Sharing insights from their experience in treating first MPJ arthritis, these panelists discuss non-surgical modalities, biologics, the cheilectomy, implants and fusion.
Is it time to rethink the role of cheilectomy for first metatarsophalangeal joint (MPJ) arthritis? Can biologics have an impact? Is arthrodesis ultimately the best procedure for late-stage osteoarthritis in the first MPJ? Do orthotic modifications provide adjunctive benefit for pain reduction? In a roundtable discussion, panelists address these questions and much more.
What non-surgical treatments have you found effective in treating first MPJ arthritis? Do you have any pearls for predicting which patients might do well with these options?
In regard to conservative measures for pain management, the majority of the panelists will initially employ topical or oral anti-inflammatory medications in combination with orthotics. Roberto A. Brandão, DPM, notes that he generally begins with non-custom orthotic inserts with a modification via a Morton’s extension, reverse Morton’s extension or a stiff shank. If the patient improves with this approach, Dr. Brandão transitions to custom orthoses.
Patrick Bull, DO, FAOAO, tries to manage symptoms and minimize joint damage with the combination of Morton’s insole extensions and nonsteroidal anti-inflammatory drugs (NSAIDs). Discussing his conservative options, Bob Baravarian, DPM, FACFAS, says one treatment is the use of carbon foot plates in shoes. He has also employed an orthotic with a Morton’s extension in late-stage cases and has utilized an orthotic with a cutout in the first metatarsal head region “to try and drop the metatarsal down and improve range of motion.”
In his experience, Collier Watson, DO, has found limited benefit with the Morton’s extension insert.
“Patients either won’t get the insert or if they do get it, they don’t tolerate wearing it in their shoe,” explains Dr. Watson.
In addition to topical and/or oral NSAIDs, Corey Fidler, DPM, initially tries custom or prefabricated orthotics with a stiff extension under the first MPJ. He also encourages activity modifications depending upon the patient’s symptoms.
Drs. Watson, Bull and Baravarian mention the use of shoes with stiffer or more rigid soles. Dr. Watson says he educates patients about wearing shoes with a stiffer sole, which “does not allow as much motion through the joint, which helps to calm down the inflamed synovium.” Dr. Bull emphasizes the benefits of rigid insoles and stability shoes.
“With the tremendous variety of stiff-soled rocker walking shoes, I can almost always find one that will satisfy even the most particular of patients,” notes Dr. Bull. “I have been amazed at how many lower demand patients do very well with shoe modifications and some topical anti-inflammatories.”
If footwear changes and anti-inflammatory medication fail to address the patient’s symptoms, Dr. Watson says fluoroscopic-guided intra-articular steroid injections can provide good pain relief. Dr. Brandão discusses corticosteroid injections with the patient if initial prefabricated orthotics with Morton’s extensions fail to provide symptom relief.
In regard to corticosteroid injections, Dr. Bull tells his patients the injection is, “at best, a temporizing treatment and pain relief beyond eight weeks is rare.” He uses steroid injections sparingly as he has seen patients that had multiple injections at other institutions come to him with subdermal fat atrophy and skin thinning over the MPJ, which increases the risk of incisional complications.
If conservative treatments fail, Dr. Brandão also obtains magnetic resonance imaging (MRI) to further delineate the pathology. For patients with acute or remote injuries, Dr. Brandão says the MRI can be useful in revealing a more focused cartilage lesion, which can help guide further treatment.
What role, if any, do “biologics,” such as PRP, bone marrow aspirate concentrate (BMAC) and amniotic injections, have in your treatment algorithms, and are there any other “outside the box” type treatments you consider?
Dr. Baravarian has employed amniotic membrane and platelet-rich plasma (PRP) injections in cases of early-stage first MPJ arthritis and cases with associated osteochondral damage.
“There is definitely a place for regenerative treatments but the main issue is the joint mechanics being off with hallux rigidus, and one would need to address this,” notes Dr. Baravarian.
For cases involving traumatic arthritis with an osteochondral lesion, Dr. Baravarian suggests using bone marrow aspirate concentrate or PRP. However, he concedes the results with these therapies in hallux rigidus cases are not as good as the results with early-stage arthritis. In regard to biologics, Dr. Brandão says he usually incorporates these therapies adjunctively to supplement cartilage repair or arthrodesis. He has also offered biologic injections as a non-surgical alternative to corticosteroids with mixed utilization.
