SLR - April 2011 - Catherine Hudson
Reference: Krause, F, Fehlbaum, O, Huebschle, L, Weber, M: Preservation of Lesser Metatarsophalangeal Joints in Rheumatoid Forefoot Reconstruction. Foot & Ankle International 32:131-40, 2011.
Scientific Literature Review
Reviewed by: Catherine Hudson, DPM/PGY-2
Residency Program: Central Alabama Veterans Health Care System
Podiatric Relevance:
Rheumatoid patients often present to with the greatest and most complicated deformities that podiatrists treat. Surgical procedures in these patients are often joint destructive rather than joint preserving due to the challenges of chronic instability, severe destruction of periarticular surfaces and rigid deformities that face the surgeon. This article presents arthrolysis as an alternative to joint destructive procedures in patients with mild to moderate deformities.
Methods:
Retrospective comparative study of 19 patients who underwent 24 forefoot reconstructions. All had an arthrodesis of their 1st MPJ in addition to a lesser metatarsal head resection (10), arthrolysis (6) or combination of the two (8). Arthrolysis consisted of a step wise reduction with extensor tendon lengthening, dorsal capsulotomy, collateral ligament release, flexor tendon transfer. The alignment was assessed after each step to determine if further dissection was necessary. Subjective, functional and radiographic results were evaluated post-operatively at 28 and 133 months. The choice of the procedure for the patient was made intra-operatively based on the amount of cartilage destruction of the head. Furthermore, irreducibly dislocated joints and subluxated joints were resected. Stable joints with a dorsiflexion contracture had arthrolysis. The authors used the student t-test and chi-square test to analyze statistical differences between the groups pre and post-operatively. Coughlins criteria was used for radiographic forefoot alignment.
Results:
All groups showed statistically significant improvement in their pre-operative AOFAS score at both the short term and long term followup. There were no substantial differences between the groups in terms of callosities, walking capacity, orthopedic aids or antirheumatic medication. An increase in the severity of the hallux IPJ was noted on x-ray in the arthrolysis and combination group at the long term followup. Arthrosis of the arthrolysis and combined group increased slightly over time. Axial and sagittal malalignment differences among groups was not significant at the last follow-up (p>0.26). Malalignment in the lesser digits did increase in all groups between the short-term and long-term followup (p<0.018). Sagittal malalignment increased significantly in the resection arthroplasty group only. On radiographic analysis, Coughlin’s criteria demonstrated 26% of lesser MPJ arthroplasties and 15% of arthrolysis showed malalignment (p=0.11).
Conclusions:
This study demonstrated overall improvement in AOFAS score after lesser MPJ arthroplasty, arthrolysis or combination. Reoperation rate was comparable in all groups and minimal differences were noted radiographically between the groups. The arthroplasty group, however, showed a significant increase in sagittal plane deformity following resection, indicating joint preserving procedures may provide greater stability long-term. The limitations I found with this study were the small sample size and lack of randomization between groups. A better study might be comparing the long term effects of arthroplasty vs. arthrolysis in patients with mild to moderate deformities.