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First MTP joint replacement- Rotaglide implant (Implants international)

    Overview

    Learn the First MTP joint replacement: Rotaglide implant (Implants international) surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the First MTP joint replacement: Rotaglide implant (Implants international) surgical procedure.
    Arguably there are mainly relative indications for any first metatarso-phalangeal joint replacement given the high rates of union and patient satisfaction with the traditional surgical option of first MTP (Big toe) fusion. After a successful first MTP fusion deterioration in the longer term (and in particular from the remaining inter-phalangeal joint) is also not a common occurrence at all.
    The main one practically speaking is patient preference. Interphalangeal joint arthritis with intercurrent with MTP arthritis would be one relative medical indication for replacement.
    There are various designs of big toe joint replacement available ranging from hemi-arthroplasties to total 3 component joint replacements (such as the Rotaglide, Implants International). One key factor when considering which first MTP replacement to use are the published results , and longevity in particular.
    A common trade-off for some element of maintained ( and also comfortable) MTP movement ( a realistic expectation after MTP replacement ) is a lower longevity with the intervention when compared to both the “gold standards” of Hip and Knee replacements and MTP fusion.
    The Rotaglide MTP replacement is well jigged which assists in reproducible implantation. It is often primarily stable after implantation which allows the potential for early joint mobilisation routines in compliant patients. The approach required for the jigging is reasonably extensive.

    Indications

    Arguably there are only relative indications for any first Metatarsophalangeal joint replacement.
    The main one practically speaking is patient preference. Interphalangeal joint arthritis intercurrent with MTP arthritis would be one relative medical indication for replacement.
    The trade-off for some element of maintained ( and also comfortable) MTP movement ( a realistic expectation after replacement , as opposed to an increased range) is a lower longevity to the intervention (compared to both other lower limb replacements and MTP fusion).

    Setup

    General or Regional anaesthetic
    Antibiotics & LMW Heparin on induction
    Laminar flow theatre
    Thigh tourniquet
    Patient supine
    Pre/post operative Nerve block (popliteal and / or inter-metatarsal )for analgesia

    Operation – 1

    A dorso-medial approach between EHL and the Dorsomedial cutaneous nerve is used for big toe replacement, exposing metatarsal head(1) and proximal phalanx(2).

    The exostosis is removed(1) in line with the long axis of the metatarsal shaft as the first step in Rotaglide big toe replacement.

    The Rotaglide is a three component press fit implant. It preserves the whole of the plantar surface, and plantar length of the metatarsal shaft. This offers a theoretical advantage if salvage is required due to potential preservation of metatarsal shaft length., though bone block still likely to be needed.

    The instrument tray for the Rotaglide showing all instuments supplied.

    The metatarsal head resection guide(2) sitting flush to the head(1)

    The slot for metatarsal head resection (3), the amount of head to be resected(1) and fixation of the jig with guide pins(2)

    The proximal metatarsal shaft(1)on which the jig is seated(2). The basal screw(3) allows an adjustment of the degree of valgus to be cut distally when resecting the head. A slight valgus(7 deg) is normal.

    The metatarsal head being resected with the initial jig for Rotaglide big toe replacement.

    The amount of resected metatarsal head(1) in preparation for Rotaglide big toe replacement.

    The prepared metatarsal shaft (1). The three trial sizes of Rotaglide big toe replacement are now offered up to see approximately which is likely to fit best. The only thing which this decision effects is the depth to which the shaft is drilled in the next stage.

    The cut surface of the metatarsal(2), showing the crista(1) which is the marker for the midline insertion of the drill for preparation of the metatarsal shaft in Rotaglide big toe replacement.

    The metatarsal reaming guide is aligned medio-laterally with the plantar located crista and dorsally with the shaft. At first appearance the entry hole would seem to be too far plantarly placed. It has however an oblique and dorsally angulated orientation.

    The guide is seated dorsally and distally and fixed with pins. The depth of the pilot hole is marked on the drill and corresponds to the chosen component size for the Rotaglide replacement.
    Care should be taken to ensure that reaming is parallel to the long axis of the shaft and does not angulate up or down.

    The pilot drill hole(1), centrally placed for the Rotaglide big toe replacement.

    Carefully enlarging the pilot hole with the reamer on power.

    Enlarging the channel for the Rotaglide big toe replacement with the broach by hand

    The entry point after countersinking(1) with the chamfer cutter. The next stage is to trial with the appropriately sized Rotaglide trial stem following a thorough lavage of any bone swarf from the prepared channel.

    The metatarsal trial being impacted.
    Needless to say the passage should be straightforward

    The Rotaglide metatarsal trial component is sitting slightly proud medially, despite a fully jigged distal cut being made. The most likely cause is that the amount of valgus “dialled in” to the cut by the position of the basal screw has been insufficient for the anatomical axis of this shaft.
    This can be rectified by taking a little more bone free-hand from the lateral cut surface distally. Note that the plantar length of the metatarsal shaft is maintained.

    The Rotaglide phalangeal resection guide,showing the two resection slots for the base of proximal phalynx.It is important not to resect too generously as only 3 meniscal sizes are available(6,7 and 8 mm).

