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Seek better treatment guideline for great toe arthritis than Coughlin grade
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Coughlin grade did not correlate with intraoperative active dorsiflexion, range of motion or VAS pain scores in patients undergoing treatment for great toe arthritis, which led a presenter to suggest surgeons should consider other variables than Coughlin grade when making treatment decisions.
Judith F. Baumhauer, MD, MPH, MS, professor and associate chair of orthopedics at University of Rochester, received the 2017 Roger A. Mann Award for this research.
She told Orthopedics Today, “Although the classification system was a good attempt to try to incorporate radiographs and clinical findings to stage severity of great toe arthritis, it did not hold true when we got into the OR and looked at the joint and the severity of the cartilage loss.”
Identifying Coughlin grade
Baumhauer and colleagues obtained range of motion, radiographic criteria and Coughlin grade for 202 patients who underwent first metatarsal phalangeal joint surgery for either fusion or cartilage replacement with a Cartiva implant (Cartiva Inc.) for treatment of great toe arthritis as part of a previously-published prospective, randomized, non-inferiority study comparing arthrodesis and Cartiva outcomes.
They analyzed VAS pain scores preoperatively and at 24-months follow-up and assessed intraoperative cartilage loss for the metatarsal head and proximal phalanx.
“We looked at correlation coefficients to determine the correlation of peak dorsiflexion, VAS pain and cartilage loss compared to the hallux rigidus grade and then we looked at hallux rigidus grade and how it affected composite clinical success at 24 months,” Baumhauer said.
Results showed Coughlin grades 2, 3 and 4 in 29%, 55% and 16% of patients, respectively. Although it might be assumed patients with grade 2 would have more cartilage remaining and patients with grade 4 would have less cartilage remaining, this was not always the case, Baumhauer noted.
“There is 30% to 46% of grade 2 [patients who] had significant cartilage loss and 15% to 21% in grade 4 that had cartilage remaining,” she said, noting there was a statistically significant rank correlation between Coughlin grade and cartilage loss on the proximal phalanx and metatarsal head, however the strength of the correlation was weak.
Using other variables
In the interview with Orthopedics Today, Baumhauer discussed the take-away from this study: “I think they will recognize that you have to use other variables to make some judgments on treatments. For example, a patient who is categorized as grade 2 should not just be offered a dorsal cheilectomy. Hopefully, this is not going to be the way people think any more. The orthopedic surgeon can assess the grade and recognize it may under-represent the degree of arthritis in the great toe joint leading to a shared decision-making discussion with the patients. The choices could be dorsal cheilectomy, toe fusion or a synthetic cartilage implant.”
These results will hopefully help orthopedic surgeons better educate patients on what great toe arthritis is and the spectrum of the disease, she noted.
Regarding possible treatment, Baumhauer said, “We do not know that definitely until we look at the joint and make some decisions that might even be made intraoperatively.” – by Casey Tingle
- Reference:
- Baumhauer JF, et al. Foot Ankle Int. 2017;doi:10.1177/1071100717735289.
- For more information:
- Judith F. Baumhauer, MD, MPH, MS, can be reached at 4901 Lac De Ville Blvd., Rochester, NY 14618; email: judy_baumhauer@urmc.rochester.edu.
Disclosure: Baumhauer reports she is a consultant for Cartiva Inc.