Current Insights On Treating Second MPJ Dysfunction
- Volume 24 - Issue 2 - February 2011
- 20961 reads
- 5 comments
Why do I say unfortunately? When people come in reporting symptoms without any evidence of subluxation, a prodromal syndrome or “stage 0” condition may exist. This stage is associated with an insidious onset of pain, which becomes progressively worse and interferes with a patient’s sense of well-being. At this time, the patient usually has not altered his or her activity level, which contributes to an ongoing and increasing inflammatory reaction as repetitive cycling of the joint continues without support or stabilization.
One may identify the condition and educate the patient about the condition at this time. However, without visible evidence of deformity, it is not uncommon for a patient to participate in a conservative care plan only temporarily. After the use of a metatarsal sling pad or other accommodative forefoot device, the symptoms may resolve. Then the negative reinforcement required to remind the patient to continue using the device is gone.
Once symptoms have disappeared, there is little reason to follow up in the office and the digital splints and other devices fall by the wayside. In this subset of patients, it is common to have them return to the office with subluxation of the digit and worse pain. Sometimes a patient will have experienced injection therapy elsewhere, resulting in end stage subluxation if not dislocation of the joint. When this happens, the patient may pursue legal action given the poor outcome and even worse prognosis.
Taking A Fresh Look At Second MPJ Surgery
There are some who believe that the traditional approach to digital surgery is misguided if not backward in logistics.2 The traditional approach has revolved around shortening the digit via arthroplasty or arthrodesis at the proximal interphalangeal joint level.3 The surgeon then uses a stepwise approach to decompress the joint, ultimately releasing the MPJ capsule and stabilizing that with K-wires across the MPJ for three to four weeks. This procedure can be associated with recurrent deformity despite the best surgical and clinical efforts. Complaints of a stiff digit, chronic swelling, ongoing forefoot pain, lateral transfer lesions and the like make digital surgery a risky prospect for some patients.
For some patients, the use of external K-wires is often aesthetically distasteful and poses an increased risk of bone and joint infection. The discussion of the risk of stiff and swollen digits often curbs a patient’s desire to have definitive correction and rightly so.
From the physician’s standpoint, there are a number of concerns with placing a K-wire across the MPJ and residual joint stiffness is among the most frequent complaints. Placing a 1.25 mm hole in the small cartilage surface area of the metatarsal head often irreparably damages the very joint we were trying to repair. Although no one has ever demonstrated the ill effect of this cartilage damage, the natural history of progression of an osteochondral lesion is well understood. In some cases, the chondral defect(s) can remain silent and asymptomatic while others may experience profound joint dysfunction and degeneration.
An alternative consideration for MPJ dysfunction, specifically second MPJ dysfunction, is arthrodesis of the MPJ. By all accounts, arthrodesis has rarely been tested so there simply is not the data to support or promote its routine use as a primary procedure unless no viable alternative is appropriate.4