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OPTIMIZATION OF TACTICS OF SURGICAL TREATMENT OF ELDERLY PATIENTS SUFFERING FROM FRIGIDITY OF THE FIRST TOE
Tokarev A.E., Amarantov D.G., Ladeyshchikov B.M., Zarivchatsky M.F., Belokrylov N.M., Denisov A.S., Shchekolova N.B., Pavlova V.N.
Perm State Medical University named after Academician E.A. Wagner, Perm, Russia
Dysfunction of the first metatarsophalangeal joint of the foot develops
in 40 % of people leading an active lifestyle [1]. The main cause of this
dysfunction is deforming osteoarthrosis. Deforming osteoarthrosis of the foot
is a degenerative-dystrophic pathology with a predominant lesion of the first
metatarsophalangeal joint. Modern researchers usually define deforming
osteoarthrosis of the I metatarsophalangeal joint as a rigid 1st toe (hallux
rigidus) [2]. The rigid toe is one of the three leaders among
degenerative-dystrophic pathologies of the extremities; in terms of frequency
of occurrence, only arthrosis of the knee and hip joints is ahead of it [1].
Among the clinical manifestations of deforming osteoarthrosis of the first
metatarsophalangeal joint, pain, a decrease in the range of motion and a
feeling of stiffness in the joint are in the lead. A characteristic feature of
deforming osteoarthrosis of the first metatarsophalangeal joint is pain in the
foot, which increases with walking. Morphological manifestations are the
destruction of the cartilage tissue of the joint, followed by the replacement
of the cartilage with overgrown bone tissue. The result of such a morphological
process is the fusion of the articular surfaces of the first
metatarsophalangeal joint, which inevitably leads to a pronounced decrease in
joint mobility and the formation of rigidity of the first toe [3].
There is a large number of classifications
dividing hallux rigidus into the stages of the disease [4]. In this work, we
used the Regnauld classification (1983), dividing deforming osteoarthrosis of
the 1st metatarsophalangeal joint into three stages (Table 1).
Table 1. Classification of deforming osteoarthritis of the first of metatarsophalangeal joint of the foot (Regnauld, 1983)
|
Deforming osteoarthritis stage |
Clinical and radiological signs |
|
I |
Unexpressed pain when walking |
|
II |
Decreased dorsiflexion in metatarsophalangeal joint < 35° |
|
III |
Decreased dorsiflexion in metatarsophalangeal joint < 35° |
At
the moment, there is no general approach to the treatment of deforming
osteoarthrosis of the first metatarsophalangeal joint. In the early stages, it
is possible to use non-steroidal anti-inflammatory drugs, and intra-articular
injections of glucocorticoids. Much attention is paid to such methods of
non-drug treatment as physiotherapy exercises, massage, physiotherapy, exercise
on a stationary bike, wearing tapes and orthoses, individual selection of
orthopedic shoes. Modern authors believe that conservative treatment is
symptomatic, since it neutralizes only pain and inflammatory syndromes [2, 4].
To date, joint-saving operations have
become the main method for correcting deforming osteoarthrosis in the early
stages of the disease. When performing such operations, the surgeon revises the
joint and, if detected, removes both the sclerosed joint capsule and cysts and
bone growth. At the next stages, modern authors recommend the use of
endoprosthetics, arthrodesis and arthroplasty [5, 6, 7].
To date, the discussion on many
aspects of surgical treatment of deforming osteoarthrosis of the first
metatarsophalangeal joint of the foot has not been completed. The question
remains unresolved about which method of surgical treatment is preferable,
depending on the stage of the disease. Thus, among modern researchers, many
issues of providing assistance to patients with this pathology are still
debatable.
Objective -
to improve the results of surgical treatment of elderly patients suffering from
deforming osteoarthritis of the first metatarsophalangeal joint of the foot by
developing optimized tactics of surgical treatment depending on the stage of
the disease.
