Revisional Medial Column Arthrodesis With Utilization of 3D Printing and Orthoplastic Techniques



Revisional Medial Column Arthrodesis With Utilization of 3D Printing and Orthoplastic Techniques


Lance J. Johnson, Coleman O. Clougherty, Peter D. Highlander


Introduction


The medial column in the sagittal plane is composed of the first tarsometatarsal joint, the naviculocuneiform joint, and the talonavicular joint.1 Medial column arthrodesis can be used to address a myriad of pathologies including primary and posttraumatic midfoot arthritis, flatfoot deformity with a midfoot apex, idiopathic cavus foot or residual clubfoot deformity, acute fracture-dislocation of the midfoot, Mueller-Weiss disease/avascular necrosis of the navicular, and Charcot neuroarthropathy.210

For propulsion, the medial column needs to be a rigid level, connecting the hindfoot to the forefoot and allowing motion to be sufficiently transferred from the proximal hindfoot to the distal forefoot during gait.5,11 Meary’s angle must be maintained for normal, pain-free propulsion. Alteration of Meary’s angle and sag of the midfoot in the sagittal plane results in inability of the medial column to act as a lever and results in abnormal propulsion during gait. In sensate patients this results in pain, and in neuropathic patients this can result in deformity, Charcot neuroarthropathy, and subsequent wound formation.1,6,12 In the transverse plane, severe abduction of the midfoot and medial column is associated with flatfoot deformity and posterior tibial tendon dysfunction.13,14

Equinus or a tight gastrocnemius-soleus complex has been described in association with several different pathologies including plantar fasciitis, Achilles tendinitis, Charcot neuroarthropathy, posterior tibial tendon dysfunction, and medial column/midfoot arthritis.1522 A contracted Achilles tendon results in early heel off. This leads to increased plantar pressure forces through the midfoot and can result in a pathologic midfoot break (plantarflexion and abduction force). In sensate patients, this can lead to pathology at the medial column in a valgus foot type and lateral column pain and overload in a cavus foot type. In neuropathic patients this can be the driving force behind midfoot Charcot neuroarthropathy and eventual development of a rocker bottom foot type.1618 Several authors have described addressing equinus in conjunction with primary and revision medial column/midfoot procedures.2,23,24 Anselmo et al described an isolated gastrocnemius recession as a primary treatment for midfoot arthritis.25

Clinical outcomes and arthrodesis rates for primary medial column arthrodesis have been favorable. In recent literature, arthrodesis rates range from 92% to 100%.2,23,26 Throughout the literature, there is agreement that reduction of any malalignment or deformity and maintenance of the corrected position is one of the most important predictors of a satisfactory outcome.5,27,28

Results as Treatment for Arthritis


Nemec et al described midfoot arthrodesis for treatment of primary osteoarthritis. They noted a 92% union rate out of 104 midfoot arthrodesis procedures. They also noted a greater than 90% patient satisfaction rate. They had 4 major complications: 1 complex regional pain syndrome and 3 deep infections. They also noted 26 patients with painful hardware that required removal.2

Gougoulias et al had a cohort of 30 patients with midfoot arthritis. Their patient population consisted of patients with and without deformity. They also had patients with posttraumatic as well as primary arthritis in their study. They reported a 93% union rate and a 90% satisfaction rate. They reported a 17% complication rate including malunion/nonunion, neuropraxia of superficial peroneal nerve, adverse reaction to metal plate, and Achilles tendon rupture. Two nonions required revision; 1 patient required an additional scarf and Akin bunionectomy for residual deformity and the other patient required additional naviculocuneiform arthrodesis. They also had a 6.6% hardware removal rate.23 Horton et al retrospectively reviewed 9 patients who underwent midfoot arthrodesis for posttraumatic or primary arthritis. Three of the patients underwent in situ arthrodesis while the other 6 had concomitant deformity correction. Mean follow-up was 27 months. They noted fusion in all patients by 12 weeks and no patients had malunion or recurrence of deformity. They noted 1 patient with screw breakage and 1 patient with screw loosening, both of which went on to fusion. They noted no other complications.26

