done in a very short period of time, to be honest. And so here's an example of a case. This was the case that we were just describing. Here's some additional photos of the spur being taken down, certainly evaluation of the joint surface with the cartilage of, with the cartilaginous surface on either side. Here's another case with a dorsal bone spur and taking that down to really, again, with the goal of, there's not a lot of arthritis that we can see on this particular lateral base view, but our goal is to feel that spur out, use the burr to smooth that down. And if you also notice, there's a little bit of a bone spur on the phalanx too, an early one. So consideration ought to be given to whether the bone spur on the phalanx should be taken down at the same time in order to optimize range of motion and recovery and perhaps limit risk of recurrence of the spur. This is actually that same patient. And over time, the spur unfortunately came back. And you can see how that proximal phalangeal spur actually is a little bit more prominent now, and so is the metatarsal head spur. So it's come back with a full throttle vengeance. And so going in there and really cleaning out both sides of that joint, in addition to removing any debris that's contained on the intraticular surface, that's really important to really the success of this approach. Now, of course, you might say, well, what's the advantage compared, at least technically speaking, to the open approach? Well, really the reason to consider an arthroscopy or a mini open is to flush out all that debris, all that inflammatory, those inflammatory processes, inflammatory chemicals, cytokines, et cetera, and cells that are likely leading to this ongoing cycle of destruction within the joint that the open approach often allows you to flush out because you've made that open incision. So if you're using, if you feel facile with the Haloxin P arthroscopy, great. You can use that to flush it out. If alternatively you wanna use a mini open approach, that's fine too. But again, it's important to dovetail the flushing of the joint effectively of all this debris alongside the minimally invasive chiolectomy, if you will, as we're describing here. So we're gonna switch gears just a little bit and think to ourselves about, well, what if the arthritis is actually advanced, right? What if you get in there and you're like, this may not work nearly as well long-term or a patient hasn't seen you in a while and the spur, you know, they did well for a bit and then now the spur's back, the arthritis is worse, and the chiolectomy has unfortunately just not, you know, panned out as far as long-term treatment. Then that's where we've gotta start thinking about, you know, other options, including that of a Haloxin P arthrodesis. And this was described originally back in the 1850s and it's been evaluated time and time again by many in the literature. And this is something that I think we're all, you know, we're all familiar with and there's various techniques that work. And it's really about, in part, what's been supported by the data that we'll go over in a little bit, but then also the extent of deformity that's there. And we've gotta really think about, hey, if there is deformity, what actually is taking place? And as you see here, the stretch or the tenodesis effect on the adductor tendon in particular is what leads to the closure or narrowing of that one-two intermetatarsal angle and allows for stabilization, correction of the metatarsopremus varus, stabilization of the medial column, and help to rebalance the weight distribution on the tripod of the first, fifth metatarsal heads and the heel in particular. And this also allows you, as you're derotating that proximal phalanx into the correct position, especially if there's a valgus-based arthritis pattern that's noted, allows you to rotate the sesamoids into an improved position too for weight distribution. Now, you know, the question that often comes up with when you're doing any sort of, you know, any sort of Hallux NP fusion is, do you often, if there's a lot of deformity, either at the interarticular level or with the Hallux valgus situation, do you have to do something proximally? And the data definitely suggests that it's not necessary as a whole. And the IMA, as we mentioned, by the mechanism described previously on the prior slide, definitely demonstrates a decrease in that IMA of anywhere between 4.6 to 8.2 degrees. So while there is one report of about 18 patients indicating that, hey, something was required or the Hallux valgus or the Hallux NP fusion was combined with either a proximal metatarsal osteotomy or first TMT arthrodesis, it is not usually required as a whole. And in a revision scenario in particular, where your adductor tendon may have been released, you know, previously from a McBride or modified McBride style procedure, then really you can't take advantage of that TMT arthrodesis effect. And certainly that's something to be aware of as well. Also, a scenario that you might have to do something proximally might be if you had a really rigid or seriously arthritic first tarsal metatarsal joint that prevents appropriate derotation of the metatarsal and not just rotatory, but also axial coronal-based correction as well. So you're sold. So someone says, hey, I wanna do this fusion. And, you know, we always discuss the goals of surgery and I review this with patients all the time. And of course, we're trying to alleviate pain, improve gait patterns and, you know, improve shoe wear as a whole. The important considerations are, you know, joint prep and, you know, fixation of which there's multiple ways to do it. And, you know, whether you go medial, whether you go dorsal, it's often easy, it's often easier to, at least in my hands anyway, easier to access everything from a dorsal approach, especially if you're planning on, you know, putting a plate on, a plate screw construct. Whereas if you're gonna go and use a cup and cone reamer system, if you are, on the other hand, gonna go from a medial-based approach, then it may be easier