Reconstructing the rheumatoid forefoot

Abstract 

Introduction

The standard procedure when operating on the rheumatoid forefoot is resection arthroplasty of the metatarsophalangeal joints of the lesser rays. Good clinical results (with a follow-up of over 10 years) have been reported when this technique is used. Another technique is repositioning of the metatarsophalangeal subluxation or dislocation of the lesser rays.

Aim

To assess the results of forefoot reconstruction using the repositioning technique performed in 54 feet (39 patients) by one surgeon using this technique.

Methods

39 RA patients (15 bilateral, 54 feet) were treated with the technique of repositioning the metatarsophalangeal subluxation or dislocation. All surgery was performed by one orthopaedic surgeon. In case of severe deformity or degeneration of the metatarsophalangeal joint of the hallux, an arthrodesis was performed. All patients were reviewed after a mean follow-up of 40 months (range 12–72 months) and an American Orthopaedic Foot and Ankle Society (AOFAS) foot score, and Foot Function Index (FFI) were obtained.

Results

When, in addition to repositioning the metatarsophalangeal joints, an arthrodesis of the hallux was performed, the mean AOFAS-forefoot score was 69.80 (SD=11.8) at a mean of 40 months (SD=15.6 months) postoperatively. In cases with no operation on the hallux, the AOFAS score was 42.2 (SD=18.8) (p=0.001). The postoperative FFI-scores were 23.0 (SD=17.5) and 43.9 (SD=14.6) respectively (p=0.026). When comparing the patients who were satisfied (satisfaction VAS>7) and those who were not, the most important factor was also fusion of the first metatarsophalangeal (MPJ) joint, without a fusion only 50% was satisfied, with a fusion the satisfaction rate was 93%. In four patients a recurrence of the deformity of one of the lesser rays developed, for which a re-operation has been performed.

Conclusions

Reconstruction of the rheumatoid forefoot by repositioning the metatarsophalangeal joints of the lesser rays, thereby preserving the joints, can be considered as a procedure that provides improvement in the clinical outcome. Best results were seen in patients in whom, in addition to reconstruction of the lesser rays, an arthrodesis of the hallux was performed.

Keywords: Rheumatoid, Arthritis, Forefoot, Surgery, Reconstruction, Outcome, RA