Johnson et al treated 15 patients with in situ fusion using a dowel technique due to posttraumatic arthritis; 13 were available for the retrospective review. Their mean follow-up was 37 months. They noted 4 total complications: 1 case of complex regional pain syndrome and 3 patients with nonunion; 1 nonunion was asymptomatic.29 Sangeorzan et al fused a total of 49 midfoot joints in 16 patients with posttraumatic degenerative joint disease of the midfoot. Twelve of the 16 patients had forefoot abduction/flatfoot deformity in addition to midfoot arthritis. Four total joints in 3 patients had symptomatic and radiographic nonunions. One of these patients required revision arthrodesis. They correlated that quicker time to treatment and adequate reduction of deformity were correlated with better outcomes.27

Komenda et al treated and retrospectively reviewed 32 patients who underwent midfoot arthrodesis for posttraumatic arthritis. Mean follow-up was 50 months. Reported complications included 3 patients with neuritis, 2 patients with metatarsalgia, 2 patients with malunion, 1 patient with wound slough, 1 patient with an asymptomatic nonunion, 1 patient with reflex sympathetic dystrophy, and 1 patient with a superficial infection.30 Mann and colleagues reported on the results of 41 feet in 40 patients with posttraumatic, primary, and inflammatory arthritis of the midfoot. Thirty-seven of the 40 patients were satisfied with their outcome. Union was achieved in 176 of the 179 joints. Only 1 of the 3 nonunions required revision surgery. There were also 2 patients with skin slough, 1 of which required operative debridement. Other complications included prominent metatarsal heads in 5 patients, stress fracture of the second metatarsal in 3 patients, and incisional neuroma formation in 3 patients.31

Filippi et al retrospectively reviewed 72 patients who underwent midfoot arthrodesis with hybrid plating fixation. Reported pathologies included primary osteoarthritis, posttraumatic osteoarthritis, midfoot instability, nonunion from a previous surgery, Paget disease, and metatarsus adductus. Five nonunions were reported, 1 of which was a septic nonunion and required hardware removal and debridement. A total of 12 complications were reported, including neuropraxia, wound dehiscence, tendon adhesion, painful hardware, and broken hardware.32

Results as Treatment for Lisfranc Fracture-Dislocation


Mulier et al treated 28 patients and retrospectively reviewed their cases. All patients had severe acute Lisfranc dislocations. Twelve of these patients underwent midfoot arthrodesis. Average follow-up was 30.1 months. All 12 patients in the arthrodesis group had proper anatomic reduction of the fracture-dislocation. Two of the patients in the arthrodesis group had a nonunion and required revision arthrodesis. Three additional patients noted persistent pain and stiffness postoperatively. No other major complications were noted in the arthrodesis group.33

Ly and Coetzee compared open reduction and internal fixation with primary arthrodesis in the treatment of ligamentous Lisfranc dislocations. They prospectively reported on 41 patients. Average follow-up was 42.5 months. Twenty-one patients were in the arthrodesis group. They achieved anatomic reduction in 20 of the 21 patients in the arthrodesis group. The arthrodesis group estimated their level of activity compared to preoperative levels was 92%. In the arthrodesis group, 1 patient had a delayed union which was treated with bone stimulator, 3 required hardware removal, and 1 patient had nonunion which required revisional arthrodesis. The revision nonunion would go on to arthrodesis at 8 weeks post revision surgery.8

Henning et al prospectively assessed 40 patients with acute tarsometatarsal fractures or tarsometatarsal fracture-dislocations. They assessed 2 groups: open reduction and internal fixation compared to primary arthrodesis. There were 18 patients in the primary arthrodesis group with a follow-up of 24 months. Seventeen of the 18 arthrodesis patients went on to fusion and had appropriate anatomic reduction of fracture-dislocation. One patient had a delayed union that healed at 6 months. Another patient had a nonunion that was treated nonoperatively. Three patients required a repeat procedure, all for hardware removal. At final follow-up, 17 of the 18 patients were able to ambulate in normal shoe gear.9

