Focus On
Rheumatoid Forefoot
Introduction
Rheumatoid arthritis (RA) is a systemic disease affecting not
only the joints, but also the connective tissues. As a polyarticular
disease, the treating surgeon needs to consider the patient as a
whole. Treatment of one joint in isolation can be dangerous if, for
example, cervical spinal disease is not considered.
Foot pain and deformity occur as the presenting feature in 20%
of patients with RA. Nevertheless, during the course of their dis-
ease 94% of patients with RA will have symptoms of pain or stiff-
ness in the foot and ankle.1 Consequently, the treatment of the
rheumatoid foot is important.
Patients with RA are immunosupressed both by their disease
and their medication. At the time of surgery Methotrexate and
steroids should be continued. Surgery should be timed to avoid
interfering with anti-tumour necrosis factor (TNF) therapy. Before
recommending surgery a thorough assessment of the macro-
and micro-vascular supply to the feet should be undertaken.
Rheumatoid arthritis may present as an ‘overlap syndrome’, and
care should be taken to ensure that patients do not have a vas-
culitis or neuropathy.
Pathophysiology
Patients with rheumatoid feet present with forefoot, midfoot and
hindfoot pathology. In general the symptoms are of pain and
deformity. Ulceration, in the absence of co-existent vascular dis-
ease or neuropathy, is rare. In general it is better to treat proximal
limb disease before foot and ankle disease, and to treat the hind-
foot before the forefoot. Clearly, if there is ulceration and infection,
this may require to be treated before surgery with implants is under-
taken. The combination of disuse and long-term treatment with
steroids often leaves these patients profoundly osteopaenic.
As with the rheumatoid hand, the forefoot is normally symmet-
rically affected. The first ray develops hallux valgus; this drives
the deformity of the lesser toes, which become clawed. Synovitis
of the lesser metatarsophalangeal joints (MTPJ) results in incom-
petent collateral ligaments, with dorsal subluxation and even-
tual MTPJ dislocation. The dorsal dislocation of the phalanx
pushes the metatarsal head into plantar flexion. This results in
increased plantar pressure with the development of plantar
callosities and bursae under the lesser metatarsal heads.
Non-operative treatment
Non-operative treatment of the rheumatoid forefoot should be
optimised before surgical management is considered. Non-
©2010 British Editorial Society of Bone and Joint Surgery
operative treatment consists of pain control, medical manage-
ment of the disease and shoe modification. A total contact
insole and rocker-bottomed shoe can decrease the pressures
under the forefoot and give significant relief of symptoms. Intra-
articular corticosteroid injections of the rheumatoid forefoot
should be used with caution as they are associated with joint
instability, and even dislocation of the MTPJ.1
Operative treatment
Hallux valgus is the most common deformity of the rheumatoid
forefoot. The deformity can be associated with degenerative
change and may be managed with a first MTPJ excision arthro-
plasty, osteotomy or arthrodesis. Correction of the hallux valgus
has the dual effect of reducing pressure over the bunion area
and also refunctioning the first ray. This refunctioning of the first
ray reduces the plantar contact stresses of the lesser MTPJ’s.
First Ray: Partial excision of the base of the proximal phalanx
(Keller’s procedure) and excision of the first metatarsal head
(Mayo’s procedure) have been shown to give initial patient satis-
faction, but usually lead to late recurrent deformity, pain and
functional deterioration.2 These procedures defunction the first
ray, and hence increase the pressures under the lesser rays,
which is undesirable. Their salvage is also complex, requiring
interposition bone grafting.
Arthrodesis of the first MTPJ offers reliable relief of pain and
predictable outcomes. Union rates over 90% are reported.3
Fusion of the first MTPJ refunctions the first ray and offloads the
lesser metatarsals. Hence, arthrodesis is preferred to excision
arthroplasty for pain relief, cosmetic appearance, shoe fitting,
maintenance of alignment, and the restoration of weight bearing
under the hallux.4
Re-alignment osteotomies may be used in the rheumatoid
patient to address hallux valgus. Osteotomy offers the benefit of
maintaining MTPJ movement while reducing pain. It should be
noted that the combination of osteopaenic bone and the pres-
ence of secondary degeneration of the first MTPJ contraindi-
cates the use of a corrective osteotomy. The choice of osteotomy
depends on the surgeon's preference. The authors use a Scarf
diaphyseal osteotomy, in those patients with medically well-
controlled disease, and a well-preserved joint space (Fig. 1).
