A Guide To First MPJ Arthrodesis For Active Patients

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Continuing Education Course #137 December 2005

I am pleased to introduce the latest article, “A Guide To First MPJ Arthrodesis For Active Patients,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

When treating active patients with hallux limitus, hallux rigidus or first metatarsophalangeal (MPJ) osteoarthritis, Lawrence A. DiDomenico, DPM, and Alfonso A. Haro III, DPM, have found surgical success with first MPJ arthrodesis. They provide a comprehensive survey of the literature on the procedure and offer pertinent pearls for surgery and postoperative care.

At the end of this article, you’ll find a 10-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 66 and successfully answering the questions on pg. 74. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Drs. DiDomenico and Haro have disclosed that they have no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of their presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists.
RELEASE DATE: December 2005.
EXPIRATION DATE: December 31, 2006.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• distinguish among the different stages of hallux rigidus according to the Modified Regnauld Classification System;
• assess the various techniques of joint preservation and joint destructive procedures;
• explain why resection arthroplasties and hemi- or total joint implants are discouraged in the athletic population;
• discuss pertinent intraoperative insights for the first MPJ arthrodesis; and
• discuss key postoperative considerations for the first MPJ arthrodesis.

Sponsored by the North American Center for Continuing Medical Education.

In this pre-op lateral radiograph, one can see a Stage II Modified Regnauld Classification of hallux rigidus.
In this AP radiograph, one can see a Stage II Modified Regnauld Classification of hallux rigidus.
As one can see on this post-op lateral radiograph, this patient has undergone a cheilectomy and Lapidus procedure.
As one can see on this AP radiograph, this patient has undergone a cheilectomy and Lapidus procedure.
In this lateral radiograph, one can see the patient has Stage III hallux rigidus as per the Modified Regnauld Classification.
Here is a post-op lateral radiograph of a Stage III patient who has undergone a cheilectomy and Lapidus procedure.
Here one can see the burr hole prepped for a shear strain graft.
Here is a post-op AP view showing arthrodesis of the first metatarsophalangeal joint.
Here is a post-op lateral view showing arthrodesis of the first metatarsophalangeal joint.
74
Author(s): 
By Lawrence A. DiDomenico, DPM, and Alfonso A. Haro III, DPM

   Surgical recommendations are sparse when evaluating treatment options for the athletic population diagnosed with hallux limitus, hallux rigidus or first metatarsophalangeal (MPJ) osteoarthritis. However, we have found success in treating athletes with first MPJ arthrodesis, and helping them to achieve pain relief and a return to activities.

   Several surgeons have found similar success as evidenced by a review of the literature on this subject. In 1996, Bouche, et. al., advocated first MPJ arthrodesis in active patients, reporting that it could “relieve pain and allow patients to perform some athletic function (including running).”1 They performed first MPJ arthrodesis for five individuals who ranged from 42 to 57 years old and each patient returned to his or her respective preoperative weightbearing activity. The daily activities of these patients included walking, exercise, race walking, power walking and running.

   While there is still controversy on whether one should perform first MPJ arthrodesis in the active population, Bouche says the first MPJ arthrodesis is the preferred joint destructive procedure in active patients and is a “definitive, predictable and viable option.”1

   In 2005, Brodsky, et. al., presented results of a retrospective study and indicated that “patients with a first MPJ fusion function extremely well and most athletic patients continue participating in sports with the advantage of greatly diminished discomfort.”2 Surgeons performed a first MPJ arthrodesis on 53 patients (60 feet), who ranged between 21 to 79 years old. These patients engaged in weightbearing activities ranging from activities of daily living to recreational sports and exercise.2 The researchers performed postoperative functional testing on 45 patients. Of those 45 patients, 64 percent could stand on their tiptoes, 94 percent could kneel, 87 percent could squat and 98 percent could pick up a small object from the floor.2

   The following are the results of patient answers to a functional questionnaire.2

   • 100 percent could ascend stairs
   • 96 percent could descend stairs
   • 100 percent could walk less than one block
   • 96 percent could walk one to six blocks
   • 90 percent could walk over six blocks
   • 75 percent returned to jogging
   • 80 percent returned to golfing
   • 92 percent returned to hiking
   • 75 percent returned to tennis
   • 98 percent returned to work
   • 45 percent had no shoe limitations
   • 47 percent required comfort shoes
   • 8 percent required prescription insoles

   Brodsky, et. al., described arthrodesis of the first MPJ as “a successful surgical procedure that provides relief of pain, correction of deformity and allows a high level of function in everyday life and in recreational activities.”2

Hallux Rigidus: Essential Staging Insights

   When staging hallux rigidus, we prefer to use the Modified Regnauld Classification as presented by Vanore, et al., and adapted by the American College of Foot and Ankle Surgeons.3-6 Here are the stages of this classification.

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