MATERIALS AND METHODS
172 elderly patients (61-75 years old)
with deforming osteoarthrosis of the first metatarsophalangeal joint were
treated in the period from 1997 to 2020 on the basis of the department of
traumatology of Perm Regional Clinical Hospital. The patients were divided into
two groups: 90 patients of the group I received treatment according to the
optimized tactics of surgical treatment developed by us, depending on the stage
of deforming osteoarthrosis of the 1st metatarsophalangeal joint; 82 patients
of the group II received treatment using classical methods of surgical
intervention - patients underwent surgery using the Schade-Brandes method and
the method from the Central Institute of Traumatology and Orthopedics without
taking into account the stage of deforming osteoarthrosis of the 1st
metatarsophalangeal joint.
The age of patients in the group I
varied from 61 to 75 years (mean age 69 ± 4.75 years), in the group II - from
61 to 73 years (mean age 68 ± 3.95 years). In the group I, among 90 (100 %)
patients, there were 84 (93.3 %) women and 6 (6.7 %) men; in the group II,
among 82 (100 %) patients, there were 74 (90.24 %) women and 8 ( 9.72 %) men.
Thus, the similarity of both groups confirms the fact that the clinical groups
did not have statistically significant differences in the age and sex of the
patients (p = 0.792 and p = 0.669, respectively).
In the preoperative period, a
standard set of clinical, morphological and X-ray examinations were performed.
In the postoperative period, we supervised both groups of patients. Patients
were actively invited for examination at the polyclinic of the Perm Regional
Clinical Hospital. Control examinations were carried out 1 and 2 years after
the operation. In some cases, the follow-up period was up to 7 years. To assess
the effectiveness of treatment, the dynamics of clinical manifestations of the
disease, data of X-ray research methods were investigated. All patients used
the biomechanical method of joint examination without fail. The stage of
deforming osteoarthrosis of the 1st metatarsophalangeal joint was determined
based on the Regnauld classification (1983).
Before and after surgery, as well as
in assessing the long-term results of treatment, biomechanical studies were
carried out: the maximum values of the angles of the plantar and dorsal
flexion of the metatarsophalangeal joint were revealed. A protractor was used
as a tool for measuring the values of the mentioned angles. Before the start of the
study, the instrument was fixed in the sagittal plane built through the axes of
the bones that form the first metatarsophalangeal joint. After that, the
maximum possible angles of dorsal and plantar flexion were determined. A
plantar flexion range of 25-35 ° and a dorsiflexion range of 35-60 ° were taken
as the norm.
The clinical and radiological
symptoms of deforming osteoarthrosis of the 1st metatarsophalangeal joint, as
well as the stages of deforming osteoarthrosis of the 1st metatarsophalangeal
joint, according to the Regnauld classification (1983), revealed in 172
patients of both groups are presented in Table 2.
