Is advanced osteoarthritic change of the first metatarsophalangeal (MTP) joint with joint space narrowing and marked erosion of the articular surfaces an indication for first MTP joint arthrodesis with bone graft?

From the Guidelines

Advanced osteoarthritic changes of the first metatarsophalangeal joint with narrowing joint space and marked erosion of the articular surfaces is a clear indication for BIG TOE MTP JOINT ARTHRODESIS and BONE GRAFT, as this procedure has been shown to provide excellent pain relief and stability in patients with severe arthritis who have failed conservative treatments.

Indications for Surgery

The decision to proceed with surgery is typically made when conservative treatments have failed to provide adequate pain relief and functional improvement.

• The patient's symptoms and quality of life are significantly impacted by the arthritis
• Conservative treatments, such as physical therapy, medications, and orthotics, have been tried and failed
• The patient has significant joint damage, such as narrowing of the joint space and erosion of the articular surfaces

Surgical Procedure

The procedure involves removing the remaining damaged cartilage, preparing the bone surfaces, and fusing the joint in a functional position using screws, plates, or other fixation devices.

• Bone graft material (either autograft from the patient or allograft) is often used to promote solid fusion, especially when there is significant bone loss from erosion 1
• The surgery aims to eliminate painful motion at the joint by creating a solid bony connection

Post-Operative Care

Patients typically require 6-12 weeks of protected weightbearing in a post-operative shoe or boot, followed by gradual return to regular footwear and activities.

• While the procedure sacrifices joint motion, it provides excellent pain relief and stability, allowing patients to return to most activities without the debilitating pain of end-stage arthritis
• The success rate for MTP arthrodesis is high (85-95%), with most patients reporting significant improvement in pain and function, although the evidence for this specific procedure is not directly addressed in the provided study 1.

From the Research

Indications for BIG TOE MTP JOINT ARTHRODESIS and BONE GRAFT

• Advanced osteoarthritic changes of the first metatarsophalangeal joint with narrowing joint space and marked erosion of the articular surfaces are indicated for BIG TOE MTP JOINT ARTHRODESIS and BONE GRAFT, as this procedure is commonly performed for the treatment of end-stage arthritis 2.
• The goals of a successful 1st MTP arthrodesis are pain alleviation and deformity correction in order to restore a comfortable gait pattern and to improve shoe wear 2.
• Arthrodesis of the first metatarsophalangeal joint has been established as the "gold standard" for the treatment of several first ray disorders, due to its perceived efficacy and the consistently reported good results in the literature 2.

Surgical Procedure

• The surgical procedure for BIG TOE MTP JOINT ARTHRODESIS and BONE GRAFT involves a dorsal approach to the first metatarsophalangeal joint, removal of all osteophytes and circumferential capsular release, debridement of the sesamoids, cartilage resection, and multiple drilling of the subchondral layer 3.
• In case of osseous defects, interposition of a corticocancellous bone graft may be necessary 3.
• Fixation with two screws, one lag screw and dorsal plating, or dorsal plating only is used to stabilize the joint 3.

Outcomes and Complications

• The outcomes of BIG TOE MTP JOINT ARTHRODESIS and BONE GRAFT are generally good, with high fusion rates and significant improvement in pain and function 3, 4, 5.
• However, complications such as delayed union, nonunion, malunion, and irritating hardware can occur 2.
• The incidence of first MTP arthrodesis was high for both patients with OA and those with RA, and those with RA appeared to achieve fusion more rapidly 5.