Using Injectable Grafts To Facilitate Implant Success

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Author(s): 
By Harold Schoenhaus, DPM, Jodi Schoenhaus, DPM, and Dawn Pfeiffer, DPM

A Closer Look At The Results
While radiographic findings are inconclusive in determining if bony regrowth has occurred (due to MIIG being radiopaque), we have observed clinically that the first MPJ functions as it would with the use of any other titanium hemi-implant. There is adequate dorsiflexory motion of the great toe and patients are able to stand on their toes.
Furthermore, radiographs have shown that the implant remains in adequate position three months after the procedure. There has not been any bulldozing or loss of stability of the implant, and the position of the implant in the proximal phalanx base has not changed.
Our patients have not experienced any postoperative infections, metal reactivity or detritic synovitis. Whether the bone regenerates with the assistance of the calcium sulfate or the MIIG is not resorbed and replaced by bone, the implant still has a stable, well-controlled seated position for adequate range of motion during propulsion.

What One Case Study Revealed
A 47-year-old woman came in to the office, complaining of severe pain in the first MPJ. The patient had multiple cheilectomies with temporary relief lasting only six months to one year. She notes recent difficulty with ambulation and it had altered her life accordingly.
Upon physical examination, we noted the patient had findings consistent with hallux rigidus along with a significant dorsal exostosis. The range of motion of her first MPJ was limited to approximately 2 degrees of dorsiflexion. Radiographic evaluation revealed a markedly decreased joint space, flattening of the first metatarsal head, subchondral sclerosis and osteophyte formation.
We directed our surgical attention to the dorsal aspect of the foot, making a curvilinear incision over the first MPJ. We proceeded to remodel the first metatarsal head and removed the base of the proximal phalanx with a micro-sagittal saw.
Upon inspection, we saw the medullary bone was absent, leaving a shallow cortical rim with poor medullary support for the hemi-implant. Accordingly, we prepared MIIG and introduced it into the proximal phalanx base. We allowed it to harden for approximately three minutes to the appropriate consistency. At this point, we inserted the properly sized hemi-implant into the base of the proximal phalanx. We noted adequate seating and range of motion intraoperatively.

Final Notes
Arthroplasty of the first MPJ with implant placement is an excellent procedure for patients with degenerative arthritis. This procedure provides marked improvement in range of motion, significant reduction in painful symptoms and maintains the length and function of the great toe.
However, some patients have less than adequate bone stock for implantation. With the technological development of MIIG, we are now able to provide an environment for proper seating of the implant. When you’re treating patients that would otherwise require a Keller arthroplasty or fusion, the option for restoring motion still exists. MIIG is an excellent alternative approach to implant seating in light of poor proximal phalangeal support.

Dr. Harold Schoenhaus is the Chief of Foot and Ankle Surgery at the Graduate Hospital of Philadelphia. He is a Fellow of the American College of Foot and Ankle Surgeons, and is board-certified by the American Board of Podiatric Surgery and the American Board of Podiatric Orthopaedics.
Dr. Jodi Schoenhaus is a second-year resident at the Graduate Hospital in Philadelphia. Dr. Dawn Pfeiffer is a third-year Chief resident at the aforementioned institution.
Dr. Burks is a Fellow of the American College of Foot and Ankle Surgeons, and is board-certified in foot surgery. Dr. Burks practices in Little Rock, Ark.

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