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Published in:

01-09-2013 | Review Article

Rheumatoid forefoot deformity: pathophysiology, evaluation and operative treatment options

Authors: Jan Willem K. Louwerens, Joost C. M. Schrier

Published in: International Orthopaedics | Issue 9/2013

Abstract

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.

Lipsky P (2005) Rheumatoid arthritis. In: Kasper D (ed) Harrison’s principles of internal medicine. McGraw-Hill, New York, p 1968

Matricali GA, Boonen A, Verduyckt J, Taelman V, Verschueren P, Sileghem A et al (2006) The presence of forefoot problems and the role of surgery in patients with rheumatoid arthritis. Ann Rheum Dis 65(9):1254–1255PubMedCrossRef

Michelson J, Easley M, Wigley FM, Hellmann D (1994) Foot and ankle problems in rheumatoid arthritis. Foot Ankle Int 15(11):608–613PubMedCrossRef

van der Leeden M, Steultjens MP, Ursum J, Dahmen R, Roorda LD, Schaardenburg DV et al. (2008) Prevalence and course of forefoot impairments and walking disability in the first eight years of rheumatoid arthritis. Arthritis Rheum 59(11):1596–1602

Coughlin MJ (2000) Rheumatoid forefoot reconstruction. A long-term follow-up study. J Bone Joint Surg Am 82(3):322–341PubMed

Borman P, Ayhan F, Tuncay F, Sahin M (2012) Foot problems in a group of patients with rheumatoid arthritis: an unmet need for foot care. Open Rheumatol J 6:290–295PubMedCrossRef

Loveday DT, Jackson GE, Geary NP (2012) The rheumatoid foot and ankle: current evidence. Foot Ankle Surg 18(2):94–102PubMedCrossRef

Tillman K (1979) The rheumatoid foot. Thieme, Stuttgart

Larsen A (1974) A radiological method for grading the severity of rheumatoid arthritis. Dissertation, University of Helsinki

10.

Stainsby GD (2004) Reply to editor: the surgical treatment of the severely clawed lesser toe. Foot Ankle Surg 10:51–52CrossRef

11.

Stainsby GD (1997) Pathological anatomy and dynamic effect of the displaced plantar plate and the importance of the integrity of the plantar plate-deep transverse metatarsal ligament tie-bar. Ann R Coll Surg Engl 79(1):58–68PubMed

12.

Waldecker U (2004) Limited range of motion of the lesser MTP joints—a cause of metatarsalgia. Foot Ankle Surg 10:149–154CrossRef

13.

Hicks JH (1954) The mechanics of the foot. II. The plantar aponeurosis and the arch. J Anat 88(1):25–30PubMed

14.

Vidigal E, Jacoby RK, Dixon AS, Ratliff AH, Kirkup J (1975) The foot in chronic rheumatoid arthritis. Ann Rheum Dis 34(4):292–297PubMedCrossRef

15.

Doorn PF, Keijsers NL, van Limbeek J, Anderson PG, Laan RF, Bosch PV et al (2011) A clinical classification system for rheumatoid forefoot deformity. Foot Ankle Surg 17(3):158–165PubMedCrossRef

16.

Hoffmann P (1912) An operation for severe grades of contracted or clawed toes. Am J Orthop Surg 9:441–449

17.

Clayton ML (1960) Surgery of the forefoot in rheumatoid arthritis. Clin Orthop 16:136–140PubMed

18.

Clayton ML (1963) Surgery of the lower extremity in rheumatoid arthritis. J Bone Joint Surg Am 45:1517–1536PubMed

19.

Clayton ML, Leidholt JD, Clark W (1997) Arthroplasty of rheumatoid metatarsophalangeal joints. An outcome study. Clin Orthop Relat Res 340:48–57PubMedCrossRef

20.

Fowler AW (1959) A method of forefoot reconstruction. J Bone Joint Surg Br 41-B:507–513PubMed

21.

Amuso SJ, Wissinger HA, Margolis HM, Eisenbeis CH Jr, Stolzer BL (1971) Metatarsal head resection in the treatment of rheumatoid arthritis. Clin Orthop Relat Res 74:94–100PubMedCrossRef

22.

Benson GM, Johnson EW Jr (1971) Management of the foot in rheumatoid arthritis. Orthop Clin North Am 2(3):733–744PubMed

23.

Bitzan P, Giurea A, Wanivenhaus A (1997) Plantar pressure distribution after resection of the metatarsal heads in rheumatoid arthritis. Foot Ankle Int 18(7):391–397PubMedCrossRef

24.

Fuhrmann RA, Anders JO (2001) The long-term results of resection arthroplasties of the first metatarsophalangeal joint in rheumatoid arthritis. Int Orthop 25(5):312–316PubMedCrossRef

25.

