From the Guidelines
Yes, arthrotomy with excision of osteophytes from the metatarsal head and proximal phalanx, joint debridement, and capsular repair is justified for degenerative osteoarthritic changes of the first metatarsophalangeal (MTP) joint with narrowing joint space of the distal interphalangeal joints. This recommendation is based on the most recent and highest quality study available, which suggests that surgical interventions such as joint arthroplasty in combination with a non-removable offloading device may be beneficial for patients with failed non-surgical offloading interventions 1.
Key Considerations
- The procedure aims to remove bone spurs (osteophytes) that limit joint motion and cause pain, while preserving joint function.
- Patients typically require 4-6 weeks for initial recovery, with weight-bearing as tolerated in a post-operative shoe or boot, followed by physical therapy to restore range of motion.
- Success rates are generally good (70-90%) for appropriate candidates, particularly those with grade 1-3 hallux rigidus who still have some preserved joint space.
Important Factors
- The indication for joint arthroplasty is for a hallux ulcer with limited range of motion of the first metatarsal-phalangeal joint.
- In case of other deformities with a hallux ulcer, joint arthroplasty may not be indicated.
- The costs, equity, acceptability, and feasibility of the intervention may vary based on the local resources available, as noted in the study 1.
Surgical Approach
- The surgical approach, often called a cheilectomy when performed on the first MTP joint, is appropriate for moderate hallux rigidus (stiff big toe) when conservative measures have failed.
- This approach is preferred over joint fusion or replacement for patients who wish to maintain joint mobility and have not progressed to end-stage arthritis with complete joint space loss.
- The procedure addresses the mechanical impingement caused by osteophytes while the capsular repair helps stabilize the joint after debridement.
From the Research
Degenerative Osteoarthritic Change of the First Metatarsophalangeal Joints
- The presence of degenerative osteoarthritic change of the first metatarsophalangeal joints with narrowing joint space of the distal interphalangeal joints is a common condition that can cause significant pain and disability 2.
- The management of this condition can be challenging, and various treatment options are available, including arthrotomy, excision of osteophytes, joint debridement, and capsular repair.
Justification for Arthrotomy, Excision of Osteophytes, Joint Debridement, and Capsular Repair
- There is evidence to suggest that arthrotomy, excision of osteophytes, joint debridement, and capsular repair can be effective in managing degenerative osteoarthritic change of the first metatarsophalangeal joints 3, 4.
- A study published in 2015 found that arthrodesis and hemiarthroplasty were effective in managing osteoarthritis of the first metatarsophalangeal joint, with similar postoperative outcomes 3.
- Another study published in 2021 found that osteophytes, bone marrow lesions, subchondral cysts, effusion-synovitis, joint space narrowing, and cartilage loss were characteristic MRI features of first metatarsophalangeal joint osteoarthritis 2.
- A study published in 2005 compared the effectiveness of phalangeal osteotomy and first metatarsal decompression osteotomy for the surgical treatment of hallux rigidus, and found that first metatarsal decompression osteotomy increased joint range of motion, but had a higher risk of complication and patient dissatisfaction 4.
Current Clinical Practice
- A survey of podiatrists and physical therapists in Australia and the United Kingdom found that they use an array of assessment and treatment approaches for people with first metatarsophalangeal joint osteoarthritis, including x-ray, range of motion, and pain scale assessment, as well as orthoses, exercise therapy, and advice on footwear 5.
- Another study published in 2014 found that arthrodesis of the first metatarsophalangeal joint was a reliable treatment option for end-stage osteoarthritis and rheumatoid arthritis, with a high incidence of fusion for both conditions 6.