Being in a group practice, Dr. Brandão says many of his patients have had exposure to the use of PRP or amniotic membrane injections for knee or hip arthritis. That said, due to the cost of biologic treatment options, he notes patients “seldom” choose these injections after failing other therapies.
“The current literature is lacking in regard to using biologics for first MPJ arthritis and given that insurance companies in my area do not cover these procedures, I do not routinely offer them to my patients,” maintains Dr. Fidler.
However, if patients insist on biologic therapies and are willing to pay for them out of pocket, Dr. Fidler will discuss these modalities with the patient. He does caution his patients that biologic therapies do not offer a permanent fix and “benefits could be short-lived.”
Drs. Bull and Watson do not use biologic therapies in their practice for first MPJ arthritis.
Dr. Baravarian has just started using botulinum toxin (Botox, Allergan) for joint pain and notes it is “incredibly impressive” for joint pain.
He says this modality seems to reduce the neurological response of the joint to pain. Dr. Baravarian notes that he has injected the inside of the joint as well as inside and around the joint, and patients had significant pain relief.
Dr. Baravarian concedes that this therapy may be “delaying the inevitable” and that the jury is still out on the utility of botulinum toxin for first MPJ arthritis.
In regard to outside of the box modalities for this condition, Dr. Brandão has not employed the use of laser therapy, shockwave therapy or cannabidiol (CBD) oil therapies in his practice for this condition.
The cheilectomy has long been considered the workhorse in treatment of “dorsal bump pain” and the surgical management of mild to moderate first MPJ arthritis. First, do you agree with this statement? Second, how far can you push the cheilectomy for later stage degenerative joint disease (DJD) of the first MPJ?
Drs. Brandão and Watson say the cheilectomy is a viable procedure that facilitates pain relief in patients with early stages of hallux rigidus. Dr. Bull concurs, calling the cheilectomy the “workhorse” for dorsal first MPJ pain. The procedure is effective for those with “dorsal bump pain” at the extreme range of motion at the first MPJ, according to Dr. Watson. He notes that the surgeon doesn’t burn any bridges with the cheilectomy. Dr. Brandão adds that a standard dorsal resection, which several authors have advocated, provides the most optimal results in his experience.
That said, Drs. Watson and Brandão do not generally utilize the cheilectomy for patients with longstanding and more painful stage 3 or stage 4 deformities. Dr. Watson says these patients do better with a fusion, especially if there isn’t much motion in the first MPJ. Dr. Brandão concurs. If the patient has severe dorsal spurring, restricted motion and degenerative changes on X-rays, arthrodesis is a better option, according to Dr. Brandão. Anecdotally, Dr. Brandão says he has had patients with stage 3 and stage 4 hallux rigidus come to him after having a cheilectomy and still complain of pain with motion.
In his experience, Dr. Baravarian says the cheilectomy has never worked well in his patients unless they have a “very early stage” of first MPJ arthritis.
“I find the joint is usually tight and there is a decrease in joint space, which does not resolve with cheilectomy in stage 2 and stage 3 disease states,” claims Dr. Baravarian.
Dr. Fidler says he learned in podiatry school and residency training that the cheilectomy is the gold standard and first line of treatment for first MPJ arthritis. However, he doesn’t agree that it is the best procedure for every patient. While the idea of not burning any bridges is true when comparing the cheilectomy to arthrodesis, Dr. Fidler says one is just delaying the inevitable in many patients.
“Also, this concept of preserving joint motion is only true on the OR table immediately after the procedure is completed while the patient is asleep,” maintains Dr. Fidler. “In reality, what usually happens is that you are exposing a large surface area of bleeding cancellous bone to the surrounding soft tissues and after a few days, the joint capsule scars in and you lose the motion you achieved with the cheilectomy.
“I tell patients that the cheilectomy can help reduce “bump pain” but it won’t address the underlying cause of their bump and therefore they will likely need another surgery down the road. If a patient says he or she only wants (or is able) to take time off for one surgery, then the cheilectomy is not for him or her. However, in those patients in whom a fusion may not be in their best interest, I usually supplement my cheilectomies with a proximal phalanx procedure like the Moberg osteotomy, which I feel maintains the increased postoperative motion for a longer period of time.”
