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#4 Surg > 64 - Surgical Treatment of Rheumatoid Arthritis and Lesser MPJ Pathology > Flashcards

64 - Surgical Treatment of Rheumatoid Arthritis and Lesser MPJ Pathology Flashcards

1
Q

Criteria for the classification of Rheumatoid arthritis

A
  • Morning stiffness
  • Arthritis of 3 or more joint areas
  • Arthritis of hand joints
  • Symmetric arthritis (unlike other pathologies)
  • Rheumatoid nodules
  • Serum rheumatoid factor (almost always present in RA patients)
  • Radiographic changes
  • Classic appearance: large bunion deformity with lateral deviation and deformity of the toes
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2
Q

Radiographic findings

A
  • SYMMETRIC involvement***
  • UNIFORM joint space narrowing***
  • Marginal erosions (means the edges of the joints get erosive changes)
  • Cystic changes of bone, cortical thinning and osteopenia (could all potentially be due to side effects of medications for RA – long term steroid treatment)
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3
Q

Typical forefoot deformities include

A
  • Hyperpronation (leads to bunion, collapsed arch, and other pathologies from pronation)
  • Metatarsalgia (fat pad thinning leads to walking on met heads)
  • MPJ dislocation (preference for MPJ)
  • Hallux valgus
  • Claw toes, hammertoes
  • Other associated conditions: peripheral neuropathy, vasculitis, Raynaud’s phenomenon (just because these are all autoimmune)
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4
Q

Typical midfoot and rear foot deformities

A
  • Talonavicular arthritis
  • Subtalar joint arthritis
  • Rupture of posterior tibial tendon
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5
Q

Nonoperative treatment

A
  • Pharmacologic: NSAIDs, DMARDs, corticosteroids (methotrexate and prednisone most common) – some of these NEED to be stopped before surgery***
  • Shoe gear modifications (rocker bottom sole – propulsion power, takes pressure off metaheads)
  • Accomodative insoles (extra cushioning for bony prominences), AFO (for hindfoot arthritis)
  • We want to prevent surgery if at all possible because RA patients are not ideal surgical candidates
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6
Q

Surgery in the rheumatoid patient

A

Should be GOAL oriented:
o Pain relief this is the BIGGEST goal of RA surgery
o Improvement of overall function
o Correction of the deformity by increasing stability and overall muscle force

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7
Q

Perioperative management

A
  • Preoperative corticosteroid supplementation
  • Adjustment of anti-rheumatic drugs
  • Prophylactic antibiosis prior to major surgery or joint replacement (This is the standard of care for all patients)
  • Prophylaxis for DVT
  • Workup for atlantoaxial subluxation
  • Overall bone stock (need to know what you’re working with)
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8
Q

Describe preoperative corticosteroid supplementatio

A

o ***If normal dose is 5mg, give regular dose PLUS 25 mg prior to surgery (many patients are on this much, meaning they have lost the ability to form their own cortisol)
o Can always consult the rheumatologist or anesthesiologist

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9
Q

Describe adjustment of anti-rheumatic drugs

A

o Most rheumatologists recommend STOPPING DMARDs 1-2 weeks prior to surgery depending on drug half life
o Need to tell patient – you will need to stop medications until either the skin or bone has healed (up to 8-12 weeks) and they may get flare ups in other joints during this time
o Methotrexate according to literature does NOT need stopped – some rheumatologists will still stop this

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10
Q

Describe prophylaxis for DVT

A

o Good for RA patients because they don’t move around as much

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11
Q

Describe workup for atlantoaxial subluxation

A

o Arthritis in the neck is common, so if you need to intubate, or if something goes wrong with sedation and you need to intubate during surgery
o NEED to take cervical films prior to surgery so you don’t paralyze your patient during intubation

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12
Q

Rheumatoid nodules

A
  • Subcutaneous nodule
  • Occurs in 20-35% of patients
  • Found more frequently in aggressive disease process
  • In foot, found around Achilles or plantar forefoot most frequently
  • If symptomatic, may need to be removed to improve pain
  • If it is not bothering them, just leave it along
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13
Q