Gould N (1982) Surgery of the forepart of the foot in rheumatoid arthritis. Foot Ankle 3(3):173–180PubMedCrossRef

26.

Grondal L, Hedstrom M, Stark A (2005) Arthrodesis compared to Mayo resection of the first metatarsophalangeal joint in total rheumatoid forefoot reconstruction. Foot Ankle Int 26(2):135–139PubMed

27.

Hamalainen M, Raunio P (1997) Long-term followup of rheumatoid forefoot surgery. Clin Orthop Relat Res 340:34–38PubMedCrossRef

28.

Hughes J, Grace D, Clark P, Klenerman L (1991) Metatarsal head excision for rheumatoid arthritis. 4-year follow-up of 68 feet with and without hallux fusion. Acta Orthop Scand 62(1):63–66PubMedCrossRef

29.

Kadambande S, Debnath U, Khurana A, Hemmady M, Hariharan K (2007) Rheumatoid forefoot reconstruction: 1st metatarsophalangeal fusion and excision arthroplasty of lesser metatarsal heads. Acta Orthop Belg 73(1):88–95PubMed

30.

Kates A, Kessel L, Kay A (1967) Arthroplasty of the forefoot. J Bone Joint Surg Br 49(3):552–557PubMed

31.

Marmor L (1975) Resection of the forefoot in rheumatoid arthritis. Clin Orthop Relat Res 108:223–227PubMedCrossRef

32.

McGarvey SR, Johnson KA (1988) Keller arthroplasty in combination with resection arthroplasty of the lesser metatarsophalangeal joints in rheumatoid arthritis. Foot Ankle 9(2):75–80PubMedCrossRef

33.

Moeckel BH, Sculco TP, Alexiades MM, Dossick PH, Inglis AE, Ranawat CS (1992) The double-stemmed silicone-rubber implant for rheumatoid arthritis of the first metatarsophalangeal joint. Long-term results. J Bone Joint Surg Am 74(4):564–570PubMed

34.

Mulcahy D, Daniels TR, Lau JT, Boyle E, Bogoch E (2003) Rheumatoid forefoot deformity: a comparison study of 2 functional methods of reconstruction. J Rheumatol 30(7):1440–1450PubMed

35.

Saltzman CL, Johnson KA, Donnelly RE (1993) Surgical treatment for mild deformities of the rheumatoid forefoot by partial phalangectomy and syndactylization. Foot Ankle 14(6):325–329PubMedCrossRef

36.

Stockley I, Betts RP, Getty CJ, Rowley DI, Duckworth T (1989) A prospective study of forefoot arthroplasty. Clin Orthop Relat Res 248:213–218PubMed

37.

Thomas S, Kinninmonth AW, Kumar CS (2006) Long-term results of the modified Hoffman procedure in the rheumatoid forefoot. Surgical technique. J Bone Joint Surg Am 88(Suppl 1 Pt 1):149–157PubMed

38.

Tillmann K (1997) Surgery of the rheumatoid forefoot with special reference to the plantar approach. Clin Orthop Relat Res 340:39–47PubMedCrossRef

39.

Vahvanen V, Piirainen H, Kettunen P (1980) Resection arthroplasty of the metatarsophalangeal joints in rheumatoid arthritis. A follow-up study of 100 patients. Scand J Rheumatol 9(4):257–265PubMedCrossRef

40.

van der Heijden KW, Rasker JJ, Jacobs JW, Dey K (1992) Kates forefoot arthroplasty in rheumatoid arthritis. A 5-year followup study. J Rheumatol 19(10):1545–1550PubMed

41.

van Loon PJ, Aries RP, Karthaus RP, Steenaert BJ (1992) Metatarsal head resection in the deformed, symptomatic rheumatic foot. A comparison of two methods. Acta Orthop Belg 58(1):11–15PubMed

42.

Watson MS (1974) A long-term follow-up of forefoot arthroplasty. J Bone Joint Surg Br 56B(3):527–533PubMed

43.

Brattström H, Brattström M (1970) Resection of the metatarsophalangeal joints in rheumatoid arthritis. Acta Orthop Scand 41(2):213–224PubMedCrossRef

44.

Barton NJ (1973) Arthroplasty of the forefoot in rheumatoid arthritis. J Bone Joint Surg Br 55(1):126–133PubMed

45.

Craxford AD, Stevens J, Park C (1982) Management of the deformed rheumatoid forefoot. A comparison of conservative and surgical methods. Clin Orthop Relat Res 166:121–126PubMed

46.

Lipscomb PR, Benson GM, Sones DA (1972) Resection of proximal phalanges and metatarsal condyles for deformities of the forefoot due to rheumatoid arthritis. Clin Orthop Relat Res 82:24–31PubMedCrossRef

47.

Mann RA, Oates JC (1980) Arthrodesis of the first metatarsophalangeal joint. Foot Ankle 1(3):159–166PubMedCrossRef

48.

