Surgical treatment for mild deformities of the rheumatoid forefoot by partial phalangectomy and syndactylization

The Role of Lesser Metatarsophalangeal Joint Arthrodesis for Revision Surgery

Revision hammertoe surgery can be extremely challenging for the foot and ankle surgeon given the scar tissue and available osseous and soft tissue. Although not a common procedure, lesser metatarsophalangeal joint arthrodesis is an option for the patient especially in lieu of an amputation. This article describes the current literature and the surgical technique for a lesser metatarsophalangeal joint arthrodesis.

Resection or preservation of the metatarsal heads in rheumatoid forefoot surgery? A randomised clinical trial

BACKGROUND

Despite impressive results of the pharmacological management of rheumatoid arthritis, still certain patients suffer from rheumatoid forefoot problems. Surgical treatment of these forefoot deformities can be an option. In literature no high-quality studies on this topic can be found. The goal of present study is to compare the results of a metatarsal head (MTH) resecting technique with a MTH preserving technique in the operative treatment of severe rheumatoid forefoot deformity.

METHODS

Patients suffering from well-defined rheumatoid forefoot deformity were prospectively enrolled in three institutions. This non-blinded study had a randomised clinical design and eligible patients were randomly assigned to undergo either resection of preservation of the MTH. The primary outcome measure consisted of the AOFAS score. Secondary outcome measures were: the FFI, the VAS for pain and the SF-36.

RESULTS

Twenty-three patients (10 in MTH preservation group) were included and analysed. After one year follow-up no significant differences in AOFAS score and additional outcome factors were found. A total of 10 complications in 23 patients were reported.

CONCLUSIONS

This randomised clinical study did not show significant clinical difference between a MTH resecting and a preserving procedure in patients suffering from rheumatoid forefoot deformity. Both procedures resulted in considerable improvement of pain and activity scores.

Rheumatoid forefoot reconstruction: outcome of 1st metatarsophalangeal joint fusion and the Stainsby procedure in the lesser toes

BACKGROUND

Rheumatoid arthritis is a chronic inflammatory disease involving connective tissue and joints. The most common rheumatoid forefoot deformities are hallux valgus and clawed lesser toes. There are a number of surgical procedures that have been described offering symptomatic relief and anatomical correction.

OBJECTIVES

This prospective case series aims to assess outcome in patients with rheumatoid forefoot deformities who underwent a novel combination of 1st metatarsophalangeal joint fusions and Stainsby procedures.

METHODS

Thirteen procedures were performed on 12 consecutive patients with an age range of 55-71 (mean=62) between 02/2009 and 05/2011. AOFAS scoring was performed preoperatively and again six and 12 months post-surgery. Hallux valgus (HVA) and intermetatarsal angles (IMA) were measured preoperatively and six weeks and six months postoperatively.

RESULTS

The mean AOFAS score increased from 46 to 72, 12 months postoperatively. The mean HVA reduced from 48° preoperatively to 14° six months postoperatively. The IMA decreased from 15° to 10° six months postoperatively.

CONCLUSIONS

The novel approach of 1st metatarsophalangeal fusion combined with lesser toe metatarsal head sparing is an effective procedure that reduces forefoot deformity and pain.

Rheumatoid forefoot deformity: pathophysiology, evaluation and operative treatment options

Despite recent advances in pharmacological management of rheumatoid arthritis, forefoot deformity, with its symptoms, remains a common problem, often requiring operative treatment. Typical deformities in these patients comprise hallux valgus and deformity of the lesser metatarsophalangeal (MTP) joints and toes. With regard to the lesser rays the standard operative procedure, advocated for the disabling forefoot pain in these patients, remains metatarsal head resection. It should be considered that with increasing success of pharmacological treatment the degree of forefoot deformity in these patients is becoming less and that resection of the lesser MTP joints is becoming more and more superfluous. This supports a trend towards metatarsal head-preserving surgery. The optimal treatment of the hallux deformity remains unclear. Fusion of the first MTP joint is, generally, recommended. This article will discuss the current surgical options in rheumatoid forefoot pathology.

Preservation of lesser metatarsophalangeal joints in rheumatoid forefoot reconstruction

BACKGROUND

A standard rheumatoid forefoot reconstruction consists of arthrodesis of the first metatarsophalangeal (MTP) joint and resection arthroplasty of the lesser metatarsal heads. However, preservation of the metatarsal heads has gained renewed interest since the medical treatment of rheumatoid arthritis has improved dramatically.

MATERIAL AND METHODS

Nineteen consecutive patients with severe rheumatoid forefoot deformities underwent 24 forefoot reconstructions including first MTP arthrodesis with lesser MTP resection arthroplasty (resection arthroplasty group, ten feet), arthrolysis (arthrolysis group, six feet), or a combination of both (combined group, eight feet). Subjective, functional, and radiographic results were evaluated at 28 and 133 months (mean) followup.

