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07/15/2013 Jerry Cosentino, DPM
Interpositional Arthroplasty (Greg Caringi, DPM)
FromGerald Cosentino Tobblock@podiatrym.com I applaud Dr. Caringi for implementing the interpositional arthroplasty for hallux limitus and rigidus deformities. It is my opinion that joint implant procedures and arthrodesis are poor alternatives for the young or athletic patient. I have been using this technique since 1991 and in the November 1995 Journal of Foot and Ankle Surgery you will find my article on "Tendon Interpositional Arthroplasty".
I originally used a rectangular flap of the Achilles' tendon near the myotendinous junction of the gastrocnemius. But this is quite cumbersome, beginning the procedure with the patient in the prone position then moving to the supine position.
I have also harvested a 3 inch segment of 50% of the width of the extensor hallucis longus tendon, dividing it in three equal strips and created a mesh type implant over the head of the first metatarsal, anchored plantarly. I have had no tendon ruptures to date with this technique.
Another alternative is to use a "fanning" technique, as tendons can be teased to nearly 3 times their original width, depending on their original thickness. This is similar to the "Lynn" technique that uses the plantaris in the repair of the Achilles' tendon.
I prefer to "butterfly or filet" the redundant capsular tissue, dorsally or medially, but when this is not available I have utilized the hallucis longus and brevis tendons, but have also harvested extensor tendon from the lesser digits.
I am sure most surgeons are evaluating the biomechanics of the 1st ray, especially in the sagittal plane. I have used an oblique osteotomy to decompress and plantarflex this distal segment when necessary for 22 years. It is now referred to as the "Weil" osteotomy.
I have not found it necessary to utilize any synthetic grafting materials, but this would seem to be another reasonable alternative.
If I can be of any help in explaining these techniques please do not hesitate to contact me.
Jerry Cosentino, DPM, Tampa, FL, drgcosentino@gmail.com
Other messages in this thread:
07/17/2013 Palmer Branch, DPM
Interpositional Arthroplasty (Greg Caringi, DPM)
RE: Interpositional Arthroplasty (David Secord, DPM) From: Palmer Branch, DPM I also would echo the recommendation of Dr. Secord about the use of any interpositional acellular dermal matrix graft for resurfacing the first metatarsophalangeal head. It precludes the potential problems of donor site defects from harvesting local or remote soft tissues. I have also used a similar technique for lesser metatarsophalangeal joints (e.g. after Freiberg's infarction).
In the article referenced by Dr. Secord, I found a similar (same?) article below from the same group referenced in Foot and Ankle International. This article has nice step-wise images of the technique. A couple of technical points: I do not do the oblique proximal phalanx osteotomy they describe due to concerns of a possible "cock-up" hallux or otherwise destabilizing the joint. I also like to roughen the plantar surface of the metatarsal head with a small rasp to facilitate healing of the graft to the metatarsal. I typically use a heavy PDS suture, but the non- absorbable sutures are also a good choice. Gregory C. Berlet, M.D.; Christopher F. Hyer, D.P.M.; Thomas H. Lee, M.D.; Terrence M. Philbin, D.O.; Jodi F. Hartman, M.S.; Michelle L. Wright, B.S. Interpositional Arthroplasty of the First MTP Joint Using a Regenerative Tissue Matrix for the Treatment of Advanced Hallux Rigidus. FOOT & ANKLE INTERNATIONAL 2008 (A link to the full article can be found using a websearch for "interpositional arrthroplasty" and following the link for the PDF file at www.orthofootankle.com. Additional reference: “Exploring The Potential Of Acellular Dermis Grafts For Wound Healing and Soft Tissue Repair”, Podiatry Today. v. 25, n. 12, December, 2012. (http://www.podiatrytoday.com/exploring-potential- acellular-dermis-grafts-wound-healing-and-soft- tissue-repair). Having used many different acellular dermal matrix products for this and other purposes, the ones that work best in my experience are the hMatrix from Bacterin and the GraftJacket from Wright Medical. Both companies have good technical support as well. Palmer Branch, DPM, Cumming, GA, drcuboid@aol.com
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