Mann RA, Schakel ME (1995) Surgical correction of rheumatoid forefoot deformities. Foot Ankle Int 16(1):1–6PubMedCrossRef

49.

Aho H, Halonen P (1991) Synovectomy of the MTP joints in rheumatoid arthritis. Acta Orthop Scand 62(Suppl 243):1

50.

Krause FG, Fehlbaum O, Huebschle LM, Weber M (2011) Preservation of lesser metatarsophalangeal joints in rheumatoid forefoot reconstruction. Foot Ankle Int 32(2):131–140PubMedCrossRef

51.

Niki H, Hirano T, Okada H, Beppu M (2010) Combination joint-preserving surgery for forefoot deformity in patients with rheumatoid arthritis. J Bone Joint Surg Br 92(3):380–386PubMed

52.

Barouk LS, Barouk P (2007) Joint-preserving surgery in rheumatoid forefoot: preliminary study with more-than-two-year follow-up. Foot Ankle Clin 12(3):435–454, viPubMedCrossRef

53.

Bolland BJ, Sauvé PS, Taylor GR (2008) Rheumatoid forefoot reconstruction: first metatarsophalangeal joint fusion combined with Weil’s metatarsal osteotomies of the lesser rays. J Foot Ankle Surg 47(2):80–88PubMedCrossRef

54.

Briggs P, Stainsby GD (2001) Metatarsal head preservation in forefoot arthroplasty and the correction of severe claw toe deformity. Foot Ankle Surg 7:93–101CrossRef

55.

Briggs P (2003) Reconstruction of the rheumatoid forefoot. Tech Orthop 18:303–310CrossRef

56.

Davies MS, Saxby TS (1999) Metatarsal neck osteotomy with rigid internal fixation for the treatment of lesser toe metatarsophalangeal joint pathology. Foot Ankle Int 20(10):630–635PubMedCrossRef

57.

De Stoop N (2002) Surgery of the rheumatoid forefoot. Curr Orthop 16:187–192CrossRef

58.

Hanyu T, Yamazaki H, Murasawa A, Tohyama C (1997) Arthroplasty for rheumatoid forefoot deformities by a shortening oblique osteotomy. Clin Orthop Relat Res 338:131–138PubMedCrossRef

59.

Nagashima M, Kato K, Miyamoto Y, Takenouchi K (2007) A modified Hohmann method for hallux valgus and telescoping osteotomy for lesser toe deformities in patients with rheumatoid arthritis. Clin Rheumatol 26(5):748–752PubMedCrossRef

60.

Newman RJ, Fitton JM (1983) Conservation of metatarsal heads in surgery of rheumatoid arthritis of the forefoot. Acta Orthop Scand 54(3):417–421PubMedCrossRef

61.

Queally JM, Zgraj OS, Walsh JC, Butt AJ, D’Souza LG (2009) Use of the modified Stainsby procedure in correcting severe claw toe deformity in the rheumatoid foot: a retrospective review. Foot (Edinb) 19(2):110–113CrossRef

62.

Trieb K (2005) Management of the foot in rheumatoid arthritis. J Bone Joint Surg Br 87(9):1171–1177PubMed

63.

Vandeputte G, Dereymaeker G, Steenwerckx A, Peeraer L (2000) The Weil osteotomy of the lesser metatarsals: a clinical and pedobarographic follow-up study. Foot Ankle Int 21(5):370–374PubMed

64.

Takakubo Y, Takagi M, Tamaki Y, Sasaki A, Nakano H, Orui H et al (2010) Mid-term results of joint-preserving procedures by a modified Mann method for big toe deformities in rheumatoid patients undergoing forefoot surgeries. Mod Rheumatol 20(2):147–153PubMedCrossRef

65.

Klenerman L (1995) The foot and ankle in rheumatoid arthritis. Br J Rheumatol 34(5):443–448PubMedCrossRef

66.

Dodd L, Atinga M, Foote J, Palmer S (2011) Outcomes after the Stainsby procedure in the lesser toes: an alternative procedure for the correction of rigid claw toe deformity. J Foot Ankle Surg 50(5):522–524PubMedCrossRef

67.

van der Heide HJ, Louwerens JW (2010) Reconstructing the rheumatoid forefoot. Foot Ankle Surg 16(3):117–121PubMedCrossRef

68.

Bhavikatti M, Sewell MD, Al-Hadithy N, Awan S, Bawarish MA (2012) Joint preserving surgery for rheumatoid forefoot deformities improves pain and corrects deformity at midterm follow-up. Foot (Edinb) 22(2):81–84CrossRef

69.

Vainio K (1991) The rheumatoid foot. A clinical study with pathological and roentgenological comments. 1956. Clin Orthop Relat Res 265:4–8PubMed

70.