RESULTS

The overall AOFAS Forefoot Score at short- and long-term followup improved significantly (all p < 0.0001). There were no substantial differences between groups with regard to subjective rating, function, use of orthopaedic aids or shoewear, and walking capacity. Radiographic evaluation revealed a significant increase in axial malalignment of the lesser toes at long-term followup in all groups (all p < 0.018). Sagittal malalignment increased substantially in the resection arthroplasty group only. Reoperation rate was comparable among all groups, and a single third MTP arthrolysis (3%, 1/40) was converted to resection arthroplasty.

CONCLUSION

In combination with first MTP arthrodesis, arthrolysis with preservation of all or only the lateral lesser MTP joints in rheumatoid forefoot reconstruction was a viable and durable alternative to resection arthroplasty when the joint destruction was mild to moderate.

Use of the modified Stainsby procedure in correcting severe claw toe deformity in the rheumatoid foot: a retrospective review

INTRODUCTION

In claw toe deformity, the plantar plate of the metarsophalangeal joint becomes displaced onto the dorsal aspect of the metatarsal head. The Stainsby procedure replaces the displaced plantar plate to its correct position beneath the metatarsal head.

OBJECTIVE

In this study we assess the efficacy of a modified Stainsby procedure for the treatment of claw toe deformity.

METHODS

Thirteen patients were operated on between 2002 and 2008. Eleven patients (13 feet) were available for review with the average follow-up period being 16 months. Clinical examination was performed and AOFAS forefoot scores were measured.

RESULTS

All 13 (100%) of the feet operated on had severe or moderate pain preoperatively. None had significant pain at review. Plantar callosities were reduced from 13 (100%) feet preoperatively to 1 (9%) foot postoperatively. The AOFAS forefoot score in the eleven patients improved significantly by 40.7 points from a preoperative mean of 20.1 to a mean of 50.2 at review (p<0.001). Ten (91%) of the 11 patients were completely satisfied with the procedure, 1 patient was satisfied with some reservations.

CONCLUSION

This study demonstrates the modified Stainsby procedure to be effective in correcting claw toe deformity in the rheumatoid patient. It relieves pain, skin callosities and improves overall forefoot function.

Rheumatoid forefoot reconstruction: first metatarsophalangeal joint fusion combined with Weil's metatarsal osteotomies of the lesser rays

This study evaluates the outcome of rheumatoid forefoot reconstruction with arthrodesis of the first metatarsophalangeal joint (MTPJ) combined with multiple Weil's metatarsal osteotomies (WMO) to the lesser rays. A retrospective study on 17 consecutive patients (26 feet) was performed with subjective, clinical, and radiological analysis. At an average follow-up of 26.2 months, patients rated the result in 88% of cases as excellent or good with 76% improvement in pain, 74% improvement in function, and 70% improvement in footwear. This corresponded with a high mean modified AOFAS score of 72/100 (34 to 90). First MTPJ arthrodesis union rate was 92%. Fourteen percent of lesser toes were aligned preoperatively compared to 86% at latest review. There was a 12% rate of recurrent metatarsalgia and or callosities. This combined procedure provides stabilization of the first ray, offloading the lesser metatarsals and preventing early recurrence of deformity. Preserving the lesser metatarsal head further widens the surgical options if revisional surgery is necessary in the future. ACFAS Level of Clinical Evidence: 4.

Hemiphalangectomy and syndactylization for treatment of osteoarthritis and dislocation of the second metatarsal phalangeal joint: an outcome study

End-stage osteoarthritis or severe dislocation at the second metatarsophalangeal joint typically presents with chronic pain and is often unrelieved by conservative treatment. The aim of this article is to review the preliminary outcomes of surgery involving resection of the base of the second proximal phalanx with syndactylization to the third toe for stability. Thirteen patients (13 feet) with second metatarsophalangeal osteoarthritis and 15 patients (15 feet) with a dislocated second toe underwent the procedure and were reviewed after a mean 12.4 months (range, 5-25 months). Patients were evaluated preoperatively and postoperatively with the American Orthopedic Foot and Ankle Society's scoring system and clinical review. A patient questionnaire was devised to yield information regarding toe alignment, cosmesis, and reflection on the procedure. Pain and activities were significantly improved in both subgroups (P < .01). Eighty-two percent were very satisfied or satisfied with the reduction in symptoms, with 11% satisfied with reservations and 7% not satisfied. Seventy-nine percent were very satisfied or satisfied with the appearance. Thirty-nine percent stated the outcome was better than expected, 14% as expected, and 14% felt the result was worse than expected. Twenty-three patients (82%) had no postoperative cosmetic concerns, and 7 patients (25%) felt there was a moderate or severe difference in the alignment with respect to the other toes. In conclusion, syndactylization can significantly improve pain and activity levels and was found to be cosmetically acceptable.

A review of rheumatoid arthritis affecting the foot and ankle

Rheumatoid arthritis is a systemic disease that often affects the foot and ankle. Approximately 20% of patients with rheumatoid arthritis present initially with foot and ankle symptoms, and most patients will eventually develop foot and ankle symptoms. Although early intervention includes conservative measures, operative treatment often is needed to adequately treat rheumatoid patients. Treatment of foot and ankle problems in patients with rheumatoid arthritis is directed to maintaining ambulatory capacity. This article reviews the clinical presentation, evaluation, and treatment of rheumatoid arthritis affecting the foot and ankle.