What is the recommended treatment for a patient with severe osteoarthritis and a nonunion nondisplaced intra-articular proximal phalanx great toe fracture?

Management of Severe Osteoarthritis with Nonunion Nondisplaced Intra-articular Proximal Phalanx Great Toe Fracture

For a patient with severe osteoarthritis and a nonunion nondisplaced intra-articular proximal phalanx great toe fracture, joint replacement surgery is the recommended treatment when conservative measures have failed to provide adequate pain relief and functional improvement. 1

Initial Conservative Management

• Begin with core treatments for osteoarthritis including:

  • Education about the condition and self-management strategies 2
  • Activity modification to reduce mechanical stress on the affected joint 2
  • Exercise regimens for range of motion and strengthening 2
  • Weight loss if the patient is overweight or obese 2

• First-line pharmacological management:

  • Regular paracetamol (acetaminophen) for pain relief 2
  • Topical NSAIDs before considering oral medications 2
  • Topical capsaicin as an adjunct for pain relief 2

• Second-line pharmacological options if first-line treatments are insufficient:

  • Oral NSAIDs at the lowest effective dose for the shortest possible period 2
  • COX-2 inhibitors with a proton pump inhibitor in patients with gastrointestinal risk factors 2
  • Opioid analgesics may be considered for short-term use when other options fail 2

• Consider intra-articular corticosteroid injections for moderate to severe pain 2

Surgical Management for Nonunion Fracture with Severe OA

• Surgical intervention is indicated when:

  • Conservative treatments have failed 1
  • The patient has marked pain and/or disability 1
  • Functional limitation is severe 2

• Surgical options for the great toe with both severe OA and nonunion fracture:

  • Arthrodesis (joint fusion) is the preferred option for intra-articular fractures with concurrent severe osteoarthritis 1, 3
  • Trapeziectomy may be considered for thumb base OA but is less applicable to the great toe 2, 1
  • Arthroplasty (joint replacement) can be considered in selected cases 2, 1

• For the specific case of nonunion intra-articular fracture:

  • Open reduction and internal fixation with bone grafting may be necessary to address the nonunion before or during the definitive procedure 4, 5
  • Intra-articular osteotomy may be considered if the fracture has malunited rather than non-united 4

Important Considerations and Potential Complications

• High complication rates have been reported with surgical intervention for intra-articular fractures of the great toe 3

  • Potential complications include redisplacement, painful nonunion, refracture, posttraumatic arthritis, avascular necrosis, and hardware migration 3

• Patient-specific factors such as age, sex, smoking, obesity, and comorbidities should not be barriers to referral for joint replacement surgery 2

• For nonunion fractures specifically, newer techniques such as extracorporeal shock wave therapy combined with platelet-rich plasma injections have shown promise in case reports but lack robust evidence for routine use 6

• Postoperative rehabilitation is essential to maximize functional outcomes and should include:

  • Progressive range of motion exercises 2
  • Strengthening exercises 2
  • Gait training with appropriate assistive devices if needed 2

Follow-up Care

• Long-term follow-up should be adapted to the patient's individual needs 2
• Regular monitoring for complications and assessment of functional outcomes is essential 2
• Continued pain management may be necessary during the recovery period 2