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GREAT TOE
Newcastle University
Bioengineering [MEC3013]
Contents
Prosthesis.............................................................................................................. 2
Anatomy................................................................................................................ 3
Loads and Motions................................................................................................. 4
Comparisions to alternative impacts..................................................................... 5
Benefits and Drawbacks of the Prostheses............................................................ 7
Regulatory and Quality Control Issues................................................................... 7
Clinical and Laboratory based treatments and results ........................................... 9
Conclusion........................................................................................................... 10
References:.......................................................................................................... 11
Table of figures
Figure 1: Image of the Primus flexible great toe joint replacement[4]................................. 2
Figure 2 Table showing different dimensions available that are manufactured for the Primus
flexible great toe joint replacement[4, 11]...................................................................... 2
Figure 3 Schematic image anatomy of the great toe joint with parts labelled[6]................... 3
Figure 4 Photograph (Screen Shot) of the great big toe joint during surgery[8]...................3
Figure 5 X-Rays showing a normal first MTP joint[1, 12]................................................. 4
Figure 6 X-ray showing first MTP joint with arthritis [10, 12]............................................ 4
Figure 7 showing the various angles of the foot during propulsion.[7]................................ 5
Figure 8 Image showing the BioPro First MPJ Hemi Implant[2]........................................ 5
Figure 9 X-Ray showing a BioPro product implanted in a foot[2]...................................... 5
Figure 10 Swanson design, silicon double-stemmed, hinged implant[3]............................. 6
Figure 11 Shows the LaPorta implant with a 15 degree angle to duplicate the natural
declination angle.[9, 10]............................................................................................. 6
Figure 12 showing the Surgery invasive Long-term use and implantable devices[9, 10].......8
Figure 13 table Showing the class IIb medical devices routes to CE marking[5]...............8
Figure 14 Implants grad via AOFAS scale[1]................................................................. 9
Anatomy
The Futura primus flexible great toe implant has been designed by Tornier for fundamental
usage in a first metatarsophalangeal joint arthroplasty [1]. Therefore the joint of concern
when identifying the key bones, muscles and ligaments is the first metatarsophalangeal joint,
the word first indicates that it is referring to the metatarsophalangeal joint of the great toe as
opposed to any of the other lesser toes within the foot. The fundamental bones that connect
to either side of the joint are the first metatarsal and the proximal phalanx as can be seen in
Fig.1, a rotary burr is used during the arthroplasty operation to create the correct shaped
slots in the aforementioned bones in order for the primus implant to be fitted [Fig.2]. The
head of the first metatarsal bone is convex shaped while the end of the proximal phalanx
that it is joined to is concave allowing seamless articulation. Stability of the first MTP is
provided by the capsuloligamentous-sesamoid complex in conjunction with the
aforementioned bones. This joint capsule consists of a number of different ligaments, the
medial and lateral sesamoid ligaments, which can be sub-divided into the
phalangeosesamoid or metatarsosesamoid medial and lateral ligaments. The function of
these ligaments is to join both the First metatarsal and the proximal phalanx to both the
medial and lateral sesamoids within the joint capsule. A sesamoid is a bone that is
embedded within a tendon, and in this case the sesamoids reside inside the tendons of the
flexor hallucis brevis muscle. Another important ligament is the intersesamoid ligament, this
simply keeps the two sesamoids from being pulled apart within the joint capsule. Also within
the joint capsule exists the plantar plate which is a fibrocartilaginous structure joining the
proximal phalanx to the neck of the metatarsal, it plays an important part in supporting the
weight of the body, distributing this weight and restricting dorsiflexion. The muscles within
the hallux (great toe) are also vital, the flexor hallucis longus muscle via the flexor hallucis
longus tendon as well as the flexor hallucis brevis muscle provide the flexion movement of
the hallux. The abductor and adductor hallucis muscles provide the extension movement of
the hallux.
6
Figure 7 showing the various angles of the foot during propulsion.[7]
The double-stem total implant was introduced in 1974 by Swanson. It is extremely similar to
the Futura Primus implant. Both are made from Silicone Elastomer and both use titanium
grommets. The Swanson was originally not a brand new design, but a modification of a hand
implant, just with thicker stems.
The Lawrence and LaPorta Implants were released in 1982. They were designed to offer
improved function and movement. Their tapered stems are angled at 15 degrees to replicate
the declination angle of the first metatarsal.
Flexible Primus Great Toe
Futura Biomedical were the first to use UltraSIL silicone elastomer for its implants in 1997.
