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Rheumatoid forefoot reconstruction

    Overview

    Learn the Rheumatoid forefoot reconstruction surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Rheumatoid forefoot reconstruction surgical procedure.
    The most commonly used combination of surgical procedures for the symptomatic Rheumatoid forefoot (though many alternatives have been described) is a corrective fusion of the 1st MTP, excision of the lesser metatarsal heads and osteoclasis (closed corrective fracturing) of lesser toe deformities, stabilised with K wire fixation.
    The results are dramatic and usually transformatory but the soft tissues not infrequently are slow to heal.
    Holistic management of these patients is important and requires considering all other joints involved as well as careful management of any disease modifying medications in the peri-operative period.

    Indications

    INDICATIONS.
    -A symptomatic Rheumatoid forefoot with destructive joint disease effecting the 1st and various lesser metatarsophalangeal joints with soft typical tissue contractures and associated lesser toe deformities.
    SYMPTOMS & ASSESSMENT.
    A significant majority of patients with Rheumatoid arthritis have some forefoot involvement and less commonly the foot and ankle is the first location that Rheumatoid presents. The typical Rheumatoid forefoot comprises a “full house” of deformities including severe Hallux Valgus/rigidus and variously fixed lesser toe claw deformities.
    The combination of extreme and fixed claw-type toe deformity combined with poor soft tissues and atrophy of the plantar fat pad leads to both widespread dorsal toe and plantar metatarsal head pain. The latter is usually the more significant source of pain. Irrespective of the subtleties of fixedness or flexibility the operative management of the lesser toes deformity is likely to the same.
    It is not uncommon for the Rheumatoid patient to have intercurrent ankle or hindfoot disease (potentially effecting joints or large tendons) and this should be examined for and its effect upon the forefoot position and loading assessed. Varus osteoarthritis of the ankle or a pes planus due to Tibialis posterior dysfunction are both possibilities .More proximal lower limb joints may have been replaced and both their alignment and function should be considered. Post-operative soft tissue wound issues of slow healing/breakdown and infection are not especially uncommon after Rheumatoid forefoot surgery. The relevance of this needs to be explained to patients and managed aggressively and rapidly should it occur , especially if they have a proximal joint replacement in the same limb which may be potentially compromised by infection seeding from an infected and broken down forefoot wound.
    The soft tissue and skin quality can be poor and must be carefully assessed pre-operatively. Intra-operatively care should be excercised when handling the tissues at the operative site (by avoiding undermining skin edges and careful placement and short periods of self-retaining retractor use). The the limb in general also needs attention paid to appropriate padding of tourniquets and careful application and removal of adhesive drapes to the skin which may easily de-glove. With respect to surgical approaches through the soft tissues slow wound healing or even areas of breakdown are not uncommon .Bone healing on the other hand (as long as supported by appropriate implants) is rarely effected by the condition.
    With more active Rheumatoid disease management and newer and more potent disease modifying medications in use (such as anti-TNF therapy) there are a cohort of symptomatic patients with better preserved joints and milder degrees of deformity. The question here is whether to undertake a more joint sparing operation such as a standard Hallux Valgus correction with Weils osteotomies to the lesser metatarsals (see results section for one paper detailing the outcome of such an approach in a small cohort of patients).
    INVESTIGATION.
    Plain X-Ray: A weight bearing A-P and lateral forefoot X-Ray is required in all . More proximal imaging may be required if more proximal disease is present.
    Cervical spine extension views if restricted or painful movement in the neck are required pre-anaesthetic.
    NON-OPERATIVE ALTERNATIVES.
    Accommodative shoe wear with orthotic support.
    SURGICAL ALTERNATIVES.
    In patients with Rheumatoid but well preserved joints one might consider joint sparing osteotomies (see results section also).
    There are various alternatives described for Hallux and lesser toes though the technique described in this section is probably the most commonly performed combination for good reason.
    Hallux: Metatarsal head resection or Kellers operation: These options leave some range of movement at the MTP joint but at the price of potentially sub-optimal function and more likely recurrent deformity. For lower demand patients these operations may be considered (See also results section on this).
    Lesser toes: Resection of proximal Phalanges. An alternative to Metatarsal head resection. A less functional and cosmetic result can be expected .
    Weils shortening osteotomies. May be considered if bone quality will take fixation & joints are well preserved .
    Stainsby procedure. A technique which preserves the metatarsal heads and relocates the plantar aponeurosis etc. Little published on it .
    CONTRAINDICATIONS.
    Medications:With respect to Rheumatoid medications it is likely the Rheumatologist involved in management of the patient will wish to maintain as much of the anti-disease medication as possible over the time of surgery. It will not take many wound breakdowns to convince you that any research on the lack of issue with such medications needs to be regarded with some circumspection.What is of most relevance perhaps is how well the patient can manage off as much of their medication as possible in the peri-operative period. Patients should be actively involved in these decisions.
    Anti-TNF medications though are routinely stopped by most clinicians peri-operatively with few disagreements.

