Arthroplasty of the 1st MTP Joint Using Acellular Allograft – Extended (Feat. Dr. Johnson)

Arthroplasty of the 1st MTP Joint Using Acellular Allograft – Extended (Feat. Dr. Johnson)

Interpositional Arthroplasty of the 1st Metatarsophalangeal (MTP) Joint Using Acellular Dermal Allograft for Advanced Hallux Rigidus
Authors: Johnson JE1, Yee A2
Published: April 1, 2019

AUTHOR INFORMATION
1 Foot and Ankle Service, Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
2 Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, Missouri

Extended Edition (190205.190308)

ABSTRACT
Hallux rigidus presents with painful, limited motion and localized arthritis at the 1st metatarsophalangeal (MTP) joint. While early-stage hallux rigidus can be managed with a dorsal cheilectomy, late-stage hallux rigidus is managed with either 1st MTP arthroplasty or arthrodesis. For patients requesting joint-preserving procedures in late hallux rigidus, several implant joint arthroplasty options exist which utilize metal, plastic, silicone or hydrogel replacement implants or biologic materials using autogenous joint capsular tissue1,2 or human acellular dermal allograft tissue.3,4 While non-biologic implant arthroplasty materials can function to resurface the 1st MTP joint, several problems can manifest in malposition, implant failure, arthrofibrosis or localized joint synovitis, and secondary osteolysis.5 Additionally, the salvage options for the joint are difficult once these implants are removed. The benefits of an interposition arthroplasty using acellular dermal allograft are that the MTP joint surface and sesamoid-metatarsal articulation can be resurfaced. Furthermore, this technique preserves the toe dorsiflexion strength of the flexor hallucis brevis attachment to the proximal phalanx, as opposed to the autogenous dorsal capsular interposition arthroplasty that transposes this tendon. In this case, a 63-year-old patient, who is 17 years following a right dorsal cheilectomy for hallux rigidus, presents with new pain and symptoms in the 1st MTP and having failed two years of conservative management. Radiographs indicate osteoarthritis with joint space narrowing, subchondral sclerosis and without significant deformity. An interposition arthroplasty using acellular dermal allograft was chosen to provide a pain relieving option that retained some MTP joint range of motion and required less immobilization than compared to fusion. This video describes this technique for managing late-stage hallux rigidus.

KEYWORDS
Hallux rigidus, 1st metatarsophalangeal joint, interposition arthroplasty, acellular dermal allograft, cheilectomy

TABLE OF CONTENTS (Extended)
00:00 Introduction
00:10 Preoperative Imaging
00:20 Orientation
00:30 Pre-operative Examination and Range-of-motion of the Hallux
00:57 Incision
01:28 Exposure of the Medial MTP Joint Capsule
02:18 Identifying and Protecting the Medial Dorsal Cutaneous Nerve
03:55 Medial Capsulotomy of the MTP Joint
05:03 Exposure of the Dorsal Aspect of the MTP Joint
06:04 Exposure of the Plantar Aspect of the MTP Joint
06:39 Placement of the Rectors and Further Exposure of Dorsal Aspect of the MTP Joint
07:33 Future Exposure of Plantar Aspect of the MTP Joint
08:01 Dorsal Cheilectomy of the Metatarsal Head
08:55 Dorsal Cheilectomy of the Proximal Phalanx Base
10:35 Checking the Gap and Motion of the MTP Joint
10:54 Additional Dorsal Cheilectomy of the Proximal Phalanx Base
11:54 Additional Dorsal Cheilectomy of the Metatarsal Head
12:12 Smoothing the Bony Surface of the Metatarsal Head and Proximal Phalanx Base
13:16 Irrigation of the MTP Joint
13:36 Additional Smoothing of the Metatarsal Head
14:00 Checking the Gap and Motion of the MTP Joint
14:30 Further Release of the Metatarsal Head from the Lateral Capsule for Anchoring
15:30 Checking the Gap and Motion of the MTP Joint
16:02 Additional Dorsal Cheilectomy of the Metatarsal Head
16:16 Checking the Gap and Motion of the MTP Joint
16:39 Further Release of the Proximal Phalanx Base from the Lateral Capsule
17:12 Intraoperative Imaging
17:22 Preparation of the Acellular Dermal Allograft
18:16 Placing the Acellular Dermal Allograft Sutures
18:47 Drilling Two Anchor Points on the Metatarsal Neck
19:40 Passing the Acellular Dermal Allograft Sutures through the Metatarsal Neck
20:50 Inserting the Acellular Dermal Allograft Over the Metatarsal Head
22:10 Checking the Gap and Motion of the MTP Joint
22:36 Suturing the Acellular Dermal Allograft
24:37 Checking the Gap and Motion of the MTP Joint
24:41 Trimming the Acellular Dermal Allograft
25:14 Suturing the Lateral Capsule to the Acellular Dermal Allograft
27:01 Closing the Acellular Dermal Allograft Over the Metatarsal Head
27:30 Suturing the Medial Capsule to the Acellular Dermal Allograft
28:50 Checking the Gap and Motion of the MTP Joint
29:00 Closure of the Medial MTP Joint Capsule
32:55 Checking the Motion of the MTP Joint
33:13 Concluding Intraoperative Imaging
33:49 Dressing and Summary of the Post-operative Management
34:56 Postoperative Imaging
35:52 Credits