Joint involvement

A
  • Can effect hindfoot, forefoot or both
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14
Q

Forefoot joint involvement

A
  • If effects forefoot, usually ALL MPJs involved***
  • Synovial inflammation leads to disruption of collateral ligaments and capsule
    o Dorsal subluxation and eventual dislocation occurs
    o Intrinsics lose mechanical advantage leading to hammer or claw toes
  • Due to joint dislocation, plantar fat pad gets displaced – painful to walk on the metatarsal heads
    o Makes shoe gear a challenge – toes dorsiflex so you need deep shoes with extra padding
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15
Q

Hindfoot joint involvement

A
  • Talonavicular, STJ and ankle
  • Pain and malalignment due to:
    o Progressive cartilage damage
    o Capsule and ligament laxity
    o Periarticular erosions
    o Tendon rupture
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16
Q

Isolated hammertoe procedures

A
  • Hallux: Arthrodesis
  • Hammertoes 2-4: Arthrodesis or arthroplasty
  • Hammertoe 5: Arthroplasty
  • Mallet toes 2-4: Arthroplasty
  • Usually not isolated toes and you will end up doing more “global” procedures of the foot
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17
Q

Isolated painful hyperkeratotic lesion procedures

A
  • Osteotomy of the metatarsal
  • Joint replacement
  • Arthroplasty
  • Condylectomy
  • Resection of involved prominence
  • ***Rare to have isolated deformity or only one or two toes symptomatic
  • Usually if it is isolated, it isn’t caused by the RA, but it is another problem (biomechanical, etc.)
18
Q

Painful 1st metatarsal phalangeal joint (MPJ) procedures

A
  • Joint replacement (implant – need to have good alignment for the implant to work correctly, which is not likely in RA patients)
  • Resection arthroplasty (Keller – may be better for less active patients, this is less invasive)
  • Arthrodesis (fuse the joint – BEST FUNTIONAL STABILITY, but poor bone stock can lead to poor healing)
19
Q

Severe deformity of forefoot with associated pain procedures

A
  • PANMETATARSAL HEAD RESECTION = Your GO-TO procedure***
20
Q

Indications for panmetatarsal head resection

A
  • Pain with motion
  • Non-reducible dislocation
  • Joint destruction (joint is really bad already)
  • Progressive arthritis
  • Trauma (less common, but possible)
  • Atrophy of fat pad (removing metatarsal head can reduce some pressure form the area)
  • Multiple hyperkeratotic lesions (reducing pressure can reduce hyperkeratotic lesions)
21
Q

Panmetatarsal head resection procedure

A
  • Hoffman first described resection of lesser met heads – still used today (Don’t need to necessarily know “Hoffman”)
  • Later Clayton suggested resection of base of proximal phalanx along with met heads to improve soft tissue relaxation and toe position – not used much because leads to toe floppiness
  • * These procedures used along with 1st MPJ arthroplasty or arthrodesis*
22
Q

Panmetatarsal head resection – INCISIONAL approach

A
  • Hoffman (1911): Plantar transverse incision
  • McKeever (1952): Dorsal longitudinal approach
  • Clayton (1963): Transverse dorsal approach
  • Larmon (1951): Three dorsal linear incision approach
  • Hodor and Dobbs (1983): Five dorsal linear incision approach
23
Q

Plantar approach (Hoffman)

A

Advantages
o Good visualization
o Relocates plantar fat pad
o Easier to remove met heads in dislocated joints

Disadvantages
o Patient needs to NWB or partial WB for at least 3 weeks for optimal healing
o Plantar scar
o Wound dehiscence is a possible complication***

24
Q

Three linear dorsal incisions (Larmon)

A

Advantages
o Post-operative scar contracture does not affect digits
o Early ambulation
o Good cosmesis

Disadvantages
o Limited surgical exposure
o Injury to neurovascular
o May be difficult to remove met heads in dislocated joints

25
Q

5 incisional approach (Hodor Dobbs)