    Setup

    General or Regional anaesthetic
    Antibiotics & LMW Heparin on induction
    Laminar flow theatre if available
    Thigh tourniquet (ankle tourniquet gets in the way of positioning the wire driver and drill during fixation of the 1st MTP joint)
    Patient supine
    Pre/post operative Nerve block (popliteal and / or inter-metatarsal )for analgesia.

    Operation

    A very characteristic Rheumatoid forefoot with a fixed and degenerate hallux valgus and fixed claw-type deformities of the lesser toes .

    The first step in a rheumatoid correction should be preparation of the first Metatarsophalangeal (MTP) joint. The surgical approach and procedure is in the main as for a standard MTP fusion. This can either be a medial midline skin incision or dorsal midline incision to the 1st MTP joint. If the deformity is particularly great it then may be helpful to release the contracted lateral soft tissues through the main approach to the joint of the joint by way of a lateral release. A vertical lateral capsulotomy is usually all that is needed in the context of a fusion as opposed to the more comprehensive open McBrides exposure required in joint sparing Hallux valgus surgery.
    The rheumatoid bone is often fairly osteopenic and fixation , even with locking plates , has its limitations. The risk is one of failure at the bone/implant interface intra-operatively if the definitive MTP fixation is carried out as an initial step and the rest of the forefoot then addressed. I would suggest that fixation of the first MTP is left until all the other toes are dealt with and K-wired. An appropriately sized dorsal plate and single compressive screw is a reliable combination , or alternatively a locking plate with the ability also to generate compression.
    The Rheumatoid first ray will usually be a relatively fixed and stiff deformity and by preparing it at the start of the operation this makes it mobile. This then allows much easier correction of the lesser toes than if this is being done against a fixed and valgus great toe.

    Plantar callosities are common and reflect high metatarsal head plantar pressures due to the combined effect of fixed hyper-extension deformities at the lesser MTP joints , plantar fat pad atrophy and plantar soft tissue retraction. This produces severe plantar pain on weight-bearing and is one of the most consistent presenting complaints (along with dorsal impingement of the fixed and deformed toes when in shoe-wear). Despite the thin tissues , poor soft tissue healing and high plantar pressures breakdown of these tissues very uncommon.

    Two dorsal skin incisions ,centered between 2 and 3 and 4 and 5 metatarsals, are used to access the lesser MTP joints if all are being operated upon.
    As wide a skin bridge should be left as possible and undermining the skin edges is avoided. The MTP joints are generally dorsally dislocated or subluxed .Deeper scissors dissection is used to exposure the longus (1, medial) and brevis (2, lateral) toe extensors.
    Plantar approaches have been used for this type of surgery to the metatarsal heads but have little to recommend them. They are slow to heal and early weight-bearing on them tends to delay wound healing further.

    The lateral (brevis) extensor tendon is first divided then the longus tendon is Z lengthened(the line of incision is shown in black).
    The greater the degree of hyper-extension at the MTP joint then the longer the Z-lengthening of the tendon that will be required.
    A self-retaining retractor is shown here in use. Its teeth need to be well beneath the skin edge and it should be frequently relaxed and de-tensioned during the operation. The soft tissues of the Rheumatoid foot (& dorsal skin in particular) are often of poor quality.

    Z lengthening of the Extensor Digitorum Longus tendon. The more severe the hyper-extension deformity the longer the longitudinal midline tendon dividing cut that is required.

    The MTP joints will usually still be dorsally displaced after this step. This is to a variable degree , ranging from subluxation to full dislocation with proximal retraction of the toe dorsally. The proximal phalanx(1) is here visible sitting on the dorsal aspect of the metatarsal neck(2). Reduction will require a close dorsal,medial and lateral sub-periosteal release at the base of proximal phalanx(3) and possibly the metatarsal head as well.
    The bone needs to be closely adhered to in such a circumferential release. It is helpful to intermittently insert a McDonalds or similar into the joint to test whether it has become reducible as this step is proceeded with.