This material was very advanced compared to previous materials used by its
competitors.The Futura Primus Flexible Great Toe, like the Lawrence and LaPorta implants,
has an angled proximal stem to correspond with the natural metatarsal declination angle.
The hinge is highly engineered to offer a 95 degree range of motion, which is greater than
the natural motion of this joint.
8
the destruction of bones due to the growth of Osteoplastic giant cells entering the bone at
the implant site causing a structural weakness.[9, 17]
The Primus Flexible isnt comparable with a natural joint as it doesnt cope well with
compressive and shear forces, therefore is not suitable for younger active patients who will
apply greater forces to the prosthetic
Figure 12 showing the Surgery invasive Long-term use and implantable devices[9, 10]
Figure 13 table Showing the class IIb medical devices routes to CE marking[5]
10
11
Conclusion
There are many different types of implant available for the replacement of the Great Toe
Joint. They have progressed through 3 generations of adaptations and improvements. They
vary from single stemmed implants, double stemmed, tapered and angled.
The Futura Primus Implant offers one of the most advanced of these designs, combining
ULTRASIL medical grade silicone elastomer with titanium, one of the most bio compatible
materials. It's tapered, angled stems allow a more natural metatarsal declination angle.
12
References:
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Science, J.o.O. Ankle Hind foot scale. Sep, 2009; Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797841/table/Tab1/.
BioPro. FIRST MPJ HEMI IMPLANT. 2014; Available from:
http://www.bioproimplants.com/first-mpj-hemi/.
Inc., W.M.T. SWANSON Titanium Great Toe Implant. 2005; Available from:
http://www.amt-med.de/Bilder2002/pdf_dateien/swanson_titan_zeh.pdf.
Tornier, I. Futura ForeFoot Arthroplasty. 2014 10th October, 2014];
Available from: http://www.tornier-us.com/lower/foot/foorec001F/.
MHRA. Class II (b) Medical devices. June, 2013; Available from:
http://www.mhra.gov.uk/home/groups/dtsbs/documents/websiteresources/con286776.pdf.
Supplies, G. Tornier DX Futura Primus Flexible Great Toe (FGT). 9th
october, 2014; Available from: https://www.youtube.com/watch?
v=gzuHWiyedQs.
Falker-Heylings, J. FIRST METATARSOPHALANGEAL JOINT ACTION. [cited
2014 23rd October]; Available from:
http://www.thealliancepsp.com/CPD/FIRST%20METATARSOPHALANGEAL
%20JOINT%20ACTION.pdf.
Supplies, G. Tornier DX Futura Primus Flexible Great Toe (FGT). 9th
October, 2013; Available from: http://www.youtube.com/watch?
v=gzuHWiyedQs.
LAWRENCE M. OLOFF, M.A.F. First Metarsophalangeal Implants. Available
from: http://www2.kent.edu/cpm/academics/library/hallux/HV-ch-24-FirstMetatarsophalangeal-Implants.pdf.
Science, J.J.o.O. Midfoot Scale. Sep, 2005; Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797841/table/Tab3/.
Clinic, A.M.M.W. Turf Toe Injury. Radsource March, 2003; Available from:
http://www.radsource.us/clinic/0303.
Society, A.O.F.A. FootCareMD. First MTP Joint Replacement 2014;
Available from: http://www.aofas.org/footcaremd/treatments/Pages/FirstMTP-Joint-Replacement.aspx.
Wikipedia. Anatomical Terms of Motion. [cited 2014 25th October];
Available from: http://en.wikipedia.org/wiki/Anatomical_terms_of_motion.
Wikipedia. Titanium biocompatibility. Available from: Titanium
biocompatibility.
footEducation. Bones and Joints of the Foot and Ankle Overview. 26th Jule,
2014; Available from: http://www.footeducation.com/bones-and-joints-offoot-and-ankle-overview/.
Barmaki, S. IMPLANTS OF SMALL JOINTS IN HAND. 14th August, 2013;
Available from:
http://www.academia.edu/5636879/Implants_of_small_joints_In_Hand_Sami
neh_Barmaki.
Linda K. Tilbrook, L.W.B., MD, Healio Orthropedics, October, 2011. 34(10:
745, 816-818).
Exellence, N.I.f.C., Interventional procedures overview of prosthetic
replacement of the hallux. February 2005(282).
Bruce R Lawrence, E.T., A retrospective review of the primus first MTP joint
double-stemmed silicone implant. December 1, 2103(6: 471-478).