Boffeli et al retrospectively reviewed 35 patients who underwent combined medial column arthrodesis and open reduction internal fixation of the central column for acute Lisfranc fracture and fracture-dislocations. Thirty four of the 35 medial column arthrodesis went on to union. The 1 nonunion required bone stimulator and revision arthrodesis for treatment. Six patients required hardware removal. Three patients developed neuritic symptoms.34

Results as Treatment for pes Planovalgus Deformity


Chi et al retrospectively assessed 60 patients who underwent medial column stabilization, lateral column lengthening, or both. All patients also had flexor digitorum longus tendon transfer and Achilles tendon lengthening or gastrocnemius recession. All patients had their final follow-up between 1 and 4 years after their surgical procedure. Eight feet in 12 patients were in the lateral column lengthening group. The lateral column lengthening group had 2 nonunion revisions, 1 revision procedure for overcorrection, and 4 patients that required hardware removal. Four patients (5 feet) underwent medial column fusion. Forty-eight feet in 40 patients underwent combined medial and lateral column procedures. Eight of these patients required revision surgery for nonunions, 2 patients experienced undercorrection and 2 experienced overcorrection, and 2 patients had persistent nerve palsies. The complications for the medial column arthrodesis group included: 1 patient with reflex sympathetic dystrophy and 1 patient with mild pain due to undercorrection of deformity. They noted over 80% of patients were pain free or had a noted decrease in their pain. In their study, the lateral Meary’s angle improved by 16° in the patients in the lateral column lengthening group, 20° in the patients in the medial column stabilization group, and 24° in the patients in the combined medial and lateral procedures group. They noted the anterior-
posterior talonavicular coverage angle improved by 14° in the patients in the lateral column lengthening group, 10° in the patients in the medial column stabilization group, and 14° in the patients in the combined medial and lateral procedures group.35

Greisberg and colleagues reviewed a retrospective cohort of 19 patients who underwent medial column arthrodesis for treatment of painful symptomatic flatfoot deformity. Three patients had arthrodesis of the first tarsometatarsal joint for deformity correction, 3 had naviculocuneiform arthrodesis, and 13 had both naviculocuneiform and first tarsometatarsal joints arthrodeses. They noted radiographic improvement in Meary’s angle, calcaneal inclination angle, and talonavicular uncoverage. They did not report or comment on any complications that occurred.36

Fraser et al reported on a cohort of 22 adolescent patients (38 feet) that underwent naviculocuneiform arthrodesis for correction of pediatric flatfoot. Their average age was 13 years and the mean follow-up was 12 years. They reported an 84% satisfactory outcome. They had a 21% nonunion rate, but of note they did not use any internal fixation in their cohort.37

Gerrity and colleagues performed medial column arthrodesis for painful flatfoot deformity with naviculocuneiform sag on 11 feet in 10 patients. Their patients had an average of 9.9-month follow-up and they noted 1 nonunion in their cohort. They noted radiographic improvement in Meary’s angle, calcaneal inclination, and talonavicular coverage. They also had 5 patients that underwent concomitant naviculocuneiform and first tarsometatarsal joint fusion.38

Results in Avascular Necrosis of the Navicular/Mueller-Weiss Disease


Avascular necrosis of the navicular and Mueller-Weiss disease can result in fragmentation and flattening of the navicular. This in turn results in loss of medial longitudinal arch height, abduction of the forefoot, as well as shortening of the first ray, thus altering normal biomechanics. In later stages of Mueller-Weiss, there can also be a resultant paradoxical varus malalignment of the calcaneus.3941 These cases are often challenging due to loss of bone and need for multiple fusions across the medial column and sometimes arthrodesis within the hindfoot as well. There is no current treatment of choice for Mueller-Weiss disease or avascular necrosis of the navicular.

