Current Insights On Treating Second MPJ Dysfunction

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Author(s): 
Molly Judge, DPM, FACFAS

   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

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Jeff A. Hallsays: February 6, 2011 at 9:58 am

Later this week, we'll be posting a follow-up blog from Molly Judge, DPM, FACFAS. Dr. Judge will expound upon the suture and button technique for plantar plate stabilization and share some questions on the technique from colleagues at a recent seminar.

Jeff A. Hall
Executive Editor
Podiatry Today

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Paul Jones, DPMsays: February 23, 2011 at 7:40 am

Is there results from the seminar yet?

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Mark Nellermoe DPMsays: February 24, 2011 at 5:39 pm

I liked the direct approach your procedure takes to this pathology. My question is how the suture affects the extensor digitorum longus (EDL). Does the tension of the suture cause damage to the tendon? How do you get motion in the joint postoperatively with the tendon tied down with the suture?

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Ed Davis, DPMsays: February 27, 2011 at 8:30 pm

The underlying biomechanical cause of many cases of 2nd MTP joint dysfunction is first ray inadequacy. Most patients in the earlier stages of 2nd MTP joint dysfunction can be treated with orthotics, not surgery. Hypermobile first ray, forefoot supinatus can be treated via a first metatarsal head cut out, forefoot valgus posting when appropriate and a metatarsal elevation in the device.

Yes, orthotics are often not covered by insurance and surgery is.

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Molly S. Judge, DPMsays: March 1, 2011 at 12:44 pm

Dr. Davis,

I appreciate your input regarding 2nd MTPJ dysfunction. I agree with you wholeheartedly regarding the potential success of treating HAV with the benefit of orthotic devices. However, the 2nd MTPJ dysfunction has not responded equally well to that therapy. Once the instability has progressed and subtle subluxation and pain has developed, the need for an external splint and accommodative support of the MTPJ predictably provides pain reduction and stability to the affected joint. In my experience, stabilizing the 2nd MTPJ via metatarsal sling pad is far and away the best way to approach this lesser MTPJ instability and pain. The ADDED benefit of a formal orthotic device is an important one but doe not preclude the use of the metatarsal sling pad.

You make a valid point regarding the benefit of orthotic devices in the face of hallux abducto valgus and I agree with you that long-term management includes providing forefoot balancing. In my opinion, treating 2nd MTPJ dysfunction is a conservative issue by and large.

Unfortunately when patients are misdiagnosed, they often present to my office LATER having undergone numerous forms of treatment failures that include surgery. In my article, I emphasize the importance of the clinical and radiographic examination, and the need to exhaust conservative therapy. Only a few patients in my practice have ever required surgical intervention for this condition and I share that experience with the readers. The cases that I discuss in the cover story article on 2nd MTPJ dysfunction are the exception to the rule. In fact, the conservative method is very effective for 2nd MTPJ dysfunction in many cases.

Best regards,
Molly S. Judge, DPM

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