to actually do flat cuts and correct any deformity that might be there. And again, that's something that you've gotta think about, particularly if the dorsal soft tissues, you know, there's flat, you know, there's scarred in incisions, poor soft tissue quality, risk of wound healing complication, and so on. You know, Dr. Coughlin described the use of the cup and cone reaming system that's now obviously pervaded every Halx MP arthrodesis system that's out there now to really give a way to optimize stability of that arthrodesis surface. And that is something that's, you know, definitely, you know, been a game changer as a whole over the years. But you've gotta be careful with, you know, soft bone. And I can't tell you how many times I've seen that on the verge, you're like just pushing forward with that reamer, and it's about to go a little bit more. And then, of course, the head either almost blows out or it blows out. So being cognizant of that bone quality is really important. And this gives you perhaps the largest surface area for union and is biomechanically superior to other joint prep, you know, constructs once the hardware is placed. And again, that, you know, we're talking in the context of an open approach. The flat, you know, the flat cuts, while ideal, they may lead to inadvertent shortening as a whole. And that's just something you've gotta be a little bit aware of. And especially if you have to reposition it and make more cuts, if you will. A burr of any sort may be helpful for, you know, poor bone stock. Sometimes if the bone is not great, I'll use a ronger just to get things started or even in a curette subsequently to finish cleaning up the remainder of the cartilage from either side of the joint. We talk about positioning and that's particularly important. Use a weight bearing surface, whatever type. I always like to check that the, that, you know, I can barely get the pulp of my finger underneath the great toe. When we are, you know, when we are positioning it before the plate goes on, in fact, because of the notion that as a plate goes on, if you're using that construct, almost invariably, the toe comes up a little bit because of the kind of tension band effect, if you will. But the goal is to help facilitate shoe wear with this positioning as described here, as well as also the rolling motion that accompanies gait. Does the fixation matter? There's been reports on all sorts of fixation types, you know, from K-wires all to staples. I've got staples on there twice in part because there's staple plate constructs out there now. And, you know, cross screws are also a great option. Plates are obviously an option. The reality is that the plate and screw construct has been deemed through an open approach to be the strongest, the most biomechanically sound. And this is a, you know, a cadaveric study that, you know, evaluated the use of different fixation constructs in the setting of a conical reamer use and, you know, found that the plate screw construct was actually stiffer. Here, we've got, you know, cross screws versus unlocked plates in one study. And the stiffest was an unlocked plate and lag screw. And then in a biomechanical sawbone study, really the cross screws were pretty strong and were pretty strong, but the plate screw constructs were actually the stiffest. So you can see the plate screw construct really rears its head as being the strongest, again, through an open approach. But more recent data to try to compare it to minimally invasive approaches without opening up and stripping the soft tissues really looked at, it really found that the screws construct had greater stiffness in this cadaveric study with equal plantar gapping. And so more recent clinical data demonstrates that the fusion rate with the minimally invasive approach is, you know, well over 90% at, you know, just shy of two years of followup. So, you know, that's a great start. The other piece is that this is a retro, you know, systematic review of 109 patients with just shy of 90% fusion rate, which approaches that of the literature between, you know, 88 and, you know, 100%. And 13 cases had complication and that's important to recognize with a 5.5% symptomatic non-union, symptomatic non-union rate of 5.5%. And, you know, I say that it means that the technical and figuring out ways to make sure you're really flushing the joint in its entirety become very important. And so here are a couple of cases of mine, you know, that, you know, demonstrate, hey, like how you can actually correct and how you can correct any sort of deformity and arthritis for that matter. In this case, it was Hallux Valgus deformities and get that thing to heal up. This is, you know, sort of, you know, true arthritis, you know, pattern. And, you know, you've got bone spurs on the top there. You've got, you know, medial site of collapse, more of a various deformity, if you will. And you've got to start somewhere, right? You can kind of do dorsomedial, dorsolateral incisions to access the joint. You've got medial, you can put the, you know, the scope in there. You can do all sorts of, you can use headed screws if you want, or headless screws. And I definitely think that accessing and demonstrating that you're in the joint is key. So you can get this burr, again, this high torque, low speed burr in there to do the joint prep. But what you've got to be very critical of yourself on is making sure that you're getting on all the dorsal plant or medial lateral joint, because this is a curved surface. And you've got to be able to ensure that you're taking away that cartilage. And so putting the scope in there, i.e. in this case, demonstrates how you've gotten the surfaces back to that, you know, subchondral bone plate. And of course, so you've got some, you know, cannulas partially threaded screws to hold the joint together. And this works. However, you know, the advent of, you know, headless screws, you know, headless screws and different as you pitch half headless screws, you know, certainly has helped and partially threaded headless screws also, you know, works well