Surgical treatments described include joint sparing osteotomies, talonavicular arthrodesis, naviculocuneiform arthrodesis, combined medial column arthrodesis, triple arthrodesis, pantalar arthrodesis, bone grafting, and vascularized bone flaps.4251 All of these were small retrospective reviews and case series, the largest being a review of 30 patients by Cao et al. They all noted improvement in patient satisfaction scores (usually American Orthopaedic Foot & Ankle Society scores) and noted clinical and radiographic union between 8 and 21 weeks postoperatively with the exception of 1 patient in Fornaciari et al’s review of 10 patients in which 1 patient had nonunion and hardware failure that required revision.47 Cao and colleagues in their review of 30 patients also noted that 16 patients required subsequent hardware removal due to painful prominent hardware, but reported no other complications.43

Indications


Indications for revision of medial column arthrodesis include symptomatic nonunion, malunion, overcorrection, undercorrection, osseous deficit due to osteomyelitis, and avascular necrosis.

Contraindications


Contraindications include systemic issues that would prevent a patient from undergoing general anesthesia, nonambulatory status, active acute osteomyelitis, and peripheral vascular disease to the operative lower extremity.

Preoperative Considerations


Vascular Assessment


The authors recommend that any patients undergoing revision surgery for medial column arthrodesis be screened for peripheral vascular disease and injury to the local vasculature. Depending on original incision placement and history of trauma to the medial column, the dorsalis pedis and medial plantar artery should be assessed for patency with a handheld Doppler or with computed tomography (CT) angiography. This is especially important if there is a concomitant soft tissue deficit that needs to be addressed. Patients with diabetes, other comorbidities, or concern for peripheral vascular disease should undergo ankle brachial indices for screening.52

If a free fibula flap is being considered for the revision, then a CT angiogram should be obtained of the donor lower extremity. This is to ensure patency of the peroneal artery as well as to rule out peroneal magnus, an anomaly in which the peroneal artery is the dominant blood supply to the lower limb and the anterior tibial and posterior tibial arteries are smaller than normal. Harvest of the peroneal artery in this instance can result in ischemia to the lower extremity and places the lower extremity at risk. Peroneal magnus can be seen in up to 5% of the population.53

Medical Optimization


All high-risk patients undergoing revision surgery should receive medical clearance and cardiac clearance when indicated prior to undergoing anesthesia. Diabetic patients and multimorbid patients are at increased risk as they often have cardiac pathology, renal insufficiency, and poor glucose control. Every attempt should be made to medically optimize these patients prior to surgery. These patients should also be set up with proper referrals prior to undergoing surgical revision and reconstruction.

Discussion should be had with these high-risk patients whether they are candidates for surgical reconstruction and the risks involved with a revision procedure. An unbraceable/nonfunctional lower extremity, severe deformity, open ulceration, or impending ulceration would all be considerations to proceed with surgical reconstruction in an attempt to save the leg.

Immunocompromised patients and patients with rheumatologic conditions also require special preoperative considerations. Endocrinology, cardiology, nephrology, and rheumatology referrals should all be considered when necessary.

Infectious Workup



Nonunion and Endocrine Workup


In addition to ruling out infection, in cases of nonunion, systemic conditions that inhibit bone healing or arthrodesis should be assessed in cases of revision. Hyperparathyroidism, hypothyroidism, and vitamin D deficiency should all be ruled out. Laboratory workup should include parathyroid hormone, thyroid stimulating hormone, and vitamin D levels. Any abnormality should prompt referral to primary care or endocrinology for treatment prior to attempted revision of nonunion.54