Dr. Baravarian has found that combining a decompression osteotomy with cheilectomy is a “far better option” than just a cheilectomy.
“This decreases the joint tightness and patients seem to have better motion, less stiffness and far less pain,” adds Dr. Baravarian.
Dr. Bull says it is important to screen patients for deeper joint pain and/or metatarsal-sesamoid pain during the physical exam as he has seen cheilectomy fail in patients with these pathologies. While he notes that he has pushed cheilectomy in more advanced stages of first MPJ arthritis, Dr. Bull maintains that he sets “appropriate functional and pain relief expectations” during discussions with the patient prior to the procedure. He adds that he has had success combining cheilectomy with cartilage restorative procedures for metatarsal head osteochondral defects sometimes with a metatarsal shortening osteotomy.
Patients are typically hesitant with the concept of fusion of their first MPJ, even if it brings pain relief. There have been various partial and total first MPJ replacements on the market for decades with mixed results. What are your thoughts and early experience, if any, with the polyvinyl synthetic joint space implant that is getting all the buzz?
Dr. Brandão has seen patient hesitancy with first MPJ arthrodesis and limitations in motion. Often, these patients quickly seek other options to preserve their motion as they feel it will limit their lifestyle, according to Dr. Brandão. He advocates appropriate patient selection and expectation management as the ultimate keys to successful long-term outcomes in active patients when it comes to discussing alternative surgical procedure options.
Dr. Watson says the polyvinyl synthetic implant (Cartiva, Wright Medical) does have a place in the surgical treatment of first MPJ arthritis.
“I believe this is a good option as one can combine it with a cheilectomy and it allows the patient to maintain some degree of joint motion,” notes Dr. Watson. “In my opinion, I’m not burning any bridges by using this implant and it can be easily converted to a fusion if it fails to provide adequate pain relief.”
For younger patients with moderate to severe arthritis who still have some decent motion of the joint, and are adamant that they do not want a fusion, Dr. Watson educates them about the use of this implant as well as the current literature regarding patient outcomes.
So far, Dr. Watson says his patients have been “fairly pleased” with the results with the Cartiva implant and they know that if it does fail, fusion is the next step. Dr. Brandão also notes that he has had some good, albeit limited, experience with the Cartiva implant and says studies have demonstrated that the implant is effective for pain relief with good clinical outcomes. Drs. Watson and Brandão emphasize being on the same page with patient expectations, educating them on potential complications with the implant and the potential need for fusion down the road.
Dr. Baravarian emphasizes that surgeons should avoid using this device. He says he was initially enthusiastic about the implant as the research results were impressive. However, Dr. Baravarian has seen high failure rates with the Cartiva implant in his practice.
“In our practice, we have seen over a 50 percent failure rate and there is a consistent pattern of the implant shrinking into the metatarsal head,” says Dr. Baravarian. “There does not seem to be bone loss, just the implant shrinking and not sitting proud.”
He notes that he has removed many of these implants for his own patients as well as others who have been referred to him and Dr. Baravarian says “they all have a similar pattern.” He believes the implant is failing because it requires fluid to stay hydrated and an arthritic joint lacks this hydration. Accordingly, Dr. Baravarian says the implant may be drying out and shrinking into the hole as a result. He concedes this theory is a guess on his part but maintains that the Cartiva implant is ineffective. If one is using an implant, Dr. Baravarian says the ToeMotion Total Toe System (Arthrosurface) is “solid, stable and seems to last very well.”
Dr. Fidler says his experience with the Cartiva implant has been converting it to fusions. He maintains that time will tell if the Cartiva implant is a valid procedure but would like to see unbiased randomized controlled trials to assess the implant.
On the other hand, Dr. Bull says his experience with the polyvinyl alcohol joint arthroplasty has been “very good.”
“As a pain relieving and function improving procedure, (the Cartiva implant) has worked very well for me in the low to moderate demand patients with advanced first MPJ arthritis,” notes Dr. Bull.
