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Arthroplasties of the ankle and foot
Arthroplasties of the ankle and foot John Kirkup
of movement.6 Hemiphalangectomy, combined with bunionectomy, was extended to hallux valgus by Keller of the United States Army in 1904 who claimed the advantages were: ‘First: The normal tripod of the foot is not disturbed. Second: The danger of ankylosis is comparitively slight. Third: it can be used when the normal arch of the foot is high, . ..‘.’ In 1912, Keller reported the results of 26 operations and suggested some minor modifications;* this arthroplasty did not achieve immediate popularity but became better known after the paper of Brandes of Dortmund in 1929’ (Fig. 1). Correction of painful deformity of the whole forefoot was advocated by Hoffman of St. Louis in 1912, when he removed all the metatarsal heads via a plantar approach, especially for severe cases of infectious arthritis (?rheumatoid arthritis). He maintained: ‘ . . . it is better to remove the entire metatarsal head and enough of the neck to permit the phalanx to drop into line with the resulting metatarsal stump without crowding against it.“’ This procedure was popularised by Kates et al of London in 1967 with the addition of plantar skin excision and a temporary stabilisation of the first ray by percutaneous wire. l1 Fowler of Bridgend in 1959l* and Clayton of Denver in 196013 advocated bone excision from both metatarsals and phalanges, using a dorsal incision, and in the Fowler procedure additional removal of plantar skin. However excision of the proximal phalangeal bases produces weak flail toes and their retention is an advantage.
Ankle and hindfoot excisions designed to eradicate joint disease (History page 3), often produced partial joint mobility as a bonus, despite the primary objective of stabilisation. Deliberate procedures to unblock joints and restore pain-free mobility are later developments, classified as either excision or replacement arthroplasties.
EXCISION ARTHROPLASTY Ankle Planned astragalectomy for inveterate club foot was performed by Lund of Manchester in 1872l and, combined with displacement of the foot, popularised by Whitman of New York for calcaneus deformity associated with poliomyelitis in 1901. After astragalectomy Whitman emphasised that: ‘Sufficient mobility is thus gained to allow of a backward displacement of the foot upon the leg, so that the body-weight, instead of falling upon an elongated heel practically in the plane of the of the flattened (wasted) calf, is advanced toward the centre of the foot.‘* Some cases, Laming Evans of London noted, in 1928, obtained 10” to 15” of controlled tibiocalcaneal movement,3 although this was fortuitus to primary correction of deformity with stability. In elective practice, functional weight-bearing excision arthroplasty at the ankle joint or between the tarsal bones did not prove a predictable objective. Metatarsophalangeal However, at the distal extremity of the foot where toe mobility, especially of the hallux, aids locomotion, balance and heel height, arthroplasty was vindicated. Excision of the first metatarsal head for hallux valgus, recommended by Hueter of Greifswald in 18714 was strongly supported by Mayo of Rochester in 1908.5 In 1887, Davies-Colley of London reported excision of the base of the proximal phalanx for hallux flexus (limitus or rigidus) in 5 young males, producing a stable arthroplasty with a useful range
REPLACEMENT ARTHROPLASTY Biological replacement, advocated in 1967 by Regnauld of Nantes,14 involves a reimplantation technique which fashions pegs from amputated metatarsal stumps in order to dovetail on to them either the original metatarsal heads or cadaver material, to shorten and realign the forefoot. 93
94
The Foot
C
D
Fig. 1
Ankle The pioneer of joint arthroplasty with foreign materials was Gluck of Berlin in 1890;i5 his ankle prosthesis consisted of ivory and metal cemented with plaster, pumice and resin. As these materials were inappropriate and the joints were tuberculous, the results proved disastrous. Since Buchholz of Hamburg,r6 and Lord and Marotte of Paris” first reported total ankle arthroplasty with modern materials in 1973, various prostheses have been proposed. In addition to the Lord and Marotte ankle, the Richard Smith” and the Bath and Wessexlg are also unconstrained, with the objective of compensating for pro-supination as well as true ankle movement and one, the New Jersey low contact stress joint, a tri-part prosthesis with an intermediate meniscus, is also polyaxial.” Unconstrained prostheses tend to have inadequate loadbearing capacity and constrained prostheses overload the fixation system with significant failures. However the New Jersey ankle has better initial results than earlier prostheses and its design may prove a step in the right direction! The latest version, the Buechel-
Pappas prosthesis, is modified for uncemented placement.*’ Thus far the results of total ankle replacement resemble those of early hip and knee prostheses and, it is possible, the ankle will parallel a similar course of modification, to achieve a similar outcome. For the present ankle prostheses are best restricted to disabled rheumatoid patients with bilateral stiff and painful hindfeet where the knees threaten to become the most distal mobile joints.
