Joint preserving surgery for rheumatoid forefoot deformities improves pain and corrects deformity at midterm follow-up
Introduction
Rheumatoid arthritis (RA) is a chronic autoimmune disorder that affects the metatarsophalangeal (MTP) joints first in 17% of patients [1]. Symptomatic rheumatoid forefoot deformities may affect as many as 89% of patients with RA [1]. The destructive synovitis results in joint erosion, destructive arthritis, loss of capsular and collateral ligament integrity leading to pain and deformity. Typical deformities include hallux valgus, hammer toe deformities of the lesser toes and subluxation or dislocation of MTP joints. Whilst there are various less commonly performed operative procedures described for the treatment of rheumatoid forefoot deformity including excision arthroplasty, silicone arthroplasty and amputation [2], [3], [4], [5], [6], [7], [8], [9], the current gold standard, and most commonly performed treatment involves arthrodesis of the first MTP joint with resection arthroplasty of the lesser metatarsal heads [2].
There have been few studies on joint preserving surgery for rheumatoid forefoot deformities and it has been previously stated that patients will have poor outcomes in surgical procedures that do not involve fusion of the hallux MTP joint due to recurrent deformities [3], [4], [10]. Scarf osteotomy of the first metatarsal with a harmonised shortening of the lesser metatarsals by Weil osteotomy has been suggested to result in good correction of forefoot deformities at midterm follow-up [5]. The Scarf osteotomy allows for a wide range of fragment displacement and has inherent stability with relatively simple internal fixation [5]. The Weil osteotomy is an oblique shortening osteotomy which has been recommended for the treatment of the subluxed or dislocated joint and correction of lesser toe deformities by reducing the soft tissue tension [11].
Advantages of joint preserving surgery include maintaining available mobility of the first MTP joint which helps compensate for fixed deformity of the mid and hind-foot, as well as preserving the ability to perform revision surgery in future should progressive joint destruction occur. One study of 30 patients (39 feet) who underwent combined first tarsometatarsal fusion and shortening oblique osteotomies of the second to fourth metatarsals reported improvements in foot function at mean follow-up of 36 months [3]. Fourteen patients had persistent forefoot stiffness and four required removal of hardware. Thordarson et al. reported on joint salvage in 15 feet affected by RA and concluded that patients will have poor surgical outcomes in those that do not involve fusion of the hallux MTP joint [10]. Concerns regarding persistent pain, stiffness and recurrence with this treatment strategy remain [3], [10].
The aim of this study was to report the clinical and radiological results of joint preserving surgery for the first MTP joint and lesser toes in 49 patients (66 feet) with rheumatoid forefoot deformities. We hypothesised that joint preserving surgery of the first MTP joint and lesser toes in patients with RA would correct deformity and improve pain at midterm follow-up.
Section snippets
Patients and methods
Between January 2000 and December 2005, 49 consecutive patients with rheumatoid forefoot deformities (66 feet) underwent Scarf osteotomy of the first metatarsal and/or Weil osteotomy of the lesser metatarsals. There were 44 females and 5 males with a mean age of 56.1 years (17–70 years) and mean follow-up of 51 months (40–65 months) (Fig. 1). Patients were diagnosed with their rheumatoid disease at a mean of 10.5 years (5–20 years) preoperatively. Seventeen patients underwent bilateral
Clinical results
Subjectively patients reported their outcome as excellent in 49 feet (74%), good in 9 feet (13.5%), fair in 7 feet (10.5%) and poor in 1 foot (1%). Postoperatively persistent pain was reported in 11 feet, stiffness in 5 feet and recurrence of hallux valgus deformity in 3 feet. Mean preoperative AOFAS score increased from a mean of 39.8 (18–56) preoperatively to 88.7 (48–92) at final follow-up. Preoperatively severe pain was present in 44 feet (67%), moderate pain in 19 feet (29%) and mild pain
Discussion
There have been several different operative procedures described for the treatment of rheumatoid forefoot deformity including excision arthroplasty, silicone arthroplasty and amputation [2], [3], [4], [5], [6], [7], [8], [9]; however the most commonly performed treatment involves arthrodesis of the first MTP joint with resection arthroplasty of the lesser metatarsal heads [2], [14]. Coughlin performed a retrospective review of 32 patients with RA forefoot deformities who underwent arthrodesis
Conflict of interest
None.
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