Name: 1st MTP Hallux Metatarsal Joint Fusion Utilizing the MTP Plate
Uploaded: 2008-08-13T00:00:00Z
Channel: Arthrex

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DVD-1110 | A | 1st MTP Hallux Metatarsal Joint Fusion Utilizing the MTP Plate

Troy S. Watson

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A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

Eine Videoaufnahme einer Operationsanleitung an einem lebenden Patienten oder Patientin in einem Operationssaal oder eine Demonstration an einem Humanpräparat.

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1st MTP Hallux Metatarsal Joint Fusion Utilizing the MTP Plate

Today we'll be demonstrating the helix Metatarsophalangeal Joint Fusion utilizing an MTP fusion plate and compression screw technique. We're going to be demonstrating today multiple procedures, but the first will be a helix metatarsophalangeal joint fusion for as you can see what she has helix varus. This was iatrogenic helix varus following a bunion procedure she had done years ago. My metatarsophalangeal joint fusions I typically do through a medial incision. She had a previous incision right along here, but that would really put us pretty well. Dorsal. I'm going to use my standard medial incision. It's been a long time since her previous surgery. So we'll go ahead and use that incision and and that's it. If we need bone graft, we can get bone graft from other sources. So we'll dissect down. So once you get your soft tissues retracted, your nerves out of the way, then it's a straight midline capsular incision. So we'll go ahead and make that midline capsular incision and elevate up the soft tissues. And we can get a pretty good look at the joint. She's got at least 50% of her metatarsal head there and a good portion of the proximal phalanx, if not all of it. That's bone on bone. Now, typically on these long standing deformities, ReDeuce in the joint can be difficult. And and some shortening should be expected. So this is the guidewire for our for our reamers. I try and get this centrally down the shaft, and that looks to be pretty good. And we'll just I'm just going to resect a little. [00:02:03] Bit of this bone here. And that's not always necessary. Sometimes I, I do resect bone there, sometimes not. And then we'll go ahead and get our reamer and we're going to go ahead and ream with the with the standard reamers for the Arthrex set, I usually start a little larger. We'll kind of we'll start here. This is an 18. And I think for a woman, that's probably fine. Now, if we needed to go up we certainly could go up in size, but these are very aggressive reamers. So you'll see, I'll just kind of start with light pressure. You just want something that's concentric to the head. So what I'm what I'm trying to do is just get this right size reamer for this head. Obviously, everybody has different shapes and sizes. So this to me the 20 is a better fit for her. So we'll do the 20 and we'll just get all the cartilage off of there. You just want to have a good cancellous surface. Now we have cancellous bone all around. So this is the circular reamer Are right here. And we'll use this to just. As you can see, there's a little rim of bone after the reaming is completed, so this should smooth that off of there. And you can see it just makes a nice little. Okay. And get rid of all the little loose fragments around here. And that gave us a nice metatarsal head. Now that we can go ahead and fuze with the proximal phalanx. So, so that's that side of the joint. Done. Oftentimes I'll take this guidewire. And as with any fusion joint preparation certainly is improved by creating multiple drill holes. Now we'll turn to this side of the joint okay. And now we'll try and find the central portion of the proximal phalanx. There we go I like that. So now we're reaming the proximal phalanx side with a 20 millimeter reamer. We've got to get through the cartilage okay. So now we'll do the same thing. We'll do the same joint preparation that we did over here. Multiple drill holes. And you can see we got nice cancellous bone. So you can see. Those two surfaces now fit together pretty nicely. So the next part we're satisfied with our joint preparation. If you feel like you'd like to bone graft you can get bone graft from numerous sources. Sometimes the medial eminence resection is is is good to to get the plate to lay on there you usually have to plane the dorsal aspect of the metatarsal. So we'll do that right now and then and then you have a little bit of cancellous bone that you can that you can drop down into the joint. [00:04:52] Which is always a nice little thing. So we'll just kind of. So this is a helix metatarsophalangeal joint fusion plate. The unique features of this place are the locking holes which there are three of. It is designed with five degrees of valgus and eight degrees of dorsiflexion built into the plate, which is a little less than than some of the other plates on the market, and should put the toe in a fairly anatomic position. Now, sometimes to get your plate slid up where it needs to go, a little bit more soft tissue release might be needed. And in this case I think that is true. So we'll need a 15 blade. So and all you have to do is just elevate the soft tissue envelope over the dorsum of