64: RA/ Lesser MPJ - Frush

Question 1

criteria for classification of RA

Answer 1

• morning stiffness
• arthritis of 3 or mor joint areas
• arthritis of hand jts
• symmetric artyhritis
• rheumatoid nodules
• serum rheumatoid factor
• radiographic changes

Question 2

radiographic findings RA

Answer 2

• symmetrical involvement
• uniform jt space narrowing
• marginal erosions
• cystic changes
• cortical thinning
• osteopenia

Question 3

typical forefoot deformities assoc with RA

Answer 3

• hyperpronation
• metatarsalgia (dislocation MPJ and thinning fat pad)
• MPJ dislocation
• Hallux valgus
• claw toes, hammertoes
• also more prone to peripheral neuropathy, vasculitis, raynaud’s phenomenon

Question 4

typical midfoot and rearfoot deformities assoc with RA

Answer 4

• talonavicular arthritis
• subtalar joint arthritis
• rupture of post tibial tendon

Question 5

non-op tx for RA

Answer 5

• medications
  
  • NSAIDs, DMARDS, corticosteriods (prednisone), methotrexate
• shoegear modifications
  
  • rocker bottom sole
• accomodative insoles
• AFO

Question 6

Pre-op management of a RA pt taking steroids or anti-rh drugs

Answer 6

• Corticosteroid supplements
  
  • less than 5 mg –> give regular, no supplement
  • greater than 5 mg –> give regular + 25 mg prior to surg
• Adjustment of anti-rh drugs
  
  • stop DMARDs 1-2 wks prior to surgery depending on drug half-life
  • methotrexate does not need to be stopped

Question 7

special periop management of RA pt

Answer 7

• prophylactic antibiosis prior to major sx or jt replacement
• prophylaxis for DVT
• workup for atlantoaxial subluxation
  
  • get cervical spine films, looking for arthritis in neck, intubation risk
• overall bone stock

Question 8

where would a rheumatoid nodule show up in the foot?

Answer 8

found around achilles or plantar forefoot most frequently

• subcutaneous nodule
• 20-35% pt
• more frequent in more aggressive
• remove if symptomatic

Question 9

if RA effects forefoot, which MPJs are involved?

Answer 9

all MPJ

can also effect hindfoot or do both

• synovial inflammation leads to disruption of colalteral ligaments and capsul
  
  • dorsal subluxationa nd eventual dislocation occurs
  • intrinsics lose mechancal advantage leading to hammer or claw toes
• due to jt dislocation, plantar fat pad gets displaced

Question 10

RA foot with hammertoes, what surg?

hallux

hammertoes 2-4

hammertoe 5

mallet toe 2-4

Answer 10

—Hallux — Arthrodesis

—Hammertoes 2-4 —- Arthrodesis or arthroplasty

—Hammertoe 5 —- Arthroplasty

—Mallet toes 2-4 —– Arthroplasty

Question 11

indications for panmetatarsal head resection (hoffman)

[resection of lesser met heads along usually with arthroplasty/arthrodesis of 1st MPJ]

Answer 11

• pain with motion
• non-reducible dislocation
• jt destruction
• progressive arthritis
• trauma
• atrophy of fat pad
• multiple hyperkatotic lesions

Question 12

advantages and disadvantages for plantar (hoffman) approach to panmet head resection

Answer 12

• —Advantages
  
  • —Good visualization
  • —Relocates plantar fat pad
  • —Easier to remove met heads in dislocated joints
• —Disadvantages
  
  • —Patient needs to NWB or partial WB for at least 3 weeks for optimal healing
  • —Plantar scar
  • —Wound dehiscence

Question 13

advantages and disadvantages to (larmon) three linear dorsal incisions for panmet head resection surgery

Answer 13

• —Advantages:
  
  • —post-operative scar contracture does not affect digits
  • —Early ambulation
  • —good cosmesis
• —Disadvantages:
  
  • —limited surgical exposure
  • Injury to neurovascular
  • May be difficult to remove met heads in dislocated joints

Question 14

advantages and disadvantages of 5 incisional approach (hodor dobbs) for panmet head resection

Answer 14

• Advantages:
  
  • —Good exposure to mpj’s and soft tissue
  • —Minimal damage to neurovascular structures
  • —Early ambulation with limited post-operative morbidity
  • —Good preservation of capsular and periosteal tissue
  • —Good cosmesis
• Disadvantages:
  
  • —Skin incisions are in close proximity to one another
  • —Higher incidence of skin slough
  • —Scar contractures are linear and may contribute to digit contractures reoccurring

Question 15

advantages of (bilotti) one linear, two lazy S approach to panmet head resection

Answer 15

• —Advantages:
  
  • —Provides for maximum tissue exposure
  • —Preservation of vital structures
  • —Minimal tissue deficit
  • —Scar contracture does not alter correction
  • —Minimal morbidity
  • —Good cosmesis
• Disadvantages:
  
  • —Technically difficult
  • —Requires meticulous dissection
  • —Incisions require careful planning

Question 16

advantages and disadvantages of panmethead resection

Answer 16

• —Advantages:
  
  • —Eliminates painful MPJ’s
  • —Ability to ambulate without pain
  • —Allows patient to wear regular shoes
  • —Allows reduction of dorsally contracted digits
  • —Elimination of plantar pressure points
• —Disadvantages:
  
  • —Loss of propulsive gait
  • —Flail toe postoperatively
  • —Incidence of hematoma formation w/fibrosis
  • —Destroys function of MPJ’s
  • —Loss of digital stability

Question 17

mayo vs. keller arthroplasty for 1st MPJ in RA pt

Answer 17

• —Mayo
  
  • Resection of 1st met head
  • Effects propulsion and WB
  • Not used much
• —Keller
  
  • Resection of the base of proximal phalanx
  • Better propulsion and weight transfer than Mayo but do lose some

Question 18

what do you do for TN, STJ arthritis?

Ankle arthritis?

Answer 18

• —TN, STJ arthritis
  
  • Triple arthrodesis
• —Ankle arthritis
  
  • Total ankle arthoplasty
  • Ankle arthrodesis

Patients need to be counseled on the length of recovery (months)

Question 19

postop plan for pan met head resection

Answer 19

• Plantar incision – NWB or Partial WB for at least 3 weeks
• Dorsal incision – may walk in postop shoe if Keller, boot if 1st MPJ fusion

Question 20

postop plan triple arthrodesis or ankle arthrodesis

Answer 20

8-12 weeks of NWB until consolidation noted

Question 21

advantages and disadvantages of arthroplasty 1st MPJ in RA pt (compare to arthrodesis)

Answer 21

• —Advantages
  
  • No hardware needed
  • Good procedure for osteopenic bone
  • No bone healing required
• —Disadvantages
  
  • HAV deformity can come back (50%)
  • Loss of propulsion
  • Floppy toe

Question 22

advantages and disadvantages of arhtrodesis

Answer 22

• —Advantages
  
  • Maintains alignment
  • Provides lever for propulsion
  • High satisfaction rates
  • Less rate of lesser metatarsalgia
• —Disadvantages
  
  • Requires hardware
  • Need bone healing to occur
  • –Union rate 84-100%
  • May lead to Hallux IPJ arthritis

Question 23

when could you do implant arthroplasty?

Answer 23

• —Need to have little deformity or correct deformity prior to placement
• —Need adequate bone stock
• —Most studies done on hinged silicone implants
  
  • High rate of complications