Metartarsophalangeal Replacement of the first metatarsophalangeal joint is less controversial than the ankle. After experience with silastic (silicone elastomer, dimethyl polysiloxane) joints in the hand, Swanson of Grand Rapids produced a single-stem phalangeal implant in 1967 for the Keller’s procedure, to preserve toe length;*’ he later recommended double-stemmed implants to better control deformity.23 From 1973, Kampner of San Francisco also employed a silastic double-stemmed flexible hinged implant combined with osteotomy ofthe first metatar-
Arthroplasties
sal proximally, to overcome metatarsus primus varus.24 Later it became evident the rigid uncemented stems of the Swanson and Kampner prostheses often provoked painful loosening or pistoning in the medullary cavities, especially in the osteoporotic bone of rheumatoid arthritis. This suggested to Helal of London the concept of a silastic bali-spacer with narrow flexible stems which simply located the implant without damaging bone integrity.25 In use since 1977, this unconstrained implant necessitates complete bony and soft-tissue correction of deformity before insertion. Despite minimal bone resection, the ball may sink slowly into the cancellous bone of the metatarsal head with reduction in movement. Unlike most authors, Gould of Burlington has advised silastic replacement of the first metatarsophalangeal joint in rheumatoid arthritis, combining this with osteotomy of the first metatarsal, excision of the remaining metatarsal heads, multiple wire stabilisation, extensor tendon lengthenings, flexor tenotomforefoot, ies, etc.26 Also for the rheumatoid Cracchiolo of Los Angeles has undertaken doublestem silastic implant arthroplasties of all five joints in each foot, ensuring full soft tissue corrections are made before insertion. 27 As with the Gould and Regnauld procedures, meticulous attention to detail and considerable surgical skill, devoted to one foot at a time, are vital to their success. Difficult though such surgery remains, it underlines the complexity of the foot as modern surgeons accord it, finally, the respect and dedication long since devoted to the hand.
1. Lund E. Removal of both astragali in a case of severe
double talipes. B M J 1872; ii: 438-439. 2. Whitman R. The operative treatment of paralytic talipes of the calcaneus type. Amer J Med Sciences 1901; 122: 593-601. 3. Evans L. Astragalectomy. In: The Robert Jones birthday volume. London: Oxford University Press, 1928: 375-394. 4. Hueter C. Klinik der Gelenkkrankenheiten mit Einschluss der Orthopaedie. Leipzig: Vogel, 1871: 345-346. 5. Mayo C. Surgical treatment of bunions. Ann Surg 1908; 48: 300-302. 6. Davies-Colley J. On contraction of the metatarsal
of the ankle and foot
joint of the great toe (Hallux flexus). With cases. Trans Clin Sot London 1887; 20: 165-l 71. 7. Keller W. Surgical therapy of bunions. N Y Med J 1904; 80: 741-742. 8. Keller W. Further observation on the surgical treatment of hallux valgus and bunions. N Y Med J 1912; 95: 696-698. 9. Brandes M. Zur operativen Therapie des Hallux valgus. Zentralb f Chir 1929; 56: 2434-2440. 10. Hoffman P. An operation for severe grades of contracted or claw toes. Amer J Orth Surg 1912; 9: 44-449. II. Kates A. Kessel L, Kay A. Arthroplasty of the forefoot. J Bone Joint Surg 1967; 49B: 552-557. 12. Fowler A W. A method of forefoot reconstruction. J Bone Joint Sure 1959: 41B: 507-513. 13. Clayton M L. Suygery of the forefoot in rheumatoid arthritis. Clin Orthop 1960; 16: 136. 