too. But the reality is that you don't always have to scope everything as long as you feel comfortable, especially as you get more experienced with the technique as far as the joint surface and, you know, joint excision as a whole, if you will. But you want to really be careful that you're not taking away too much bone because that can inadvertently lead to shortening, right? That's perhaps the big thing, you know, naturally as we talked about with the flat cut approach on the medial open side of it all, that can be a problem. So this is where you've got to be careful that you're not shortening the toe inadvertently, you know, get your wires in there to stabilize things. And of course you can use this cross screw construct that described, you know, more recently in biomechanical scenarios can do well and do well for these patients. And this is an example of that. Of course, nothing's perfect. And even though the non-unions, we've all had them, whether it be on the open side or minimally invasive side, I've seen that myself. And that was why it was a little bit, you know, a little bit apprehensive going back to the MIS approach. I have, you know, I've definitely, you know, kind of figured out ways for me that work and I'll kind of demonstrate or talk about them in a second, but this is where, you know, was it the lack of bicortical fixation in this case that, you know, it caused it to develop into a non-union? Was the joint prepped inadequately? These are, you know, were the screws not spaced out enough? These are all things that you have to think about. And it's, you know, hard to say what exactly is contributing factor. Humbly, I think that if, especially if it's early in the learning curve of this technique, you've got to know that, hey, like, is there still stuff in the joint that's preventing it, is not debrided enough? Are those surfaces getting opposed, you know, appropriately and, or like, I think certainly do you have enough compression that you've imparted to the joint itself and maximize your stability of the screw construct that you're putting in there? Here's a case I had, you know, semi-recently, halox valgus recurrence, kind of looked like metatarsus adductus initially, but wasn't quite that, if you will. And we, you know, we went ahead and, you know, not only did the MIS fusion bone was very soft, I also did these, you know, kind of oblique osteotomies to help, you know, get the lesser toes over and metatarsal head osteotomies to help, you know, laterally translate them and the whole toe to get that toe straight. This patient's, you know, doing quite well, about six weeks out at this point. So still pretty early, but everything seems to be holding well, including most recent X-rays that were obtained closer to that two month mark, if you will. Here's another case recently that was done where I used a screw staple construct instead, again, put that burr in there, you know, some valgus arthritis with lateral wear of the joint surface, and, you know, using a combination of a staple and a staple and a screw, we were able to, you know, kind of get this fusion, get this fusion going. The patient is doing quite well with this. One thing I will say on both accounts is, I, you know, I, like some of my partners and some of my contributors, I don't, I have not been putting the scope in there, and I do think that the joint prep is critical. So I have been making a small dorsal incision, you know, really almost about two centimeters at most, and probably quite less than that, to be frank, it's probably about, yeah, between 1.5, two centimeters, in order to just get in the joint and pull debris out. So it's very small, it's very limited, very limited soft tissue stripping, but does allow me to evaluate the joint surface quite well to make sure I've debrided it with the burr adequately enough. And if I need to throw in curettes or a small ronger, and it really doesn't add much time, I can do that. And I also feel better about the joint prep as a whole, if sometimes you don't necessarily get a great feel, you know, from a manual feedback or haptic feedback perspective as how the joint preparation is going. So just some pearls of wisdom to wrap up here. You know, this isn't, you know, chiolectomy is an easy introduction to minimally invasive techniques. You gotta be careful with the extent of resection on the phalanx or the metatarsal head, especially, you know, consider taking the bone spur away earlier rather than later, as you saw before on the proximal phalanx side. Flush the joint out with a mini open or arthroscopic technique. That's gonna probably help with the longevity of that chiolectomy before the patient may need to be converted to, you know, an arthrodesis or some other procedure later on, or even a revision chiolectomy. From an MP arthrodesis perspective, I would definitely say that you ought to be mindful of, you know, not over resecting the joint and causing shortening. That's perhaps one of the biggest challenges. You know, don't be afraid to make a small dorsal incision to fine tune that joint debridement. And while cross screws are commonly used and staples can be helpful, you know, staples can be a helpful adjunct for compression. But, you know, use what makes, especially if the bone quality is not great, you really wanna make sure you've got a good stable construct. In some of these recent cases I've actually, that I've done in the last, you know, handful of weeks, I've gone to screws, not because I, I mean, I'm a fan of staples in general, but I definitely think the screws impart stiffness, a stiffness characteristic to the construct, and also rotational control too. And on that note, I wanna thank you for your time. I want to thank my fellow contributors, Dr. Cliff Chang, Dr. Tyler Gonzalez, Dr. Jonathan Kaplan, once again, for their insight and help with these slides. I just wanna thank everyone and the AOFAS for putting this on. Thanks again, and feel free to reach out with any questions. Thank you.

Hallux rigidus

minimally invasive techniques

treatment

chilectomy

arthrodesis

rehabilitation