Dr. Alan Ng utilizing NuShield as a surgical barrier in a Cheilectomy procedure.
Dr. Alan Ng is a podiatric surgeon specializing in foot and ankle reconstruction at Orthopedic Centers of Colorado, with more than 23 years of experience. He is the Fellowship Director at Rocky Mountain Reconstructive Foot and Ankle Fellowship. Dr. Ng is the President Elect of the American College of Foot and Ankle Surgeons as well as the past President of the American Board of Foot and Ankle Surgery.
Good morning. My name is Doctor Allen. I'm here in Denver, Colorado. Uh We are going to perform a chom me of the first mears family and del joint. This particular case patient has a late stage su how limits? So, uh this incision, uh this medial cents lus longest tendon. Uh I'll make the incision here. I'm gonna show you here is the head of the first metatarsal and we can see here that's missing its cartilage essentially on the central aspect right here. So she has spurs dorsally, loss of cartilage centrally and also a medial bump here that we're going to clean all this up. So, what we gonna do now is take an elevator and I'm gonna expose this joint a little better and break up some of the adhesions. And now you can really see the head of the bone. So Jeff, so, um as I expose us. Yeah. OK. Um You can see the erosion essentially, this is a late stage Haux Lius, we can see the loss of cartilage in the central head here. Uh We're gonna tore off these the bumps here. Currently, I'm gonna elevate this doctor. He is gonna hold this, I'm gonna take my saw and we're gonna clean this up a little bit. I think I need your bump up first. Good ball. Dorsal. Take this dorsal bump off. So here we take it off the spurs, the main symptoms we're causing from the joint line. Um, the cartilage catching what I'll do on the first met head here is I'll look for what's loose. So I look at the joint here, I'll peel the cartilage and see what's tight and what's loose. Usually what's loose is what catches a joint and causes discomfort. Our goal of this kind of a 35 K wire also, and sometimes on these patients, I will penetrate the exposed plate just a little bit with the smallest wire possible just to get a little bit of sub condal bleeding. I've got a very shallow drill so I won't go too deep just enough to get a little bit of penetration in that. And then I'm going to come out for a second here and I'm going to assess where her joints sitting and their bumps gone. So that looks really good. So I don't need to release a lateral side. Sometimes I'll conjoin in a lateral release with this as well to make sure that everything is loose. There's a little spur on the lateral side here. So come across with the, yeah, here's the first metros head. We had went ahead and shaved out the dorsal and medial spurs or exostosis stage, late stage two. How on this? We see the chondral erosion in the central part of the head here. We've trimmed deck, the cartilage, the firm edges a little bit more loose here that we're gonna get minute. And we also fenestrated some of the subchondral bone. Very, very lightly small one here, very lightly with a 35 wire to try to get some of that subchondral bleeding. We wanna make sure there's no loose cartilage, but we don't want Debre the cartilage off. So this patient understands that with the chom me, she still may need a joint destructive procedure down the road. Whether that be a partial replacement or a fusion of her. Do you want to take the wire back, please? So what I'm trying to do with this is a very shallow, very shallow drill just to penetrate the sub clonal bone plate to get a little bit of vascularity to the area, hopefully form some fiber cartilage and get this area to kind of form some scar cartilage. I will use the stromal side for my new shield in this case to adhere to this area and leave the epithelial side on top. Again, looking at your graft itself, my notch is to the left which tells you my stromal side is facing me. My knots is the right. Then the epithelial side is facing me. It's very important when you're using your new shield to understand which layers which side more irrigation. And what I tend to do is use like a mcgray elevator and to hold my bone in position. So I can see I got a scar tissue here and Alex is gonna hold it just like that. I'm gonna take my stromal side up, notch to the left side, stroma is facing me. I want that going against the bone. So my epithelial side, which is this side, so notch the right epithelial side is facing me or facing out. So anything that comes in scar wise wants to hit this side, so it prevents it from attaching or sticking to that area. So what I'll do is lay this on the bone and we'll hydrate this and it kind of absorbs that and I will gently remove my glamouring. I'll distract my joint and slide this in. Pick it up. There we go. So I have my epithelial side on top here where the bone was resected. So when there's bleeding bone, we want to adhere here. And then I also have a large segment of this new shield over drilled holes in this case here. Relax. I'll take a two of echo. That's it. I close over the top and again, use the stromal side of the amnion for its inherent properties. I'll close the capsule and layers standard closure very straightforward. But we found that this has improved anecdotally our patients' outcomes in regards to range of motion in regards to inflammatory response, post cy same post-operative course on these patients, we bear them immediately in a little surgical shoe and progressively watch them. And every one of these patients with a cy when there's some arthritic changes in the head, understand that this could be a bridge procedure. And that long term, they may need a joint destructor type procedure such as an MP J fusion or a some sort of Orthoplast from the layer and make sure that my capsule closure is over my adhesion barrier and not to sew it in this dorsal component if possible. So the new shield is interarticular on the bone and the cartilage remaining cartilage in the joint you do want, if you are using this new shield in these, in the cy, you do have to close the capsule. If you don't want that extruding, you want it in the joint and for its purpose for its inherent properties and that's it.
