Naomi Shields, M.D.Clinical Associate Professor, University of Kansas, School of Medicine-Wichita2778 N. Webb Rd Wichita, KS 67226nshields@aoaortho.com

1. Proper Patient Selection / Education / Expectations a. Set proper expectations for the patient preoperatively

i. 20-40 degree increase from preop ROM and toe is not fused

ii. Plantar pain - may hurt up to 2 months postop as the toe has not moved in a long time

b. Surgeon expectations i. restore normal alignment if not presentii. majority of ROM is achieved in first 3 months

c. High IM angle, Mild hallux valgus needs to be corrected

2. Tissue Handling and Techniquea. Free all soft tissues to increase ROM b. Perform a good exposurec. Gentle handling of the skin will help to avoid

inflammatory response and secondary scarringd. Perform capsular releases laterally/medially/dorsally –

free up plantar platee. Minimize inflammatory responsef. Must visualize crista as a reference point and free

up flexors

3. Proper Bone Resectiona. Remove osteophytes laterally/medially/dorsally and

medial eminenceb. Surgeons are dealing with distorted anatomy. Heads

are flattened and dorsally angulated therefore reference off sesamoid crista

c. Shape the bone after the implant is in placed. Irrigate to rid the joint of debris and perform a good

closure4. Phalangeal side cheilectomy

a. Remove lateral and dorsal osteophytesb. Failure to do so may cause impingementc. Leave plantar cortex intact

5. Postop carea. Loose dressing allows for active toe wiggling – not in

a bunion dressingb. At one week postop visit, out of postop shoe – get them movingc. Tell patient “No cheating while walking! Use proper

Heel to Toe (over your toe). No walking on the side of your foot”

d. Active and Passive motion for plantarflexion and to prevent the dorsal capsule from scarring down which can tether your dorsiflexion as well

e. If they get swollen/stiff: i. formal PT regimen to control inflammation, ii. scar massage iii. heat & ice to warm up and after exerciseiv. start on ibuprofens after one week

Considerations when Resurfacing the Metatarsophalangeal Joint for Hallux Rigidus:

Adjunct Procedures that correlate with the HemiCAP® MTP implant

Summary:

Articular resurfacing of the first metatarsal head has been shown in recent studies to be an effective procedure

for patients looking to reduce pain, improve range of motion and avoid an arthrodesis. As the metatarsal head

is frequently more damaged than the phalangeal side, a metatarsal sided resurfacing can effectively address

the pathology. However, Hallux Rigidus/Limitus is seldom an isolated problem. Osteophyte formation, angular

deformities, dorsal erosion and fused sesamoids are all part of the overall destructive process of the MTP joint in

hallux rigidus. Failure to address these adjunct pathologies may result in a less optimal outcome. The following

foot and ankle surgeons have collaborated to provide this clinical outline of their most frequent considerations

when addressing hallux rigidus in conjunction with a metatarsal head resurfacing.

PN0020.qxd 9/12/07 4:50 PM Page 1

John Fleischli, D.P.M., FACFAS2901 Old Jacksonville Road, Suite C Springfield, IL 62704drjohn@footankleassociates.net

1. Address the Architecturea. Reduce the natural jamming by eliminating the dorsal

1/3 bone on metatarsal and phalanxb. Resect the dorsal 1/3 bone on both sides of the joint

as supported in literature (Valenti/Stone procedure)c. Since you are not losing intrinsic musculature then

does it matter what the metatarsal size is?d. Use a 12mm implant with a dorsal 1/3 cut in smaller

patients and females and taper the head to match theimplant

2. Movement is key in the first 24-48 hours postopa. Patients must bend their toe 100 times a day – Plantar

and dorsiflexion3. Swelling

a. Control swelling intraoperative and immediately postop

b. “Keeping swelling away is easier than getting rid of swelling once it happens”

c. ELEVATE the foot – Above hips to let gravity helpd. Use anti-inflammatories

4. Release the Sesamoids a. Use blunt elevator – McGlamry - if they are fusedb. Release the posterior capsulec. Aim for 70 degrees or greater on the OR table – if not

achievable then the sesamoids are the culprit5. Dealing with Elevatus

a. More often patients are rolling their foot during x-rayb. Not frequent – usually patients are overcompensating

for their toe pain

Tracey Toback, D.P.M., FACFAS3433 Rt 9 WestHighland, NY 12528drtoback@tobackpodiatry.com