Radiographic and Clinical Deformity Correction


One of the most important determinants of success in primary or revision medial column surgery is adequate reduction and maintenance of reduction of any deformity of the medial column in the sagittal plane. Restoration of Meary’s angle is necessary for proper biomechanical function. Proper assessment of all imaging both preoperatively and postoperatively is crucial for optimal outcomes in revision cases; any deformity present along the medial column should be addressed. The authors have used structural wedge osteotomies, bone grafts, 3D printed metallic implants, and distraction osteogenesis to correct malunion. In addition, equinus should be assessed in all revision cases as it can be a driving factor of midfoot pain and dysfunction.15,24 If present, then either a gastrocnemius recession or Achilles tendon lengthening should be performed depending on surgeon preference and Silfverskiold exam.

Management of Osseous Deficits


In cases where avascular necrosis or infection is present, osseous deficits may be present after debridement of nonviable bone. The authors’ preferred management of osseous defects depends on the size of the deficit. The authors’ approach to osseous defects is a modification of the recommended treatment proposed by Decoster et al for posttraumatic defects of the tibia.55 For small defects of 2 cm or less, the authors prefer using a combination of shortening and either autologous bone graft or allograft in the absence of infection and utilization of Masquelet technique in cases of infection. For defects of 2 cm or larger, the authors utilize distraction osteogenesis, custom 3D implants augmented with bone graft to facilitate arthrodesis, or vascularized free fibula flaps. The decision on which specific technique to use is personalized to each patient depending on the presence of soft tissue deficit, history of infection, systemic issues, and patient’s mental/psychological capacity.

Operating Room Considerations


For revision medial column arthrodesis cases, the authors recommend general anesthesia with a regional block for optimal postoperative pain control. If other concomitant procedures are being performed, we recommend a supine position with an ipsilateral hip bump. If the medial column is being addressed in isolation, the authors also find it helpful to have the knee bent with several blankets underneath and the foot flat on the operative field. A thigh tourniquet is applied to the operative extremity.

Depending on prior cicatrices, planned fixation, and any microvascular anastomosis, a dorsomedial incision along the medial column extending from the first tarsometatarsal joint toward the talonavicular joint is utilized. Accessory incisions over the second and third tarsometatarsal joints as well as along the plantar first metatarsal extending along the junction between the medial and plantar skin may be utilized. For the dorsomedial incision, after the skin incision is made, the surgeon should be mindful of any tributaries of the medial marginal vein or branches of the medial dorsal cutaneous nerve. Once these have been ligated or retracted, attempt should be made at utilizing full-thickness incisions, being mindful of the tibialis anterior tendon at the dorsal first tarsometatarsal joint. All joints to be incorporated into the arthrodesis should be accessed and prepped using curettage, osteotomes, subchondral drilling, and fenestration. Any nonviable, necrotic, or infected tissue or bone should also be excised.

For fixation, depending on surgeon preference, external fixation, plantar plating systems, and large medial column reconstruction plates should all be available depending on the specific needs of each case. Sagittal/oscillating saw, intraoperative C-arm fluoroscopy, soft tissue retractors, osteotomes, curettes, Kirschner wires for temporary fixation, Hintermann retractors, trephines for bone autograft harvest, and lamina spreaders should also be at the availability of the surgeon. Any biologics or bone graft that is needed should also be available. If any regional flaps or microvascular work is being performed, the authors also recommend a handheld Doppler be available intraoperatively as well as indocyanine green fluorescence imaging (SPY). The fluorescence imaging allows for visualization of the perfusion to the tissue intraoperatively.