the toe. And that does give us pretty good position. And you can see that that that plate is about right where I had the toe. Now I still will check my alignment on the AP view. To make sure that I dialed in the right amount of valgus. And then I'll use a simulated weight bearing view or a simulated weight bearing device to check my sagittal alignment. Now I just feel in the far cortex and put the pin through. So through. So now we'll take the the plate back. And with it in this position it seems to be contoured pretty good to that eight eight degrees of dorsiflexion. Now if we need to how do I check the sagittal alignment. Well I like to use a simulated weight bearing surface. So I'll put the foot on this. And with the foot firmly pressed against this device you should have a little bit of give here. And the toe should come off of this surface. What we want to see is that little bit of toe separation okay. If, on the other hand, you try and raise the toe up and and it will not move off the surface, then you have too much plantar flexion dialed in to this. So so from a dorsiflexion plantarflexion standpoint I think she's where we would like to have her. But I'm looking at the toe from this position and I don't I think that we have too much varus. So we'll check that on an AP. So bring in your x ray so you can see we got a little bit of still some varus there. So I'm going to pull that pin back. Push her over a little bit more and hopefully maintain our sagittal plane alignment. I really like to take the time to get this right, so I like that better. On occasion, if I don't get the best compressive bite, then we will go to a. We will go to a two screw compression technique with a dorsal plate. So we have a cross pin fixation. And I think your options at this point are to put a couple of screws or a couple of screws and, and a plate 2.0mm drill. So these are 3.0mm partially threaded screws with a head on them. And this is what I use for my compression. And then I really buttress the repair with the plate. So I'm just going to countersink this hole a little bit. I'll usually try to really hold my toe in position so that I create no stresses through the joint as I secure it. Now we can go ahead and remove these. Usually they come right out by hand. And and that really is it. Now in in a patient with really solid bone. It may be a little younger patient that's getting a fusion. At this point I think you'd be fine to stop. The plate is good in the little older patient or somebody that maybe you want to walk on the foot a little quicker, at least with heel weight bearing. So I like the plate, which really affords me to allow my patients to get up on it a little sooner. We'll essentially get our plate right about there, so we'll start with one distal screw. Let's have the drill for a quick fix. So this is a quick fix screw. It's made to go down and break off. So we're drilling now the the oblong hole. And when we drill this we start at the distal margin of the oblong hole and drill towards the proximal aspect. And so as this as this screw tightens down, we should see some added compression through the joint. One other technique that I will state here is as you put these quick fix screws in, drive them into about that point and then use the screwdriver to tighten it down. I think we have found that, that the that the bite by doing so is much greater. And there's our plate. We should be able to get those other screws through pretty easily. Okay. And this is the jacket. It screws into the. You'll see there are a total currently of three of these locking holes. So it just screws in said device. And then you can measure off of this when you get up to the far cortex. So there's a little laser line on there. So right now we're at about a 14. But I would say give me a 16 and just screw this in and then we'll take the sleeve back there. Now, this plate has two locking holes on the proximal side of the plate and one on the distal side of the plate. And we'll go ahead and place screws in these various locking holes using our locking sleeve. We'll drill measure and then place each of these screws. So this is our quick fix screw here. It essentially feeds into a normal wire Colette. And it just zips right in there. It has a thin neck that is made to break away at a certain torque. This is the hardest screw on this plate, I think, to put in. So once we get it to right there, we're still a few millimeters off the plate. Now I'm going to hand tighten it and it should bottom out and snap off. And that's it. So that is the that really is the technique to put those quick fix screws into the into the plate. Here's our A plate contour to the dorsum of the MTP joint. You can see here's our MTP joint which was there. And it is solidly compressed. The joint surfaces are compressed and it looks good. Our fixation screws, compression screws, plate with locking and quick fix screws. And that's really the construct. From here we'll go ahead and close the capsule over the plate and close the skin with nylon. And you're. Done. For information on the Arthrex Surgical Skills Training program, contact Arthrex or visit the Arthrex website at arthrex.com.

1st MTP Hallux Metatarsal Joint Fusion Utilizing the MTP Plate

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