    The lesser MTP joint is now open and visible (2) .The Phalanx can be reduced plantar-wards using a McDonalds’ (3) to lever it . On occasion the soft tissues will be so contracted that the base of the proximal phalanx may need some bony excision to allow the toe to sit down into a reduced position (prior to Metatarsal head excision). The neck of the metatarsal requires clear sub-periosteal exposure prior to metatarsal head excision(1).
    Once the neck is appropriately displayed the Metatarsal head can be removed with a long and flat power-saw cut . This cut runs from the distal neck dorsally to the plantar cortex approximately 1cm + or so proximally, leaving a long plantar surface for weight transference. The plantar bone must obviously not be left in any way sharp-edged .The medial and lateral soft tissues require protection with Homans’ retractors during this step. It is also important that the “metatarsal arcade” of correct sequential metatarsal lengths is preserved . It is easiest to achieve this by performing all the exposures and joint preparation first and then finally the bony cuts rapidly one after the next to keep a handle on the relative lengths being produced.
    The toes themselves ( not illustrated) will require correction either with closed and straightening fractures through the fixed joint deformities (called osteoclasis) or by open corrective fusion. With significant fixed flexion deformities at the PIP joints it can be difficult to achieve adequate correction by osteoclasis alone and open correction of the joints is more likely required.
    They are then fixed over doubled-ended 1.6 mm K wires which are routed proximally into the Metatarsal shafts having first splinted the toes. Often a fair proportion of a K wire needs to be inserted retrograde into the metatarsal until good bone purchase is achieved .
    It is an easier task to K-wire a toe if the PIP (proximal inter-phalangeal) joint has been opened and prepared for fusion. The K-wire can be routed from a central portion in the opened joint distally out through the distal phalanx and then directed back retrograde through the PIP joint( again under direct vision) and then across the MTP joint.
    It is key to centralise the K-wire as much as possible during this . Achieving this with an entirely closed approach from distal to proximal can be more difficult for the less experienced than an open method.
    When fixing the toes to the Metatarsals it is worth remembering the plantar inclination (from proximal to distal) of the metatarsal shafts . It is technically possible to route the k-wires into a completely contained intra-medullary position in the Metatarsals but the toes will then appear too plantar flexed with respect to the first ray (it being fused into a functional & slightly dorsiflexed position). This could be ignored as the MTP alignment of the toes will normalise once the K wires are removed (at 5 or 6 weeks). Such a position may however compromise the vascular inflow in particular if the deformity has been severe and a better point of fixation here may simply be through the dorsal cortex of the metatarsal neck, resulting in more dorsally aligned toes which sit more it keeping with the Hallux.
    It is easiest to first prepare each of the toes and excise all the metatarsal heads and then insert the K-wires one after the other .
    Once the toes are stabilised the 1st MTP joint can be fixed .The preparation and alignment are as per the technique detailed elsewhere in the Atlas. Fixation should be with a single axial ,compressive screw and a dorsally located MTP fusion plate of appropriate size (and ideally with locking screws). Alternatively a plate that generates compression can be used.
    Rheumatoid bone unites well though can be of poor quality and it may be that the axial screw has little purchase. A compressive plate can be relied upon alone in this situation if needed. Two crossed screws are often not adequate to hold the correction in the context of soft bone associated with deformity.

    The X-Ray appearance after correction of the rheumatoid forefoot by excision of lesser metatarsal heads, soft tissue correction and fusion of the 1st MTP joint.
    Note that a plate has been used as part of the first MTP fusion. Rheumatoid bone in the type of patients requiring this sort of surgery is frequently osteopenic and

    The “on Table” appearance before and after corrective first MTP fusion, dorsal releases of all MTP joints and metatarsal head excision combined with osteoclasis (closed corrective fracturing) of the PIP deformities and wiring across toes and MTPs.
    Once the wounds are closed and bandaging applied the tourniquet is released . The toes must re-vascularise before the patient leaves the theatre.
    With acute correction of very significant lesser toe deformities ,as is often the case with the Rheumatoid forefoot , this can be sluggish. To encourage it the following should be tried (in this order) if a toe remains white. After each maneuver give the foot a few minutes to see if it responds :
    -Hang the foot off the table (whilst keeping it sterile, and covering it with copious sterile cotton wool padding to warm the area) and support it.
    -Release the post-operative bandaging (and fully remove the tourniquet)
    -Remove any adhesive dressings applied to the toes
    -Gently massage the plantar aspect of the toe in the region of the metatarsal heads and plantar web space
    -Re-position the lie of the toe relative to the metatarsal by re-positioning the K wire across the MTP space
    -Remove the K-wire entirely from metatarsal but keep it in the toe .
    If all this fails it may be required to remove the K wire altogether. Do not hesitate to do this if needed( though this will be a rare occurrence). The effected toe will require corrective sterile strapping if the wire is removed completely but significant re-deformation is unusual. The strapping will need to be applied for the same duration that the K wires would have been in situ.
    Following any poor vascular inflow episode it is probably best that the foot is not routinely elevated in the immediate post operative period, as would otherwise be routine.

    Clinical photographs documenting the progression of the surgical wounds and spontaneous reduction in 1/2 Inter-metatarsal angle, following a fairly in-situ MTP fusion.
    The post-operative photos are taken at at 2 weeks, 3 months and 18 months post op.
    The 3 month image (bottom left) demonstrates a superficial soft tissue breakdown that simply required regular dressing changes and salt water baths.