Clinical Cases


Case 1


A 38-year-old female patient with controlled type 2 diabetes mellitus and rheumatoid arthritis presented several years following a motor vehicle accident at which time she sustained a closed midfoot injury which was treated nonoperatively. She presented with painful posttraumatic midfoot arthritis and underwent naviculocuneiform arthrodesis as well as first, second, and third tarsometatarsal joint arthrodesis (Figures 10.1 and 10.2). Patient had nonunion of the medial column and was diagnosed with a nickel allergy. She underwent laboratory workup for a nonunion and was noted to have elevated inflammatory markers. At 10 months postoperatively, the patient underwent hardware removal, bone biopsy, and culture of synovial fluid. Her pathology and culture results of bone and synovial fluid were negative. She then underwent revision arthrodesis. Due to the metal allergy, it was decided to use external fixation so no residual hardware would remain after removal of the monolateral external fixation. Six weeks after hardware removal, the patient underwent revision arthrodesis with bone graft and application of mini rail external fixator (Figures 10.310.5). The patient sustained a ground level fall 1 month after application of the external fixator and had mechanical failure of the distal pins. She underwent revision of the external fixator at that time (Figure 10.6). The external fixator was removed 9 weeks after the initial application. She transitioned to weight bearing as tolerated in a controlled ankle motion (CAM) boot and then into normal shoe gear as her edema allowed (Figures 10.7 and 10.8).



Figure 10.1 Preoperative lateral (A) and anterior-posterior (AP) (B) radiographs.



Figure 10.2 Postoperative lateral (A) and AP (B) radiographs.



Figure 10.3 Intraoperative fluoroscopy with interim removal of medial column hardware.



Figure 10.4 Postoperative (A and B) radiographs with noted failure of distal pins.




Figure 10.6 A-C, Postoperative radiographs after pin exchange and alteration of medial column mini rail.




Figure 10.8 Clinical photos (A-D), 10 weeks after revision.

Case 2



She complained of difficulty propulsing and her hallux was unable to contact the ground (Figures 10.9 and 10.10). On radiographs, she had an osseous union, but had a malunion resulting in a plantarflexed first ray as well as a short first ray (Figure 10.11). In addition she had pain and stiffness at the second metatarsophalangeal joint. On physical examination, she was also noted to have decreased ankle joint dorsiflexion with a positive Silfverskiold test.



Figure 10.9 A and B, Weight-bearing clinical photos demonstrating a plantarflexed first ray and a dorsally contracted hallux at the first metatarsophalangeal with an inability to contact the ground. This led to abnormal propulsion.




Figure 10.11 Preoperative AP (A), oblique (B), and lateral (C) radiographs.

The patient had failed months of conservative treatment including bracing, padding, orthotics, shoe gear modification, and physical therapy. Patient refused arthrodesis of the first metatarsophalangeal joint. It was decided to revise the first tarsometatarsal joint arthrodesis to reestablish length of the first metatarsal as well as correct the Meary’s angle.

For the revisional procedure, the hardware was removed in total. An osteotomy was then made utilizing a sagittal saw at the previous tarsometatarsal arthrodesis, which was noted to be the apex of the deformity. An allograft soaked in bone marrow aspirate concentrate was placed with a dorsal apex and a plantar base at the osteotomy site. To avoid placement of internal hardware, a monolateral external fixation was placed along the medial column. The graft restored both Meary’s angle as well as length of the first ray (Figures 10.12 and 10.13). A capsulotomy and cheilectomy was performed at the first metatarsophalangeal joint and a Z lengthening of the extensor hallucis longus was performed. After manipulation of the first metatarsophalangeal joint, an additional carriage was added to the external fixator and an arthrodiastasis was performed. A capsulotomy and cheilectomy were also performed on the second metatarsophalangeal joint and an amniotic graft was placed at this joint. The patient was kept non–weight bearing for 8 weeks. At 8 weeks, a CT scan was obtained which revealed osseous union across the graft site at the first tarsometatarsal joint. Her external fixator was then removed at 9 weeks postoperatively. She was then transitioned to weight bearing as tolerated in a CAM boot for 4 weeks and then transitioned to normal shoe gear with custom inserts (Figures 10.14 and 10.15).


Oct 22, 2022 | Posted by in ORTHOPEDIC | Comments Off on Revisional Medial Column Arthrodesis With Utilization of 3D Printing and Orthoplastic Techniques
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