14. Regnauld B. Techniques chiruricales du pied. Paris: Masson, 1974; 47. 15. Gluck T. Referat uber die durch das moderne chirurgische Experiment Tampons in der Chirurgie. Archiv Klinische Chirurgie 1891; 41: 187. 16. Buchholz H W, Engelbrecht E, Siegel M. Sprunggelenk - endoprosthese ‘Model St Georg’. Der Chirurgie 1973; 44: 241-244. 17. Lord G, Marotte J H. Prothese totale de cheville: technique et premier resultats. A propos de 12 resultats. Rev Chir Orthop 1973; 59: 139-151. 18. Kirkup J R. Richard Smith ankle arthroplasty. J R Sot Med 1985; 78: 301-304. 19. Marsh C H, Kirkup J R, Regan M W. The Bath and Wessex ankle arthroplasty. J Bone Joint Surg 1987; 69B: 153. 20. Buechel F F. Total ankle replacement - the state of the art. In: Jahss M H (ed), Disorders of the foot and ankle, 2nd Ed. Philadelphia: Saunders, 1991: 2675. 21. Ibid: 2681. 22. Swanson A B. Implant arthroplasty for the great toe. Clin Orth 1972; 85: 75-81. 23. Swanson A B. Silicone implant resection arthroplasty of the great toe. J Bone Joint Surg 1975; 57A: 1173. 24. Kampner S L. Total joint prosthetic arthroplasty of the great toe - a 12-year experience. Foot Ankle 1984: 4: 249-26 1. 25. Helal B, Chen S C. Arthroplastik des Groschengrundgelenks mit einer neue SilastikEndonrothese. Orthonadie 1982: 11: 200-206. 26. Gould N. Surgery of-the forepart of the foot in rheumatoid arthritis. Foot Ankle 1982; 3: 173-180. 27. Cracchiolo A. Management of the arthritic foot. Foot Ankle 1982; 3: 17-23.
The author John R. Kirkup
Weston Hill 1 Weston Park East Bath BAI 2XA UK.
95
of movement.6 Hemiphalangectomy, combined with bunionectomy, was extended to hallux valgus by Keller of the United States Army in 1904 who claimed the advantages were: ‘First: The normal tripod of the foot is not disturbed. Second: The danger of ankylosis is comparitively slight. Third: it can be used when the normal arch of the foot is high, . ..‘.’ In 1912, Keller reported the results of 26 operations and suggested some minor modifications;* this arthroplasty did not achieve immediate popularity but became better known after the paper of Brandes of Dortmund in 1929’ (Fig. 1). Correction of painful deformity of the whole forefoot was advocated by Hoffman of St. Louis in 1912, when he removed all the metatarsal heads via a plantar approach, especially for severe cases of infectious arthritis (?rheumatoid arthritis). He maintained: ‘ . . . it is better to remove the entire metatarsal head and enough of the neck to permit the phalanx to drop into line with the resulting metatarsal stump without crowding against it.“’ This procedure was popularised by Kates et al of London in 1967 with the addition of plantar skin excision and a temporary stabilisation of the first ray by percutaneous wire. l1 Fowler of Bridgend in 1959l* and Clayton of Denver in 196013 advocated bone excision from both metatarsals and phalanges, using a dorsal incision, and in the Fowler procedure additional removal of plantar skin. However excision of the proximal phalangeal bases produces weak flail toes and their retention is an advantage.
Ankle and hindfoot excisions designed to eradicate joint disease (History page 3), often produced partial joint mobility as a bonus, despite the primary objective of stabilisation. Deliberate procedures to unblock joints and restore pain-free mobility are later developments, classified as either excision or replacement arthroplasties.