1. Preoperative Expectationsa. Use the patient education pamphlet (ask your rep

for a pack) to explain the different options and why resurfacing the met head makes most sense

b. Inform the patient to visit the Arthrosurface website for more information

2. Radiographic evaluationa. Typical patient is Stage III or IVb. X-rays may underestimate the amount of articular

damage seen intraoperativelyc. When planning a std. bunionectomy, if there is a

chance of more advanced erosion considerpre-consenting for HemiCAP® resurfacing

3. Implantation Pearlsa. Use the C-arm to assure guidewire is inline with

sagittal and transverse planesb. Remodel the “lipping” – Use rongeur for medial/lateral

and dorsal osteophytes4. Decompression with the HemiCAP® implant

a. If the 1st metatarsal is long or elevated, then you should decompress the joint

b. Technique for decompression using the implanti. Set screw/taper post at proper height per

technique guideii. Before mapping, turn the screwdriver 90o

(per 1mm) to begin joint decompression by 1-3mm

iii. Decompress the joint no more than 1-3mm to avoid compromising the sesamoid apparatus

c. Remodel the met head with the implant in situ and remove any remaining bone distally

d. If ROM is less than 70°, remove more bone from met head and phalanx and double check the sesamoids

e. Excise redundant capsule

2

Figure 2: HemiCAP® resurfacing with decompressionFigure 1: MTPJ with no joint space

PN0020.qxd 9/12/07 4:50 PM Page 2

Carl T. Hasselman, M.D.Clinical Instructor, University of PittsburghDepartment of Orthopedics200 Delafield Rd. Suite 1040Pittsburgh, PA 15215hasselmanct@upmc.edu

1. Establish realistic expectations with your patient a. I explain to them that HemiCAP® surgery is like a total

knee replacement (or any other joint surgery) in terms of postop recovery

i. This means that all surgery has a somewhat painful recovery initially

ii. It will hurt initially but by 6 weeks the pain is goneiii. You have to move your toe – like it or notiv. If you “push through” the pain of early ROM you will

have positive resultsb. If patients understand this preop they are more likely to

work with you on rehabilitation2. Intraoperative

a. Deformityi. Any deformity will need to be corrected intraopera-

tively or after performing a HemiCAP® resurfacingb. Aggressive Cheilectomy

i. Remove all non-essential bone/osteophytes1. Cut away everything around the implant dorsally,

medial and laterally2. Cut straight back so no bone is more prominent

than the implant3. Turn the metatarsal into a bony cylinder that is

distally capped with the HemiCAP® implantc. Ligaments

i. Must take down all ligaments – medial, lateral, dorsally

ii. Aggressive capsular releases are safe to do – I have a series of 80 patients with no postop AVN

1. deglove entire met head of attachments2. be careful not to cut met head bone where

ligaments attach3. use a freer or blunt elevator for the plantar

surface

d. Proximal Phalanxi. If 50% or more of Phalangeal cartilage is remaining

then do an aggressive cheilectomy (removing dorsal 1/2 will keep the joint stable w/ no subluxation)

ii. If 50% or less of Phalangeal cartilage remains intact than consider adding an interpositional arthroplasty using the redundant capsule – I use bioabsorbable suture anchors to hold the interpositional graft but you can use drilled tunnels as well

e. Sesamoidsi. Soft tissue releases

1. ROM: Achieve 90° of easy dorsiflexion with little pressure or you must release more soft tissues

2. If patient has decreased ROM preop, then you will know you will need to release more soft tissues intraop

3. Postoperativea. Dressing and daily anti-inflammatory

i. Very thin dressing on toe – one layer of gauzeii. Walk immediately (barefoot) in house on Day 1 –

postop shoe for comfort onlyiii. Active and passive motion starting Day 1iv. Anti-inflammatory daily for first 10 days to reduce

swellingb. Rehabilitation and Motion

i. Review and re-explain expectations to patient1. Patient cannot “hurt” the implant – it will not

loosen or fall out – so they must “push” past thepostop pain for increased ROM

2. Postop pain is “good” and normal3. No pain – No gain!

ii. If there is not significant improvement at 2-3 weeks, continue patient on anti-inflammatory for another 3 weeks and begin formal PT

iii. If there is still pain and stiffness at 6 to 8 weeks: patient will get a intraarticular cortisone shot to help get them “over the edge”