A

Advantages
o Good exposure to mpj’s and soft tissue
o Minimal damage to neurovascular structures
o Early ambulation with limited post-operative morbidity
o Good preservation of capsular and periosteal tissue
o Good cosmesis

Disadvantages
o Skin incisions are in close proximity to one another, skin necrosis is a possibility
o Higher incidence of skin slough
o Scar contractures are linear and may contribute to digit contractures reoccurring

26
Q

New incisional approach: One linear, two “lazy S” – known as the Bilotti

A 
Advantages
o	Provides for maximum tissue exposure
o	Preservation of vital structures
o	Minimal tissue deficit
o	Scar contracture does not alter correction
o	Minimal morbidity
o	Good cosmesis

Disadvantages
o Technically difficult
o Requires meticulous dissection
o Incisions require careful planning

27
Q

Panmetatarsal head resection example

A
  • ***Done on patient with psoriatic arthritis, and so no 1st ray work was done.
  • With RA arthroplasty or arthrodesis would be added.
  • Usually don’t pin the 5th because it is hard to get in the shoe
  • This is an example of a good first MPJ, which is not common – usually you have to do something here too
28
Q

Advantages of panmetatarsal head resection

A
  • Eliminates painful MPJs
  • Ability to ambulate without pain
  • Allows patient to wear regular shoes (and their toes won’t rub up on the top of the shoe)
  • Allows reduction of dorsally contracted digits
  • Elimination of plantar pressure points
29
Q

Disadvantages of panmetatarsal head resection

A
  • Loss of propulsive gait (if you take out all of them, it can make toes somewhat floppy)
  • Flail toe postoperatively
  • Incidence of hematoma formation with fibrosis
  • Destroys function of MPJ’s
  • Loss of digital stability
30
Q

HAV deformity

A
  • Joint destructive procedures recommended due to progressive nature
  • Head or base osteotomies could be performed alone – Results not thought to last long, however, no long term studies performed
31
Q

Arthroplasty

A

Mayo
o Resection of 1st metatarsal head
o REALLY effects propulsion and WB, so not used much

Keller
o Resection of the base of proximal phalanx
o Better propulsion and weight transfer than Mayo but do lose some

32
Q

Advantages of arthroplasty

A
  • No hardware needed
  • Good procedure for osteopenic bone
  • No bone healing required
33
Q

Disadvantages of arthroplasty

A
  • HAV deformity can come back – 50% of patients (Jeng et al. F & A Int. 2008)
  • Loss of propulsion
  • Floppy toe (if you have don too much resection)
34
Q

Advantages of arthrodesis

A
  • Maintains alignment
  • Provides lever for propulsion
  • High satisfaction rates
  • Less rate of lesser metatarsalgia
35
Q

Disadvantages of arthrodesis

A
  • Requires hardware
  • Need bone healing to occur – Union rate 84-100% (Jeng et al. F & A Int. 2008)
  • May lead to Hallux IPJ arthritis
36
Q

Implant arthroplasty

A
  • Need to have little deformity or correct deformity prior to placement (for implant to work right)
  • Need adequate bone stock
  • Most studies done on hinged silicone implants – High rate of complications
37
Q

Hindfoot and ankle arthritis

A
  • Procedure for TN, STJ arthritis = Triple arthrodesis
  • Procedure for ankle arthritis = Total ankle arthroplasty or ankle arthrodesis
  • Patients need to be counseled on the length of recovery
  • Not just 6 weeks – it will be 8, 12, 16 weeks (3-4 months) so it is really hard on the patient
38
Q

Post-op course

A
  • For any surgery, forefoot or rearfoot, patients need to be advised that prolonged healing is likely
39
Q

Panmetatarsal head resection post-op course

A

o Plantar incision – NWB or Partial WB for at least 3 weeks

o Dorsal incision – may walk in postop shoe if Keller, boot if 1st MPJ fusion

40
Q

Triple arthrodesis or ankle arthrodesis post-op course

A

o 8-12 weeks of NWB until consolidation noted

41
Q

Complications

A
  • Delayed healing (soft tissue or bone)
  • Infection
  • Continued pain or recurrent deformity

#4 Surg (14 decks)

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