    Post Operative

    Rheumatoid medications: It is worth considering that patients cease ideally immuno-modulating medications prior to operation and until soft tissues are adequately healed or symptoms of the disease necessitate restarting the medications.
    Overnight stay: This is recommended both due to the magnitude of the operation and the fact that pain levels in the short term can be difficult to manage as well as the small risk of vascular compromise to the toes. With large & acute corrections of toe deformities (in particular the lesser toes) there is certainly an incidence of acute and temporary vascular compromise post surgery. The measures detailed in the operative technique should be undertaken to correct this problem.
    LMW Heparin for 2-4 weeks
    Weightbear using post operative shoe for 6 weeks
    Crutches likely required 2 weeks
    Change dressings at 1 and 2 weeks and as required thereafter. A heavy , padded forefoot dressing /Kellers bandage is used for this duration. Dressings to the wound should be continued 24/7 until the wounds are completely dry and healed. After this continue dressings whenever in shoe wear for a further month.
    If a wound breakdown occurs there are various immediate straightforward things which should be adopted . Forefoot wounds can be very exudative and a basic principle is allowing any exudate minimal time in contact with the skin. Frequent dressing changes (of breathable dressings, on occasion even 3-4 times a day) is key as is fairly strict elevation and minimising weight-bearing .The wound should be swabbed and if clinically indicated antibiotics commenced in advance of results. In general disease modifying medications if stopped should not be recommenced until the wounds have healed and patients should definitely not be smoking. Salt-water bathing of the wounds as long as strict hygiene is observed using dedicated /sterile bowls & gauze to dry. Later interventions on rare occasions may include VACs dressings.
    Sutures removed at 3 weeks. K wires removed at 6 weeks. Patient to continue corrective strapping to toes daily from week 6 to 12 (in a dorsal to plantar direction).
    K wires can on occasion work themselves entirely free or get pulled out inadvertently in the post operative period. The situation should be accepted , the patient reassured and supportive/corrective tape strapping (eg micropore ) applied to the toe effected. The patient should be taught how to do this themselves and reapply to keep an appropriate corrected position.
    Check X-Ray required post-operatively and at 6 weeks to confirm bony union. Subsequent X-Ray is occasionally required if appearance equivocal.
    Appropriate shoe-wear fit is vital in the first month or so after the post-op shoe
    I advise fit-flops , Uggs , wider fits or open sandals. Stiff soled and low heeled shoes ( platform or wedge) are encouraged in women , from when comfortable .

    Recommended Reading

    Rheumatoid forefoot reconstruction.A long term follow up study.
    J Bone Joint Surg.2000.82-A;322-340.
    Coughlin MJ
    Follow up of almost 50 feet over 6 years .
    Technique was with a first MTP fusion , excision of lesser metatarsal heads and K wire correction of toe deformities.
    Almost 100% of patients classified the outcome as excellent or good .
    30 % required re-operation for various reasons
    The long term results of resection arthroplasties of the first metatarsophalangeal joint in rheumatoid arthritis.
    Int Orthop.2001. 25:312-316
    Fuhrmann RA, Anders JO.
    An almost 8 year follow up of 254 feet .147 feet underwent a Mayo operation with resection of all metatarsal heads & 107 with a Kellers (resection of base of proximal Phalanx of hallux) and lesser metatarsal head resection.
    Subjectively the Mayo group reported excellent or good outcome in 70% whereas in the Keller group this figure was 50%.
    60% of the Kellers group and 30% of the Mayo group had persistent metatarsalgia.
    Failure of Hallux MP preservation surgery for Rheumatoid Arthritis.
    Foot & Ankle .2002.23(6): 486-490
    Thordarson DB, Soheil A, Krieger L.
    Of 15 feet in 8 patients that underwent operation for rheumatoid forefoot 13 had the 1st MTP spared from fusion at time of primary surgery (due to a non-degenerate joint).
    Over the course of the subsequent 3 years 11 of these had deformed or developed articular erosions. 5 had been revised to 1st MTP fusions.
    Long-term results of the modified Hoffman procedure in the Rheumatoid forefoot.
    Journal Bone and Joint Surg.2005.87-A; 748-752.
    Thomas S, Kinninmonth AWG, Kumar CS.
    37 feet were assessed 65 months post-operatively. All underwent excision of all 5 metatarsal heads.
    Approximately 50% of feet had no residual deformity , and 50% reported varying degrees of recurrent deformity. Outcome based on weight bearing pain were 3 excellent ,8 good ,17 fair and 9 poor.
    Management of the foot in Rheumatoid arthritis.
    J Bone Joint Surg(Br) 2005:87-B:1171-7
    K.Trieb
    A good review article .

    Reference

    • orthoracle.com

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