However, he emphasizes that he is “strict with indications” and avoids using the implant in young patients, patients with deformity and those with activity aspirations that are too aggressive. Dr. Bull also adds that arthrodesis remains his “workhorse procedure” for advanced first MPJ arthritis.
In your experience, do your patients who undergo first MPJ fusion do well functionally and return to a reasonable level of activity? Are there any permanent restrictions you emphasize or activities you tell them they shouldn’t participate in after a fusion?
Dr. Bull says first MPJ arthrodesis is an “excellent procedure for end-stage first MPJ osteoarthritis.” Functionally, Drs. Bull, Fidler and Baravarian say most patients with end-stage first MPJ osteoarthritis have already adapted to a fused joint preoperatively due to longstanding pain and do not notice substantial functional deficits postoperatively.
“In fact, with a well-positioned fused joint and a set of modern stiff rocker-soled walking shoes, most arthrodesis patients feel they have gained rather than sacrificed considerable function,” points out Dr. Bull.
The fist MPJ arthrodesis is “the best procedure for middle to end-stage arthritis,” according to Dr. Fidler. Dr. Baravarian says fusion is his mainstay treatment for patients with late stage 2 and up first MPJ arthritis. Dr. Watson has had a lot of success with first MPJ fusions. When discussing the procedure with patients, he says they are going from having a “painful stiff joint now” to having a “painless stiff joint” with fusion. Dr. Watson adds that most of his patients return to the previous activity level they had prior to fusion. Dr. Brandão concurs, noting that his patients return to a very reasonable level of activity.
“A well-positioned arthrodesis allows for good, unrestricted motion of the hallux interphalangeal joint, leaving patients with the ability to push off and extend effectively,” says Dr. Brandão.
In regard to post-op restrictions on activity, Dr. Watson encourages patients to refrain from high-impact activities such as box jumps but notes that most patients get back to playing tennis, golf or doing light jogging for exercise. Unless the patient is an avid marathon participant or a competitive athlete, Dr. Fidler says his patients return to whatever activities are tolerated after fusion.
Dr. Bull notes that he tries to avoid post-op restriction of activity with his patients and focuses on patients having appropriate shoes, insoles and devices to reach their functional goals.
“Highly repetitive forefoot loading activities like running and jumping are obviously going to be challenging for this group but not impossible to achieve with the right combination of education and equipment,” says Dr. Bull.
Dr. Brandão counsels patients that they may need to modify certain activities like yoga maneuvers and gardening as well as certain shoe gear choices (i.e. high heels). Dr. Fidler recommends limiting heel height to no more than a couple of inches.
Dr. Baravarian says fusion patients should not wear high heels. Other than that, he has found that “fusion allows anything and everything else, and also allows a patient to be very active without pain.” For women who must wear high heels, Dr. Baravarian will discuss other treatment options. In many cases, though, he says they prefer the “one and done outcome of fusion and the ability to do whatever they want without restriction of implant failure or stress.”
Dr. Baravarian is an Assistant Clinical Professor at the UCLA School of Medicine. He is the Director and Fellowship Director at the University Foot and Ankle Institute in Los Angeles (https://www.footankleinstitute.com/podiatrist/dr-bob-baravarian ) .
Dr. Brandão is a fellowship-trained foot and ankle surgeon in private practice at Orthopedic Associates of Central Maryland. He is an Associate of the American College of Foot and Ankle Surgeons.
Dr. Bull is a board-certified orthopedic surgeon in private practice at Orthopedic Foot and Ankle Center in Worthington, Ohio. He is a Fellow of the American Osteopathic Academy of Orthopedics.
Dr. Fidler is a fellowship-trained foot and ankle surgeon who is in private practice in Virginia. He is an Assistant Professor of Orthopaedic Surgery at the Virginia Tech Carilion School of Medicine.
Dr. Watson is a board-certified orthopaedic surgeon in private practice in Columbus, Ga. He is a member of the American Osteopathic Association, the American Osteopathic Academy of Orthopedics and the American Orthopedic Foot and Ankle Society.
Dr. Hyer is the Co-Director of the Orthopedic Foot and Ankle Center Fellowship at the Orthopedic Foot and Ankle Center in Westerville, Ohio. He is a Fellow of the American College of Foot and Ankle Surgeons.