Hulse N, Thomas AM (2006) Metatarsal head resection in the rheumatoid foot: 5-year follow-up with and without resection of the first metatarsal head. J Foot Ankle Surg 45(2):107–112PubMedCrossRef

71.

Shi K, Hayashida K, Tomita T, Tanabe M, Ochi T (2000) Surgical treatment of hallux valgus deformity in rheumatoid arthritis: clinical and radiographic evaluation of modified Lapidus technique. J Foot Ankle Surg 39(6):376–382PubMedCrossRef

72.

Mayo CH (1908) The surgical treatment of bunion. Ann Surg 48:300–302PubMedCrossRef

73.

Keller WL (1904) The surgical treatment of bunions and hallux valgus. N Y Med J 80:741

74.

Vandeputte G, Steenwerckx A, Mulier T, Peeraer L, Dereymaeker G (1999) Forefoot reconstruction in rheumatoid arthritis patients: Keller-Lelièvre-Hoffmann versus arthrodesis MTP1-Hoffmann. Foot Ankle Int 20(7):438–443PubMedCrossRef

75.

Henry AP, Waugh W, Wood H (1975) The use of footprints in assessing the results of operations for hallux valgus. A comparison of Keller’s operation and arthrodesis. J Bone Joint Surg Br 57:478–481PubMed

76.

Mann RA, Thompson FM (1984) Arthrodesis of the first metatarsophalangeal joint for hallux valgus in rheumatoid arthritis. J Bone Joint Surg Am 66(5):687–692PubMed

77.

Haro AA III, Moore LF, Schorn K, DiDomenico LA (2010) The surgical reconstruction of the rheumatoid forefoot. Clin Podiatr Med Surg 27(2):243–259PubMedCrossRef

78.

Roukis TS, Meusnier T, Augoyard M (2012) Arthrodesis of the first metatarsal-phalangeal joint with flexible, ridged titanium intramedullary nails alone or supplemented with static staples and immediate weight bearing: a consecutive series of 148 procedures. Foot Ankle Spec 5(1):12–16PubMedCrossRef

79.

Roukis TS, Meusnier T, Augoyard M (2012) Nonunion rate of first metatarsal-phalangeal joint arthrodesis for end-stage hallux rigidus with crossed titanium flexible intramedullary nails and dorsal static staple with immediate weight-bearing. J Foot Ankle Surg 51(3):308–311PubMedCrossRef

80.

Beauchamp CG, Kirby T, Rudge SR, Worthington BS, Nelson J (1984) Fusion of the first metatarsophalangeal joint in forefoot arthroplasty. Clin Orthop Relat Res 190:249–253PubMed

81.

Grondal L, Broström E, Wretenberg P, Stark A (2006) Arthrodesis versus Mayo resection: the management of the first metatarsophalangeal joint in reconstruction of the rheumatoid forefoot. J Bone Joint Surg Br 88(7):914–919PubMed

82.

Rosenbaum D, Timte B, Schmiegel A, Miehlke RK, Hilker A (2011) First ray resection arthroplasty versus arthrodesis in the treatment of the rheumatoid foot. Foot Ankle Int 32(6):589–594PubMedCrossRef

83.

Torikai E, Kageyama Y, Suzuki M, Ichikawa T, Nagano A (2008) Comparison between resection arthroplasty alone and resection arthroplasty with arthrodesis of the first MTP joint for rheumatoid forefoot deformities. Mod Rheumatol 18(5):486–491PubMedCrossRef

84.

Hanyu T, Yamazaki H, Ishikawa H, Arai K, Tohyama CT, Nakazono K et al (2001) Flexible hinge toe implant arthroplasty for rheumatoid arthritis of the first metatarsophalangeal joint: long-term results. J Orthop Sci 6(2):141–147PubMedCrossRef

85.

Sebold EJ, Cracchiolo A III (1996) Use of titanium grommets in silicone implant arthroplasty of the hallux metatarsophalangeal joint. Foot Ankle Int 17(3):145–151PubMedCrossRef

86.

Townley CO, Taranow WS (1994) A metallic hemiarthroplasty resurfacing prosthesis for the hallux metatarsophalangeal joint. Foot Ankle Int 15(11):575–580PubMedCrossRef

Title: Rheumatoid forefoot deformity: pathophysiology, evaluation and operative treatment options
Authors: Jan Willem K. Louwerens
Joost C. M. Schrier
Publication date: 01-09-2013
Publisher: Springer Berlin Heidelberg
Published in: International Orthopaedics / Issue 9/2013
Print ISSN: 0341-2695
Electronic ISSN: 1432-5195
DOI: https://doi.org/10.1007/s00264-013-2014-2

At a glance: The STEP trials

Springer Medicine

Rheumatoid forefoot deformity: pathophysiology, evaluation and operative treatment options

Abstract

At a glance: The STEP trials

Springer Medicine

Abstract

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