64: RA/ Lesser MPJ - Frush Flashcards Preview

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Flashcards in 64: RA/ Lesser MPJ - Frush Deck (23)

criteria for classification of RA

  • morning stiffness
  • arthritis of 3 or mor joint areas
  • arthritis of hand jts
  • symmetric artyhritis
  • rheumatoid nodules
  • serum rheumatoid factor
  • radiographic changes


radiographic findings RA

  • symmetrical involvement
  • uniform jt space narrowing
  • marginal erosions
  • cystic changes
  • cortical thinning
  • osteopenia


typical forefoot deformities assoc with RA

  • hyperpronation
  • metatarsalgia (dislocation MPJ and thinning fat pad)
  • MPJ dislocation
  • Hallux valgus
  • claw toes, hammertoes
  • also more prone to peripheral neuropathy, vasculitis, raynaud's phenomenon


typical midfoot and rearfoot deformities assoc with RA

  • talonavicular arthritis
  • subtalar joint arthritis
  • rupture of post tibial tendon


non-op tx for RA

  • medications
    • NSAIDs, DMARDS, corticosteriods (prednisone), methotrexate
  • shoegear modifications
    • rocker bottom sole
  • accomodative insoles
  • AFO


Pre-op management of a RA pt taking steroids or anti-rh drugs

  • Corticosteroid supplements
    • less than 5 mg --> give regular, no supplement
    • greater than 5 mg --> give regular + 25 mg prior to surg
  • Adjustment of anti-rh drugs
    • stop DMARDs 1-2 wks prior to surgery depending on drug half-life
    • methotrexate does not need to be stopped


special periop management of RA pt

  • prophylactic antibiosis prior to major sx or jt replacement
  • prophylaxis for DVT
  • workup for atlantoaxial subluxation
    • get cervical spine films, looking for arthritis in neck, intubation risk
  • overall bone stock


where would a rheumatoid nodule show up in the foot?

found around achilles or plantar forefoot most frequently

  • subcutaneous nodule
  • 20-35% pt
  • more frequent in more aggressive
  • remove if symptomatic


if RA effects forefoot, which MPJs are involved?

all MPJ

can also effect hindfoot or do both

  • synovial inflammation leads to disruption of colalteral ligaments and capsul
    • dorsal subluxationa nd eventual dislocation occurs
    • intrinsics lose mechancal advantage leading to hammer or claw toes
  • due to jt dislocation, plantar fat pad gets displaced


RA foot with hammertoes, what surg?


hammertoes 2-4

hammertoe 5

mallet toe 2-4

—Hallux --- Arthrodesis

—Hammertoes 2-4 ---- Arthrodesis or arthroplasty

—Hammertoe 5 ---- Arthroplasty

—Mallet toes 2-4 ----- Arthroplasty


 indications for panmetatarsal head resection (hoffman)

[resection of lesser met heads along usually with arthroplasty/arthrodesis of 1st MPJ]


  • pain with motion
  • non-reducible dislocation
  • jt destruction
  • progressive arthritis
  • trauma
  • atrophy of fat pad
  • multiple hyperkatotic lesions


advantages and disadvantages for plantar (hoffman) approach to panmet head resection

  • —Advantages
    • —Good visualization
    • —Relocates plantar fat pad
    • —Easier to remove met heads in dislocated joints
  • —Disadvantages
    • —Patient needs to NWB or partial WB for at least 3 weeks for optimal healing
    • —Plantar scar
    • —Wound dehiscence


advantages and disadvantages to (larmon) three linear dorsal incisions for panmet head resection surgery

  • —Advantages:
    • —post-operative scar contracture does not affect digits
    • —Early ambulation
    • —good cosmesis
  • —Disadvantages:
    • —limited surgical exposure
    • Injury to neurovascular
    • May be difficult to remove met heads in dislocated joints


advantages and disadvantages of 5 incisional approach (hodor dobbs) for panmet head resection

  • Advantages:
    • —Good exposure to mpj’s and soft tissue
    • —Minimal damage to neurovascular structures
    • —Early ambulation with limited post-operative morbidity
    • —Good preservation of capsular and periosteal tissue
    • —Good cosmesis
  • Disadvantages:
    • —Skin incisions are in close proximity to one another
    • —Higher incidence of skin slough
    • —Scar contractures are linear and may contribute to digit contractures reoccurring


advantages of (bilotti) one linear, two lazy S approach to panmet head resection

  • —Advantages:
    • —Provides for maximum tissue exposure
    • —Preservation of vital structures
    • —Minimal tissue deficit
    • —Scar contracture does not alter correction
    • —Minimal morbidity
    • —Good cosmesis
  • Disadvantages:
    • —Technically difficult
    • —Requires meticulous dissection
    • —Incisions require careful planning


advantages and disadvantages of panmethead resection

  • —Advantages:
    • —Eliminates painful MPJ’s
    • —Ability to ambulate without pain
    • —Allows patient to wear regular shoes
    • —Allows reduction of dorsally contracted digits
    • —Elimination of plantar pressure points
  • —Disadvantages:
    • —Loss of propulsive gait
    • —Flail toe postoperatively
    • —Incidence of hematoma formation w/fibrosis
    • —Destroys function of MPJ’s
    • —Loss of digital stability


mayo vs. keller arthroplasty for 1st MPJ in RA pt

  • —Mayo
    • Resection of 1st met head
    • Effects propulsion and WB
    • Not used much
  • —Keller
    • Resection of the base of proximal phalanx
    • Better propulsion and weight transfer than Mayo but do lose some


what do you do for TN, STJ arthritis?

Ankle arthritis?

  • —TN, STJ arthritis
    • Triple arthrodesis
  • —Ankle arthritis
    • Total ankle arthoplasty
    • Ankle arthrodesis

Patients need to be counseled on the length of recovery (months)


postop plan for pan met head resection

  • Plantar incision – NWB or Partial WB for at least 3 weeks
  • Dorsal incision – may walk in postop shoe if Keller, boot if 1st MPJ fusion


postop plan triple arthrodesis or ankle arthrodesis

8-12 weeks of NWB until consolidation noted


advantages and disadvantages of arthroplasty 1st MPJ in RA pt (compare to arthrodesis)

  • —Advantages
    • No hardware needed
    • Good procedure for osteopenic bone
    • No bone healing required
  • —Disadvantages
    • HAV deformity can come back (50%)
    • Loss of propulsion
    • Floppy toe


advantages and disadvantages of arhtrodesis

  • —Advantages
    • Maintains alignment
    • Provides lever for propulsion
    • High satisfaction rates
    • Less rate of lesser metatarsalgia
  • —Disadvantages
    • Requires hardware
    • Need bone healing to occur
    • –Union rate 84-100%
    • May lead to Hallux IPJ arthritis


when could you do implant arthroplasty?

  • —Need to have little deformity or correct deformity prior to placement
  • —Need adequate bone stock
  • —Most studies done on hinged silicone implants
    • High rate of complications

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