Table 2. Clinical and radiological symptoms and stages of deforming osteoarthritis of the first of metatarsophalangeal joint of the foot according to classification of Regnauld (1983) (n = 172)
|
Signs of deforming osteoarthritis |
Groups of patients |
p |
|
|
group 1 |
group 2 |
||
|
Mild pain |
36 (40 %)* |
36 (43.9 %) |
0.795 |
|
Moderate pain |
38 (42.22 %)* |
33 (40.24 %) |
0.966 |
|
Intense pain |
16 (17.78 %)* |
13 (15.85 %) |
0.961 |
|
Joint gap without features |
35 (38.39 %)* |
34 (41.46 %) |
0.867 |
|
Articular gap is uneven |
39 (43.33 %)* |
34 (41.46 %) |
0.976 |
|
No joint gap |
16 (17.78 %)* |
14 (17.07 %) |
0.896 |
|
Osteophytes are minor |
34 (37.78 %)* |
35 (42.68 %) |
0.707 |
|
Moderate osteophytes |
40 (44.44 %)* |
32 (39.02 %) |
0.665 |
|
Osteophytes pronounced |
16 (17.78 %)* |
15 (18.29 %) |
0.874 |
|
There are cysts |
54 (60 %)* |
48 (58.54 %) |
0.987 |
|
No cysts |
36 (40 %)* |
34 (41.46 %) |
0.987 |
|
Subchondral sclerosis |
54 (60 %)* |
46 (56.1%) |
0.795 |
|
No subchondral sclerosis |
36 (40 %)* |
36 (43.9 %) |
0.795 |
|
Dorsiflexion unlimited |
36 (40 %)* |
37 (45.12 %) |
0.691 |
|
Dorsiflexion 20-35° |
38 (42.22 %)* |
31 (37.8 %) |
0.748 |
|
Dorsiflexion < 20° |
16 (17.78 %)* |
14 (17.07 %) |
0.896 |
|
1st stage |
35 (38.39 %)* |
36 (43.9 %) |
0.657 |
|
2nd stage |
39 (43.33 %)* |
32 (39.02 %) |
0.758 |
|
3rd stage |
16 (17.78 %)* |
14 (17.07 %) |
0.896 |
|
Total number of victims |
90 (100 %) |
82 (100 %) |
|
Note: * – p > 0.05 compared with group II. Statistical analysis method – Z criterion.
Pain syndrome was present in all
patients of both groups, while severe pain syndrome was observed in 16 (17.8 %)
patients in the group I and 13 (15.85 %) patients in the group II. An unevenly
narrowed joint space was found in 39 (43.3 %) patients in the group I and 34
(41.46 %) in the group II; joint space was absent in 16 (17.8 %) patients in the
group I and 14 (17.07 %) ) in the group II.
In a biomechanical study,
dorsiflexion limitation was found in 54 (60 %) of the patients in the group I
and in 45 patients (54.88 %) in the group II. The limitation of dorsiflexion of
20 ° - 35 ° was determined in 38 (42.2 %) patients of the group I and 31 (37.8
%) patients in the group II, less than 20 ° − in 16 (17.8 %) patients of the
group I and 14 (17.07 %) patients of the group II.
The ratio of patients with deforming
osteoarthrosis of the first metatarsophalangeal joint, depending on the stage
of the disease in the group I, was as follows: we found the first stage in 35
(38.9 %) patients, the second one - in 39 (43.3 %), the 3rd stage - in 16 (17.8
%). In the group II, the stage 1 was detected in 31 (38.8 %) patients, the
stage 2 - in 34 (42.5 %), and the stage 3 - in 15 (18.7 %).
As can be seen from the data
presented, the clinical groups were similar in the proportion of all clinical
and radiological signs of osteoarthrosis, as well as in the number of patients
with different stages of the disease: there were no statistically significant
differences between the groups for all these criteria (p > 0.05).
Statistical
analysis. The statistical data were processed using the Excel
and Stat Soft Statistica 6.0 programs. Quantitative indicators were assessed by
means of arithmetic mean values (M) and standard deviations (σ), qualitative
ones - in absolute values with percentages (%). The assessment of the
reliability of the results was carried out using the Student's criteria (t) and
Z. The critical level of significance was taken equal to 0.05. Differences were assessed as statistically significant at p < 0.05.
This study was carried out in
accordance with the principles of the Declaration of Helsinki of the World
Medical Association - Ethical Principles for Medical Research Involving Human
Subjects (2013), and the Rules for Clinical Practice in the Russian Federation
(June 19, 2003). The consent was received from the Ethics Committee of the V.I.
Academician E.A. Wagner Perm State Medical University. The informed consent was
obtained from all patients included in the study.
RESULTS AND DISCUSSION
Today, surgical interventions aimed
at correcting deforming osteoarthrosis of the first metatarsophalangeal joint
are common, in which subchondral tunnelization of the distal metaepiphysis of
the first metatarsal bone is performed. However, as noted in the literature and
our own observations, these operations do not completely restore the range of
motion in the metatarsophalangeal joint.
