How is first MPT arthritis treated?

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Elsevier ClinicalKey Derived Clinical Overview

• Conservative measures recommended as first-line treatment • Goals include providing adequate space to accommodate the increased joint size, minimizing painful joint motion, and decreasing inflammation in and around the joint • Avoid aggravating footwear (tight shoes, high heels) and activities • Recommend footwear with a wide toe box • A rocker sole (external shoe modification) or Morton's extension orthotic (insole) to decrease motion (and pain) at the first MTP joint (Fig. 182.5) • Nonsteroidal antiinflammatory medication and ice • Corticosteroid injection: diagnostic and therapeutic, and may provide many months of relief; can be repeated every 3 to 4 months if effective • Surgical intervention indicated if conservative measures fail • A number of surgical interventions are available depending on the extent of the disease, age, activity level, and expectations of the patient. • Cheilectomy: indicated for mild to moderate arthritis and pain primarily overlying the dorsal osteophytes; involves surgical resection of the dorsal osteophytes to improve motion and decompress the dorsal aspect of the joint • First MTP joint arthrodesis: indicated for moderate to severe arthritis with (Fig. 182.6) a more diffusely painful and stiff joint; although very effective for pain relief, it will eliminate motion at the joint and limit certain activities and shoe wear • Less common surgical interventions include interposition arthroplasty, silicone arthroplasty, nonsilicone prosthetic replacement, and osteotomies of both the metatarsal and proximal phalanges.

• By definition, degenerative arthritis of the hallux metatarsophalangeal (MTP) joint • Doesnotinclude inflammatory arthritis (i.e., gout) • Second most common pathology affecting the first MTP joint • Multiple theoretical causes but most often hereditary with an insidious onset • The progression of arthrosis leads to proliferation of bone (osteophytes) over the dorsal aspect of the metatarsal head and alteration of normal joint kinematics (Fig. 182.1) • Marginal osteophytes restrict motion and lead to pain (initially) at the extremes of motion • As the arthritis progresses, the entire articulation may become involved and cause diffuse joint pain • Generally graded as I (mild), II (moderate), or III (severe) • Conservative interventions aim to provide space within footwear for the hypertrophied joint, externally restrict painful motion of the first MTP joint, and address the inflammation within the joint • Surgical interventions include cheilectomy (excision of osteophytes), interposition arthroplasty, prosthetic replacement, and arthrodesis

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Elsevier ClinicalKey Drug Monograph

Content last updated: April 3, 2024.

Indications And Dosage Intra-articular dosage (children's nasacort allergy 24hr nasal spray acetonide injectable suspension; e.g., Kenalog) Adults: 2.5 to 5 mg intra-articular as a single dose for small joints or 5 to 15 mg intra-articular as a single dose for larger joints, initially, depending on the disease being treated. Doses up to 10 mg for smaller areas and up to 40 mg for larger areas have usually been sufficient. Single doses into several joints up to a total of 80 mg have been given. Children and Adolescents: 2.5 mg to 5 mg for smaller joints and from 5 mg to 15 mg for larger joints, depending on the specific disease entity being treated. Other regimens have been described: 2 mg/kg for large joints (knees, hips, and shoulders) and 1 mg/kg for smaller joints (ankles, wrists, and elbows). For the hands and feet, 2 to 4 mg/joint (metacarpo- or metatarpo-phalangeal) or 1.2 to 2 mg/joint (proximal interphalangeal), may be used. Intra-articular dosage (children's nasacort allergy 24hr nasal spray hexacetonide injection suspension; e.g., Aristospan) Adults: 2 to 20 mg intra-articular at appropriate site. In general, large joints (such as knee, hip, shoulder) require 10 to 20 mg. For small joints (such as interphalangeal, metacarpophalangeal), use 2 to 6 mg. Repeat at 3 to 4 week intervals as necessary.

