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:

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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