To eliminate this drawback, we have
created and applied a new method of surgical treatment in the treatment of
patients with deforming osteoarthrosis of the first metatarsophalangeal joint
with hallux valgus (patent for invention No. 2279857 RF dated 5 June 2006). The
method consists in the simultaneous surgical correction of the hallux valgus of
the first toe, elimination of bone exostosis (cheilectomy), subchondral
tunneling of the head of the first metatarsal bone, as well as arthroplasty of
the first metatarsophalangeal joint. This method of surgical treatment
eliminates the components of the forefoot deformity and the consequences of
deforming osteoarthritis.
The developed method of surgical
treatment formed the basis for the optimized tactics of surgical treatment that
we created, depending on the stage of deforming osteoarthrosis of the first
metatarsophalangeal joint, each stage of which had its own modification of the
surgical intervention.
After identifying the stage of
deforming osteoarthrosis of the first metatarsophalangeal joint, 90 patients of
the group I underwent surgical treatment according to the optimized tactics of
surgical management developed by us, depending on the stage of deforming
osteoarthrosis of the first metatarsophalangeal joint. With regard to patients
of the group I, our tactics looked as follows: 35 (38.39 %) patients of the group
I with the stage 1 of deforming osteoarthrosis of the first metatarsophalangeal
joint underwent organ-preserving surgery. After bursexostosectomy, the head of
the 1st metatarsal bone was modeled (cheilectomy) (Fig. 1). Synovectomy and
tunnelization of the head of the first metatarsal bone were performed. Surgical
intervention was completed by stopping the bleeding of the operated bone tissue
with wax (Fig. 2). An important component of organ-preserving surgery was
subchondral tunneling of the head of the first metatarsal bone.
Figure
1. Cutting
out U-shaped flap from the joint capsule, cheilectomy
Figure 2. Bone
hemostasis by wax
Its implementation gave rise to a
number of factors that positively affect the healing process. First, when
performing tunneling, the veins and arteries located in the metaphysis of the
first metatarsal bone were mixed, which led to a restructuring of the bone blood
circulation and to a decrease in the level of pressure inside the bone tissue.
Secondly, this intervention destroyed the sympathetic nerve fibers that
innervate the bone. This effect on the sympathetic innervation contributed to
the disappearance of pain and eliminated vasospasm in the operation area. As a
consequence of the described processes, at the site of subchondral
tunnelization, an increase in the processes of bone and cartilage tissue
regeneration occurred [8].
During the surgical treatment of 39 (43.33
%) patients of the group I with stage 2 of deforming osteoarthrosis of the
first metatarsophalangeal joint for the correction of hallux valgus, we
performed an operation according to the Schade-Brandes method, during the
production of which we additionally performed subchondral tunneling of the
distal head of the 1st metatarsal bones and cheilectomy (Fig. 3). When
performing this operation, we combined resection arthroplasty with
capsuloplasty in 22 (24.44 %) cases: the resulting defect in the phalanx of the
first toe was covered with a flap cut from the articular capsule. The flap was
fixed with transosseous sutures with the first toe brought out to the
mid-physiological position. Additional fixation of the first toe after the
Brandes operation (needles, plaster casts) was not performed. At the end of the
operation, it was mandatory to stop bleeding from the operated bone areas with
wax.
Figure
3. Subchondral tunneling of
the distal head of the first metatarsal bone
When treating 16 (17.78 %) patients of the group I with stage 3 of deforming osteoarthrosis of the first metatarsophalangeal joint, we performed cheilectomy with the obligatory modeling of the distal head of the 1st metatarsal bone. After that, her subchondral tunnelization was performed. The next step was to cut out a flap from the articular capsule, which was used to cover the resected surface of the base of the phalanx of the first toe. The finger was placed in an average physiological position. In 3 (3.33 %) cases, we performed arthrodesis of the first metatarsophalangeal joint (Fig. 4).
