Second MTPJ Arthritis

 

Introduction

Primary (atraumatic) degenerative osteoarthritis of the 2nd MTP joint is rare. A few studies have examined its pathogenesis in the context of instability of the joint, Freiberg’s infraction, or trauma. Hallux valgus is also speculated to increase the load on the 2nd MTP joint, inducing degenerative osteoarthritis.

 

Pathophysiology

The second metatarsal is the longest of all metatarsals and has been shown to sustain the greatest stresses during normal activity. The keystone configuration of the tarsometatarsal joint confers substantial stability to the second metatarsal base making this bone the least mobile. This potentially increases the stress on the metatarsal head distally.

Toe dorsiflexion pushes the metatarsal head plantarwards during push-off phase, generating compressive and shear forces on the dorsal aspect of the head and damaging the articular cartilage as the base of the proximal phalanx rides dorsally over the metatarsal. 

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Presentation

  • Pain and tenderness
  • Reduced ROM, with particular limitation of dorsiflexion

This clinical manifestation may be similar to Freiberg's, but differs from that of 2nd MTPJ instability.

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Imaging​

Radiological findings are typical of OA in other joints including:

  • joint space narrowing
  • osteophyte formation, especially at the dorsal aspect of the joint
    • spurs involving the MT head and base of PP

These findings are in contrast to those in Freiberg's infraction (collapse of the 2nd MT head)

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Treatment

Non-operative

Aim is to decrease forefoot pressures and unload the affecfted metatarsal

  • custom accommodative insoles to offload the MT head
  • metatarsal bar / dome to reduce pressure distally
  • rocker-soled shoes to reduce the bending force through the joint
  • analgesia

In cases in which the second metatarsal is long or plantarflexed, and associated with chronic, well-localized forefoot pain, then decompression of the MPJ should be the primary procedure. Repairing the primary stabilizing structure of the MPJ (the plantar plate) becomes a mandatory adjunct.

Surgical

Fusion:

  • poor outcomes due to:
    • altered gait mechanics (toe doesn't bend with the others)
    • transfer metatarsalgia
    • adjacent joint disease

Arthroplasty:

  • various options have been attempted with variable results:
    • debridement
    • MT dosrisflexion osteotomy (re-aligns undamaged plantar cartilage)
    • soft tissue interposition (e.g. rolled tendon auto/allograft)
    • silastic replacement
    • MT head excision
    • synthetic hydrogel implants (only 8 or 10mm currently available)

 

*Awaiting image upload*

Osteoarthritis of the 2nd metatarsal head

 

References

Osteoarthritis of the Second Metatarsophalangeal Joint Associated With Hallux Valgus Deformity. Kyung Tai Lee, Young Uk Park, Hyuk Jegal, Ki Won Young, Jin Su Kim, and Seong Yeon Lim. Foot & Ankle International 2014 35:12, 1329-1333

Stautberg EF 3rd, Klein SE, McCormick JJ, Salter A, Johnson JE. Outcome of Lesser Metatarsophalangeal Joint Interpositional Arthroplasty With Tendon Allograft. Foot Ankle Int. 2020 Mar;41(3):313-319. doi: 10.1177/1071100720904033. Epub 2020 Jan 31. PMID: 32003228

Özkul E, Gem M, Alemdar C, Arslan H, Boğatekin F, Kişin B. Results of two different surgical techniques in the treatment of advanced-stage Freiberg's disease. Indian J Orthop. 2016 Jan-Feb;50(1):70-3. doi: 10.4103/0019-5413.173514. PMID: 26955180; PMCID: PMC4759878

Cho J, Kim JR, Lee WC. Degenerative osteoarthritis of the second metatarsophalangeal joint: second toe rigidus. Int Orthop. 2013 Sep;37(9):1863-9. doi: 10.1007/s00264-013-2035-x. Epub 2013 Jul 30. PMID: 23892518; PMCID: PMC3764303

Bohl DD, Idarraga AJ, Hur ES, Lee S, Hamid KS, Lin J. Second Metatarsophalangeal Joint Interpositional Arthroplasty Using Decellularized Human Dermal Allograft: Operative Technique. Foot Ankle Orthop. 2020 Apr 22;5(2):2473011420920856. doi: 10.1177/2473011420920856. PMID: 35097377; PMCID: PMC8697115

Georgiannos D, Tsikopoulos K, Kitridis D, Givisis P, Bisbinas I. Osteochondral Autologous Transplantation Versus Dorsal Closing Wedge Metatarsal Osteotomy for the Treatment of Freiberg Infraction in Athletes: A Randomized Controlled Study With 3-Year Follow-up. Am J Sports Med. 2019 Aug;47(10):2367-2373. doi: 10.1177/0363546519859549. Epub 2019 Jul 12. PMID: 31298927

Saragas, N.P., Ferrao, P.N.F. & Strydom, A. A new lesser metatarsophalangeal joint replacement arthroplasty design - in vitro and cadaver studies. BMC Musculoskelet Disord 22, 424 (2021). https://doi.org/10.1186/s12891-021-04257-x