Arthroplasty of the MTPJ of the hallux has been proposed as
an alternative to resection arthroplasty or arthrodesis for the
rheumatoid patient and early case series are now reported in the
literature.5 There is currently no evidence to support this
1
2 B. OLLIVERE, A. H. N ROBINSON
Fig. 1
Scarf osteotomy of the first metatarsal. The cuts are made as shown, and
the metatarsal head is displaced laterally.
approach, and the bone loss associated with joint arthroplasty
makes revision challenging.
Lesser Rays: The aim of surgery to the lesser toes is to reduce
the MTPJ’s and realign the toes, thereby reducing the plantar
pressure under the MTPJ’s and the dorsal pressure over the
proximal interphalangeal joints (PIPJs). It is rare for a single ray
to require surgery in isolation. In planning a forefoot reconstruc-
tion one should routinely consider all four rays and aim to pro-
duce a balanced forefoot. Reduction of the MTPJ is the most
important aspect of surgery, and can be addressed by metatar-
sal head excision,6 Weil’s metatarsal osteotomy7 (Fig. 2) or prox-
imal phalangectomy.8
Excision of the metatarsal heads, in a cascade and cut paral-
lel to the floor,6 is still widely used and addresses the metatar-
salgia. It effectively reduces pain.
Barouk and Barouk9 proposed joint-preserving surgery as an
alternative approach to the rheumatoid forefoot. The principle of
joint preservation is shortening and realignment osteotomies of
all the metatarsals. The Weil's osteotomy (Fig. 2) is designed to
allow shortening without plantar flexion of the metatarsal heads.
This reduces the plantar pressure by reducing the joint and the
plantar plate.
The final option is the Stainsby procedure.8 Through a dorsal
approach an extensor tenotomy and generous proximal
phalangectomy are performed, excising the proximal half to two-
thirds of the proximal phalanx. The plantar plate is mobilised and
the toe is held reduced with an axial K-wire. Stainsby originally
recommended tenodesis of the extensor and flexor tendons
through the phalangeal resection, although this is not univer-
sally performed. The Stainsby procedure has been shown to be
associated with good functional, if not cosmetic, results.10
Distal deformities in the lesser toes at the proximal and distal
interphalangeal joints may be addressed by either fusion or exci-
sion arthroplasty. We prefer to undertake an arthrodesis as we
feel this gives a more durable result.
Summary
Forefoot reconstruction should only be performed after thorough
investigation and optimisation of medical and orthotic treat-
Fig. 2
Weil's osteotomy of the lesser metatarsals: The osteotomy is cut, parallel
to the ground, the metatarsal head is then displaced proximally to allow
the MTPJ to reduce.
ment. Forefoot reconstruction should involve correction of the
hallux valgus and shortening of the lesser metatarsals. Current
evidence supports the use of an arthrodesis of the first MTPJ or
diaphyseal osteotomy in combination with either a Weil's osteo-
tomy, metatarsal head excision or a Stainsby procedure.
B. Ollivere, A. H. N Robinson
Department of Orthopaedics, Cambridge University NHS Trust, Hills
Road, Cambridge CB2 0QQ
References
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Int 2008;29:959-68.
2. Majkowski RS, Galloway S. Excision arthroplasty for hallux valgus in the elderly:
a comparison between the Keller and modified Mayo. Foot Ankle 1992;13:317-20.
3. Bolland BJ, Sauve PS, Taylor GR. Rheumatoid forefoot reconstruction: first meta-
tarsophalangeal joint fusion combined with Weil's metatarsal osteotomies of the
lesser rays. J Foot Ankle Surg 2008;47:80-8.
4. Mulcahy D, Daniels T, Lau J, Boyle E, Bogoch E. Rheumatoid forefoot deformity:
a comparison study of 2 functional methods of reconstruction. J Rheumatology
2003;30:1440-50.
5. Konkel KF, Menger AG, Retzlaff SA. Results of metallic hemi-great toe implant for
grade III and early grade IV hallux rigidus. Foot Ankle Int 2009;30:653-60.
6. Hoffmann P. An operation for severe grades of contracted or clawed toes. Am J
Orthop Surg 1911;9:441-9.
7. Barouk LS. Weil's metatarsal osteotomy in the treatment of metatarsalgia. Ortho-
pade 1996;25:338-44.
8. Briggs PJ, Stainsby GD. Metatarsal head preservation in forefoot arthroplasty.
Foot Ankle Surg 2001;7:93-101.
9. Barouk LS, Barouk P. Joint-preserving surgery in rheumatoid forefoot: preliminary
study with more-than-two-year follow-up. Foot Ankle Clin 2007;12:435-54.
10. Hossain S. Stainsby procedure for non-rheumatoid claw toes. Foot Ankle Surg
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