[Follow-up following Lelièvre's method of metatarsal head resection]

Long-term results after metatarsal head resection in the treatment of rheumatoid arthritis

BACKGROUND

In this retrospective study, both the patients' and surgeons' satisfaction with resection of the first through fifth metatarsal heads for long-standing rheumatoid forefoot deformity was evaluated.

METHODS

Thirty-four patients (56 feet) had first through fifth metatarsal head resection. After a mean time of 5.3 years, 39 feet (69.6%) (26 patients) were examined clinically and radiographically.

RESULTS

The complication rate was 14% (8 of 56). There were four superficial and four deep wound infections. Plantar pressure pain under the resected metatarsal heads occurred in six feet. Most patients rated their cosmetic and functional results as good. Eighteen percent of patients (6 of 34) were satisfied and 78% (26 of 34) were satisfied with reservations. Thirty-three percent of patients (11 of 34) were pain free and 53% (18 of 34) had mild pain. The surgeons assessment of the patients' anatomical correction (cosmesis) was good in 90% (50 of 56) and poor in 10% (6 of 56).

CONCLUSIONS

Our results, which are comparable to those of other studies, confirm the success of metatarsal head resection for the treatment of inflammatory forefoot destruction in rheumatoid arthritis to correct deformity, reduce pain, improve ambulation, and offer the patient a greater variety of shoewear.

Surgery of the rheumatoid forefoot with special reference to the plantar approach

The key to the understanding of rheumatoid forefoot deformities is the predominant joint involvement of the tibial side of the hindfoot, of the fibular tarsometatarsal joints, and the destruction especially of the metatarsal heads. Independent of these patterns, the predominant sources of pain and impaired function, and thus of surgical remedies, remains the metatarsophalangeal joints. The authors prefer forefoot arthroplasty consisting of a judicious resection of the metatarsal heads, plantar capsulorraphy, tenolysis and rerouting of the tendons, through a dorsomedial approach to the great toe basal joint, and through a transverse plantar approach with dermodesis (plastic resection of a plantar wedge of skin and subcutaneous tissue) for the lesser toes. This method yields excellent pain relief that does not deteriorate for at least 15 years. However, 1/2 of the nearly complete postoperative correction was lost again within 10 years, and barefoot walking again became more difficult. Reviewing the literature, one cannot detect a clearcut superiority of plantar versus dorsal approaches, nor of one surgical routine versus another.