3

Figure 3: Optimal bony resection

Figure 4: Bone cuts around finalimplant–medial,dorsaland lateral

PN0020.qxd 9/12/07 4:50 PM Page 3

PN 0020-0201 REV A

Thomas P. SanGiovanni, M.D.Voluntary Assistant Professor, University of Miami School of MedicineDepartment of Orthopaedics and RehabilitationUHZ Sports Medicine Institute1150 Campo Sano Avenue, Suite 200Coral Gables, FL 33146tsangiovanni@uhzsmi.com

1. Preoperativea. Set reasonable patient expectations – pain relief and

improvement of 20° - 40° ROMb. Obtain weight-bearing A/P, Lateral and Oblique x-raysc. Assess for concomitant angular deformity (i.e. Hallux

Valgus) as well as Hallux Rigidus on x-rays2. Angular Deformity

a. Place the HemiCAP® implant prior to performing any angular corrections and bony corrections

b. Hallux Valgus – with Akin osteotomy on prox phalanxc. Hallus Varus with 1st MTP arthrosis – combine HemiCAP®

with EHB or split EHL tendon transfer3. Achieving more ROM

a. Assess intraop motion – aim for 70°- 80° Dorsiflexionb. Assume you may lose up to 40° of that motion postopc. For deformed heads and contracted joints, consider using

conical fusion reamers on met head to restore a spherical head and decompress joint by 1-2mm

d. If you can only achieve 60° or less intraoperatively then consider:i. Use Moberg osteotomy for decompressing dorsal aspect

of joint (contraindicated when less than 10° plantarflexion)1. Moberg osteotomy is extrarticular and bone

preserving for future surgery or fusion2. 3mm dorsal closing wedge made 2-3mm distal to

phalangeal articular cartilage3. Fix with oblique headless compression screw

ii. Can easily combine Akin and Moberg osteotomies with aHemiCAP® implant

e. If patient has loss of plantarflexion in addition to dorsiflexion:i. Decompress the implant by turning in the screw by half

turn (2mm) before mappingii. Combine this with an interpositional graft on proximal

phalanx using capsulef. Be sure to remove all extra bone on dorsal aspects of the

MTP joint

Brian Carpenter, D.P.M., FACFASNorth Central Texas Orthopaedics1713 S FM 51 Suite 103Decatur, TX 76234bcarpenter@nctosm.com

1. Preoperative assessmenta. Ideal Patient has: pain, loss of ROM, is in Stage 2-3 and

early Stage 4 – if patient is low activity elderly and looking for pain relief rather than motion

b. Physical Exam and X-rays are critical to determine pathology that caused the Rigidus in the first place

2. The following pathologies MUST be addressed during surgerya. Elevatus

i. Plantar Flexory Osteotomy to bring met head down to ground - easier and faster healing

ii. Take a small wedge out of plantar cortex and fix it with a screw, plate, or staple

b. Intermetatarsal angle that is too widei. Base procedure to correct intermetatarsal angle

c. Long metatarsal with bad metatarsal parabolai. Decompression

1. with base procedure to shorten first ray and soft tissue

2. Normally decompress 2-3mm. Can decompress 3-4mm as long as you do not get into the sesamoid apparatus

3. If sesamoids are arthritic, take a rongeur and debride the arthritic tips of the sesamoids wherethey might impinge distally

4. For more severe sesamoid arthritis; consider taking sesamoids out.

ii. Implant selection1. Skip the mapping on deteriorated met head: Use

the most curved (dorsal to plantar) implant to create a bigger arc and allow for more ROM in sagittal plane (4.5 x 2.5)

d. Hypermobility of first Tarso-Metatarsal joint i. Lapidus type arthrodesis to get rid of first ray elevatus

with excessive 1st Tarso-metatarsal joint ROM whichcauses jamming of the 1st MPJ

ii. Can correct angular deformity in transverse or sagittal plane to get a rectus first ray

3. Postoperativea. Ambulate normally with no lateral column walking within

the first 48-72 hours and back into normal shoegear when sutures are removed.

b. If patient has a lapidus fusion or base osteotomy, then keep patient non-weightbearing until osteotomy heals (4 weeks for Base and 8 weeks for lapidus). Early range of motion is started immediately.

c. If not walking in normal ambulatory pattern in surgical shoeat 2 -3 week mark, then active PT for gait training

4

PN0020.qxd 9/12/07 4:50 PM Page 4