EXCISION ARTHROPLASTY Ankle Planned astragalectomy for inveterate club foot was performed by Lund of Manchester in 1872l and, combined with displacement of the foot, popularised by Whitman of New York for calcaneus deformity associated with poliomyelitis in 1901. After astragalectomy Whitman emphasised that: ‘Sufficient mobility is thus gained to allow of a backward displacement of the foot upon the leg, so that the body-weight, instead of falling upon an elongated heel practically in the plane of the of the flattened (wasted) calf, is advanced toward the centre of the foot.‘* Some cases, Laming Evans of London noted, in 1928, obtained 10” to 15” of controlled tibiocalcaneal movement,3 although this was fortuitus to primary correction of deformity with stability. In elective practice, functional weight-bearing excision arthroplasty at the ankle joint or between the tarsal bones did not prove a predictable objective. Metatarsophalangeal However, at the distal extremity of the foot where toe mobility, especially of the hallux, aids locomotion, balance and heel height, arthroplasty was vindicated. Excision of the first metatarsal head for hallux valgus, recommended by Hueter of Greifswald in 18714 was strongly supported by Mayo of Rochester in 1908.5 In 1887, Davies-Colley of London reported excision of the base of the proximal phalanx for hallux flexus (limitus or rigidus) in 5 young males, producing a stable arthroplasty with a useful range
REPLACEMENT ARTHROPLASTY Biological replacement, advocated in 1967 by Regnauld of Nantes,14 involves a reimplantation technique which fashions pegs from amputated metatarsal stumps in order to dovetail on to them either the original metatarsal heads or cadaver material, to shorten and realign the forefoot. 93
94
The Foot
C
D
Fig. 1
Ankle The pioneer of joint arthroplasty with foreign materials was Gluck of Berlin in 1890;i5 his ankle prosthesis consisted of ivory and metal cemented with plaster, pumice and resin. As these materials were inappropriate and the joints were tuberculous, the results proved disastrous. Since Buchholz of Hamburg,r6 and Lord and Marotte of Paris” first reported total ankle arthroplasty with modern materials in 1973, various prostheses have been proposed. In addition to the Lord and Marotte ankle, the Richard Smith” and the Bath and Wessexlg are also unconstrained, with the objective of compensating for pro-supination as well as true ankle movement and one, the New Jersey low contact stress joint, a tri-part prosthesis with an intermediate meniscus, is also polyaxial.” Unconstrained prostheses tend to have inadequate loadbearing capacity and constrained prostheses overload the fixation system with significant failures. However the New Jersey ankle has better initial results than earlier prostheses and its design may prove a step in the right direction! The latest version, the Buechel-
Pappas prosthesis, is modified for uncemented placement.*’ Thus far the results of total ankle replacement resemble those of early hip and knee prostheses and, it is possible, the ankle will parallel a similar course of modification, to achieve a similar outcome. For the present ankle prostheses are best restricted to disabled rheumatoid patients with bilateral stiff and painful hindfeet where the knees threaten to become the most distal mobile joints.
Metartarsophalangeal Replacement of the first metatarsophalangeal joint is less controversial than the ankle. After experience with silastic (silicone elastomer, dimethyl polysiloxane) joints in the hand, Swanson of Grand Rapids produced a single-stem phalangeal implant in 1967 for the Keller’s procedure, to preserve toe length;*’ he later recommended double-stemmed implants to better control deformity.23 From 1973, Kampner of San Francisco also employed a silastic double-stemmed flexible hinged implant combined with osteotomy ofthe first metatar-
Arthroplasties
sal proximally, to overcome metatarsus primus varus.24 Later it became evident the rigid uncemented stems of the Swanson and Kampner prostheses often provoked painful loosening or pistoning in the medullary cavities, especially in the osteoporotic bone of rheumatoid arthritis. This suggested to Helal of London the concept of a silastic bali-spacer with narrow flexible stems which simply located the implant without damaging bone integrity.25 In use since 1977, this unconstrained implant necessitates complete bony and soft-tissue correction of deformity before insertion. Despite minimal bone resection, the ball may sink slowly into the cancellous bone of the metatarsal head with reduction in movement. Unlike most authors, Gould of Burlington has advised silastic replacement of the first metatarsophalangeal joint in rheumatoid arthritis, combining this with osteotomy of the first metatarsal, excision of the remaining metatarsal heads, multiple wire stabilisation, extensor tendon lengthenings, flexor tenotomforefoot, ies, etc.26 Also for the rheumatoid Cracchiolo of Los Angeles has undertaken doublestem silastic implant arthroplasties of all five joints in each foot, ensuring full soft tissue corrections are made before insertion. 27 As with the Gould and Regnauld procedures, meticulous attention to detail and considerable surgical skill, devoted to one foot at a time, are vital to their success. Difficult though such surgery remains, it underlines the complexity of the foot as modern surgeons accord it, finally, the respect and dedication long since devoted to the hand.
