64 - Surgical Treatment of Rheumatoid Arthritis and Lesser MPJ Pathology Flashcards
Criteria for the classification of Rheumatoid arthritis
- 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
Radiographic findings
- 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)
Typical forefoot deformities include
- 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)
Typical midfoot and rear foot deformities
- Talonavicular arthritis
- Subtalar joint arthritis
- Rupture of posterior tibial tendon
Nonoperative treatment
- 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
Surgery in the rheumatoid patient
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
Perioperative management
- 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)
Describe preoperative corticosteroid supplementatio
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
Describe adjustment of anti-rheumatic drugs
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
Describe prophylaxis for DVT
o Good for RA patients because they don’t move around as much
Describe workup for atlantoaxial subluxation
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
Rheumatoid nodules
- 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
Joint involvement
- Can effect hindfoot, forefoot or both
Forefoot joint involvement
- 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
Hindfoot joint involvement
- Talonavicular, STJ and ankle
- Pain and malalignment due to:
o Progressive cartilage damage
o Capsule and ligament laxity
o Periarticular erosions
o Tendon rupture
Isolated hammertoe procedures
- 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
Isolated painful hyperkeratotic lesion procedures
- 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.)
Painful 1st metatarsal phalangeal joint (MPJ) procedures
- 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)
Severe deformity of forefoot with associated pain procedures
- PANMETATARSAL HEAD RESECTION = Your GO-TO procedure***
Indications for panmetatarsal head resection
- 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)
Panmetatarsal head resection procedure
- 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*
Panmetatarsal head resection – INCISIONAL approach
- 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
Plantar approach (Hoffman)
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***
Three linear dorsal incisions (Larmon)
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