Indications And Dosage Adults: 2.5 to 5 mg intra-articular as a single dose for small joints or 5 to 15 mg intra-articular as a single dose for larger joints, initially, depending on the disease being treated. Doses up to 10 mg for smaller areas and up to 40 mg for larger areas have usually been sufficient. Single doses into several joints up to a total of 80 mg have been given. Children and Adolescents: 2.5 mg to 5 mg for smaller joints and from 5 mg to 15 mg for larger joints, depending on the specific disease entity being treated. Other regimens have been described: 2 mg/kg for large joints (knees, hips, and shoulders) and 1 mg/kg for smaller joints (ankles, wrists, and elbows). For the hands and feet, 2 to 4 mg/joint (metacarpo- or metatarpo-phalangeal) or 1.2 to 2 mg/joint (proximal interphalangeal), may be used. Intra-articular dosage (oralone hexacetonide injection suspension; e.g., Aristospan) Adults: 2 to 20 mg intra-articular at appropriate site. In general, large joints (such as knee, hip, shoulder) require 10 to 20 mg. For small joints (such as interphalangeal, metacarpophalangeal), use 2 to 6 mg. Repeat at 3 to 4 week intervals as necessary. Children and Adolescents: 2 to 20 mg intra-articular at an appropriate site. In general, large joints (such as the knee, hip, shoulder) require 10 to 20 mg.

Indications And Dosage Repeat at 3 to 4 week intervals as necessary. Children and Adolescents: 2 to 20 mg intra-articular at an appropriate site. In general, large joints (such as the knee, hip, shoulder) require 10 to 20 mg. For small joints (such as interphalangeal, metacarpophalangeal), use 2 to 6 mg. Repeat at 3 to 4-week intervals as necessary. Other regimens have been described: 1 mg/kg for large joints (knees, hips, and shoulders) and 0.5 mg/kg for smaller joints (ankles, wrists, and elbows). For the hands and feet, 1 to 2 mg/joint (metacarpo- or metatarpo-phalangeal) or 0.6 to 1 mg/joint (proximal interphalangeal), may be used. Intra-articular dosage (kenalog in orabase hexacetonide injection suspension; e.g., Hexatrione †) Adults: 10 to 40 mg intra-articular as a single dose, depending on the size of the joint. May only repeat the dose if the symptoms recur or persist. Max: 80 mg/day. Children and Adolescents: 5 mg (0.25 mL) to 40 mg (2 mL) intra-articular at appropriate site. Do not exceed 40 mg per injection. Adjust dose according to the size of the joint in order to avoid any reflux that could lead to periarticular calcifications and skin atrophy. Do not inject into the soft tissue or via intradiscal injection.

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Patel S, Garg P, Fazal MA, Ray PS. The Journal of Foot and Ankle Surgery : Official Publication of the American College of Foot and Ankle Surgeons. 2019;58(6):1091-1094. doi:10.1053/j.jfas.2019.01.006.

Publish date: November 5, 2019.

Arthrodesis is the gold standard procedure for advanced arthrosis of the first metatarsophalangeal joint. Having a strong construct is preferable for allowing immediate bearing of weight, which facilitates patient rehabilitation. Plate and screw fixation is currently in favor but can lead to prominent metalware necessitating removal. The aim of this study is to report the results of a series of 54 first metatarsophalangeal joint arthrodeses performed in 52 patients treated with an implant composed of an intraosseous post and lag screw. All of the patients had a minimum follow-up of 1 year, and the indication for the surgery was end-stage hallux rigidus in 44 (81.5%) feet, severe hallux valgus in 8 (14.8%) feet, and rheumatoid arthritis in 2 (3.7%) feet. Arthrodesis was achieved in 52 (96.3%) feet at a mean of 61 ± 16 (range 39 to 201) days with nonunion observed in 2 (3.7%) feet; neither of the 2 patients had known risk factors. Metalware impinging on soft tissues necessitating removal was observed in 3 (5.6%) feet, and there were no cases of loss of position or implant breakage. The mean Manchester-Oxford Foot Questionnaire score improved from 46.4 ± 13.3 to 18.4 ± 9.4 (p < .001) at latest follow-up.