    The base of the phalanx is removed with a fine power saw (2). The lateral soft tissues are protected using a Homans retractor (1).
    Toe rotation needs to be controlled (3) as the Rotaglide jig doesn’t do this well. An interphalangeus can be corrected at this stage by asymmetric resection of the phalangeal base.

    Finishing the phalangeal resection cut freehand(1), taking care with the plantar surface and FHL tendon as well as the lateral soft tissue envelope.

    A McDonalds (1) in contact with the FHL tendon, which has been sharp dissected off the resected phalangeal base.

    To locate the stem appropriately in the proximal phalanx the drill guide is placed dorso-centrally.

    Drilling the pilot hole for the phalangeal stem of the big toe replacement. The correct depth, relating to component size, is marked on the drill.

    Operation – 2

    Carefully enlarging the pilot hole with the power reamer.This stage of the Rotaglide replacement can also be done by hand without power.

    Enlarging the channel with the broach.

    Countersinking the channel with the chamfer cutter.Here it is being done using power gently. It can also be finished by hand . It is key that this is correctly aligned and of course that the cortex remains intact. This is then followed by a trial using the appropriately sized trial stem.

    The trial phalangeal stem for the Rotaglide replacement.

    The trial phalangeal stem for the Rotaglide replacement seated well and demonstrating correct alignment.

    Once the metatarsal (1) and phalangeal (2)trial implants are seen to sit well the sesamoids (3,4) are inspected and any osteophytes removed.
    These may otherwise impinge upon the components.

    Generally the “standard” menisci with a dorsal lip (to reduce the chance of dorsal meniscal dislocation) are used. There should be as little telescoping of the Rotaglide big toe joint as possible. Plantar impingement of the meniscus upon the seasamoids should be checked for. If present the anterior bulk of the seasamoids should be reduced with bone nibblers.

    After the components have been trialed the definitive prostheses are inserted, metatarsal first.

    Impaction of the metatarsal component of the big toe replacement. Care needs to be taken to control rotation of the implant during this phase.

    The metatarsal component well seated.

    The metatarsal and phalangeal implants(2) press-fitted

    The asymmetric black trial meniscus with a dorsal lip, marked “+” , is again used. Sizes 6mm, 7mm and 8mm available. An “anatomical”Rotaglide meniscus without the lip is also available. Check for stability, range of movement and plantar impingement on Crista and seasamoids.

    A dorsal view of the big toe replacement with trial meniscal component.

    The definitive mensicus now inserted the joint is trialled for range of movement and stability.

    Check for range of movement, impingement inferiorly of the meniscus upon the seasamoids and stability after capsular closure.

    Pre and post operative x-ray images of the rotaglide replacement.

    Post Operative

    Day-case or overnight stay
    LMW Heparin 2 weeks
    Weight bear using post operative shoe for 5 weeks
    Crutches likely required 1-2 weeks
    Patient taught self-mobilisation of MTP from 2 weeks post op (assuming good primary on-table stability of the implant), both active and passive. A thera-band is useful for this .The key is achieving dorsi-flexion early. My routine is to suggest 20 -30 cycles of plantar/dorsi-flexion using & against the thera-band three times per day. Physio supervision from 5 weeks if havent achieved adequate range.
    Kellers bandage/post operative splint for 5 weeks
    Dressings to continue 24/7 until all wounds dry
    From 5 weeks the patients should cleanse the foot twice a day, once in a salt water bath and once by bathing/showering
    Dressings ,especially to medial wounds , to continue for the first month in shoe-wear.
    Appropriate shoe-wear fit is vital in the first month or so after post-op shoe
    I advise fit-flops , Uggs , wider fits or open sandals. Stiffer Heels ( platform or wedge ) are encouraged in women , from when comfortable , to promote MTP dorsi-flexion.

    Recommended Reading

    Prospective analysis of a first MTP total joint replacement. Evaluation by bone mineral densitometry, pedobarography, and visual analogue score for pain
    Eva Wetke MD, Bo Zerahn MD, Hakon Kofoed MD
    Foot and Ankle Surgery 18 (2012) 136–140
    From January 1st 2000 to December 2005 patients with grade 3 or 4 osteoarthritis of the first MTP joint undergoing a Rotaglide joint replacement were enrolled. Exclusions to participate included bilateral disease.
    12 patients were studied with a mean follow-up of 3.1 years (range 1.0–7.2).
    A Footscan (single step version) was used for pedobarographic measurements.
    The Rotaglide was demonstrated to both normalise loading through the first ray ( by direct pedobarographic measurement evidence as well as by inference from the bone mineral density data) whilst reducing pain levels.
    Comparison of arthrodesis and metallic hemiarthroplasty of the hallux metatarsophalangeal joint.
    J Bone Joint Surg.2007.89-A:1979-1985.
    S.M.Raikin , J.Ahmad , A.E.Pour, N.Abidi
    Not a paper about the rotaglide or even a 3 component replacement but worth a read
    46 patients , 21 replacements(BioPro) & 27 fusions followed up over mean 79.4 months.
    Of the fusions all united , good or excellent outcome in 22 of the 27
    Of the replacements excellent or good results only in 12 & a 24% failure rate requiring revision.

    Reference

    • orthoracle.com

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