1. Lund E. Removal of both astragali in a case of severe
double talipes. B M J 1872; ii: 438-439. 2. Whitman R. The operative treatment of paralytic talipes of the calcaneus type. Amer J Med Sciences 1901; 122: 593-601. 3. Evans L. Astragalectomy. In: The Robert Jones birthday volume. London: Oxford University Press, 1928: 375-394. 4. Hueter C. Klinik der Gelenkkrankenheiten mit Einschluss der Orthopaedie. Leipzig: Vogel, 1871: 345-346. 5. Mayo C. Surgical treatment of bunions. Ann Surg 1908; 48: 300-302. 6. Davies-Colley J. On contraction of the metatarsal
of the ankle and foot
joint of the great toe (Hallux flexus). With cases. Trans Clin Sot London 1887; 20: 165-l 71. 7. Keller W. Surgical therapy of bunions. N Y Med J 1904; 80: 741-742. 8. Keller W. Further observation on the surgical treatment of hallux valgus and bunions. N Y Med J 1912; 95: 696-698. 9. Brandes M. Zur operativen Therapie des Hallux valgus. Zentralb f Chir 1929; 56: 2434-2440. 10. Hoffman P. An operation for severe grades of contracted or claw toes. Amer J Orth Surg 1912; 9: 44-449. II. Kates A. Kessel L, Kay A. Arthroplasty of the forefoot. J Bone Joint Surg 1967; 49B: 552-557. 12. Fowler A W. A method of forefoot reconstruction. J Bone Joint Sure 1959: 41B: 507-513. 13. Clayton M L. Suygery of the forefoot in rheumatoid arthritis. Clin Orthop 1960; 16: 136. 14. Regnauld B. Techniques chiruricales du pied. Paris: Masson, 1974; 47. 15. Gluck T. Referat uber die durch das moderne chirurgische Experiment Tampons in der Chirurgie. Archiv Klinische Chirurgie 1891; 41: 187. 16. Buchholz H W, Engelbrecht E, Siegel M. Sprunggelenk - endoprosthese ‘Model St Georg’. Der Chirurgie 1973; 44: 241-244. 17. Lord G, Marotte J H. Prothese totale de cheville: technique et premier resultats. A propos de 12 resultats. Rev Chir Orthop 1973; 59: 139-151. 18. Kirkup J R. Richard Smith ankle arthroplasty. J R Sot Med 1985; 78: 301-304. 19. Marsh C H, Kirkup J R, Regan M W. The Bath and Wessex ankle arthroplasty. J Bone Joint Surg 1987; 69B: 153. 20. Buechel F F. Total ankle replacement - the state of the art. In: Jahss M H (ed), Disorders of the foot and ankle, 2nd Ed. Philadelphia: Saunders, 1991: 2675. 21. Ibid: 2681. 22. Swanson A B. Implant arthroplasty for the great toe. Clin Orth 1972; 85: 75-81. 23. Swanson A B. Silicone implant resection arthroplasty of the great toe. J Bone Joint Surg 1975; 57A: 1173. 24. Kampner S L. Total joint prosthetic arthroplasty of the great toe - a 12-year experience. Foot Ankle 1984: 4: 249-26 1. 25. Helal B, Chen S C. Arthroplastik des Groschengrundgelenks mit einer neue SilastikEndonrothese. Orthonadie 1982: 11: 200-206. 26. Gould N. Surgery of-the forepart of the foot in rheumatoid arthritis. Foot Ankle 1982; 3: 173-180. 27. Cracchiolo A. Management of the arthritic foot. Foot Ankle 1982; 3: 17-23.
The author John R. Kirkup
Weston Hill 1 Weston Park East Bath BAI 2XA UK.
95