Figure
4. Plastic surgery of the
inner part of the joint capsule with U-shaped capsular flap with fixation of
the flap with transosseous sutures
Patients of the group II received
assistance using classical methods of surgical treatment: 82 (100 %) patients
underwent surgery using the Schade-Brandes method and the method from the
Central Institute of Traumatology and Orthopedics, without taking into account
the stage of deforming osteoarthrosis of the 1st metatarsophalangeal joint.
To determine the effectiveness of the
optimized tactics of surgical treatment developed by us, depending on the stage
of deforming osteoarthrosis of the first metatarsophalangeal joint, we
evaluated the long-term results of treatment of patients in both clinical
groups. The results were assessed within 1 and 2 years. In some cases, the
observation lasted up to 7 years. Long-term results of surgical treatment were
assessed in 64 (71.1 %) patients in the group I and in 61 (74.39 %) patients in
the group II. There were no statistically significant differences between the
number of examined patients in both clinical groups (p = 0.667).
Among 64 (100 %) patients in the group
I and 61 (100 %) patients in the group II, in whom long-term results of
treatment with stage 1 deforming osteoarthrosis of the 1st metatarsophalangeal
joint were evaluated, there were 26 (40.63 %) patients in the group I and 28 (45.9
%) patients of the group II, with stage 2 - 32 (50 %) patients of the group I
and 26 (42.62 %) patients of the group II, with stage 3 - 6 (9.38 %) patients
of the group I and 7 patients (11.48 %) of the group II. The similarity of the
analyzed groups emphasizes the fact that there were no statistically significant
differences between groups I and II in the number of patients with stages 1, 2
and 3 of deforming osteoarthrosis of the 1st metatarsophalangeal joint (p =
0.679, p = 0.517 and p = 0.927, respectively).
Based on the literature data, when
evaluating the results, the following categories were distinguished: "good
result", which included the absence of recurrence of pain and the absence
of joint deformity with a repeated decrease in the volume of movement; "satisfactory
result", which was characterized by a decrease in the range of motion by
< 30 % of the norm, the presence of pain; "unsatisfactory result",
in which there were recurrences of pain syndrome and repeated deformities of
the joint.
Long-term
results of treatment of patients with deforming osteoarthrosis of the 1st
metatarsophalangeal joint are presented in Table 3. In the analysis of
long-term results of treatment, a number of regularities were revealed. At the
1st stage of deforming osteoarthrosis of the 1st metatarsophalangeal joint, the
results of treatment of groups I and II are similar: there are no
unsatisfactory results of treatment, good results were obtained in 24 (37.5 %)
patients in the group I and in 23 (37.7 %) patients in the group II.
Table 3. Estimation of long term results of treatment of deforming osteoarthritis of the first of metatarsophalangeal joint of the foot (n = 64 – group I, n = 61 – group II)
|
A stage of deforming osteoarthritis of the first of metatarsophalangeal joint |
Result |
Groups of patients |
p |
|
|
Group I |
Group |
|||
|
Stage 1 |
Good |
24 (37.5 %) |
23 (37.7 %) |
0.872 |
|
Satisfactory |
2 (3.13 %) |
5 (8.2 %) |
0.399 |
|
|
Poor |
0 (0 %) |
0 (0 %) |
0.000 |
|
|
Stage 2 |
Good |
27 (42.19 %) |
15 (24.59 %) |
0.058 |
|
Satisfactory |
5 (7.81 %) |
10 (16.39 %) |
0.230 |
|
|
Poor |
0 (0 %) |
1 (1.64 %) |
0.980 |
|
|
Stage 3 |
Good |
3 (4.69 %) |
0 (0 %) |
0.259 |
|
Satisfactory |
3 (4.69 %) |
5 (8.2 %) |
0.663 |
|
|
Poor |
0 (0 %) |
2 (3.28 %) |
0.455 |
|
|
Patients of all stages |
Good |
54 (84.38 %)* |
38 (62.3 %) |
0.009 |
|
Satisfactory |
10 (15.6 %)* |
20 (32.79 %) |
0.041 |
|
|
Poor |
0 (0 %) |
3 (4.92 %) |
0.226 |
|
Note: * – p - 0.05 compared with group II. Statistical analysis method – Z criterion.
At the 2nd and 3rd stages of
deforming osteoarthrosis of the 1st metatarsophalangeal joint, the prevalence
of good results in patients of the group I is clearly observed. At stage 2,
good results were obtained in 27 (42.19 %) patients in the group I and in 15
(24.59 %) patients in the group II. At stage 3, good results in the group II
were absent, while among 6 patients in the group I, 3 (4.69 %) good results
were obtained.
There is also a tendency for the
prevalence of the number of satisfactory results among patients of the group II
at all stages of deforming osteoarthrosis of the 1st metatarsophalangeal joint.
In the group II, at stages 1, 2 and 3 of deforming osteoarthrosis of the first
metatarsophalangeal joint, 5 (8.2 %), 10 (16.39 %) and 5 (8.2 %) satisfactory
results were obtained, respectively. Moreover, in the group I at stages 1, 2
and 3, respectively, 2 (3.13 %), 5 (7.81 %) and 3 (4.69 %) satisfactory results
were obtained.
We did not observe unsatisfactory
results in the group I, while in the second group there were no unsatisfactory results
only at the 1st stage of deforming osteoarthrosis of the 1st
metatarsophalangeal joint, and at the 2nd and 3rd stages, 1 (1.64 %) and 2 (3.28
%) unsatisfactory results, respectively.
In total, 54 (84.38 %) good treatment
results were obtained in the group I patients, which statistically
significantly prevailed over 38 (62.3 %) good treatment results obtained in the
group II (p = 0.009).
The number of satisfactory treatment
results also significantly prevailed among patients in the group II as compared
with patients in the group I (20 (32.79 %) and 10 (15.6 %), respectively) (p =
0.041).
A significant predominance of good
treatment results, as well as a significantly lower number of satisfactory
treatment results, in patients of the group I in comparison with patients in the
group II indicates the effectiveness of the use of optimized tactics of
surgical treatment, depending on the stage of deforming osteoarthrosis of the
first metatarsophalangeal joint.
In
addition, the absence of unsatisfactory treatment results among patients of the
group I, as well as the fact that after surgical treatment of patients of the group
I with the third stage of the disease, good treatment results were noted in
half of the cases, speaks in favor of the optimized tactics developed by us.
CONCLUSION
The proposed method of surgical treatment
of deforming osteoarthrosis of the first metatarsophalangeal joint of the foot
is a complex surgical intervention that combines surgical correction of the
hallux valgus of the first toe with the removal of bone exostosis
(cheilectomy), subchondral tunneling of the head of the first metatarsal bone
and arthroplasty of the first metatarsophalangeal joint. This method of
surgical treatment eliminates the components of the forefoot deformity and the
consequences of deforming osteoarthritis.
The developed optimized tactics of
surgical treatment involves the use of various modifications of the proposed
method of surgical treatment of deforming osteoarthrosis of the first
metatarsophalangeal joint of the foot at different stages of the disease.
The
use of the optimized tactics of surgical treatment developed by us, depending
on the stage of deforming osteoarthrosis of the first metatarsophalangeal joint
of the foot, made it possible to significantly increase the number of good
treatment results by 22.08 % (from 84.38 to 62.3 %), significantly reduce the
number of satisfactory treatment results by 17.19 % (from 32.79 to 15.6 %) and
to avoid unsatisfactory treatment results, which makes it possible to recommend
the proposed tactics in the clinical practice of treating elderly patients with
deforming osteoarthrosis of the first metatarsophalangeal joint of the foot.
Funding information and conflicts of interest
The study was not sponsored.
The
authors declare no obvious and potential conflicts of interest related to the
publication of this article.
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