RHEUMATOID FOREFOOT RECONSTRUCTION. FIRST METATARSOPHALANGEAL JOINT ARTHRODESIS WITH WEIL METATARSAL OSTEOTOMIES OF THE LESSER TOES

Abstract

Introduction Rheumatoid arthritis commonly produces disabling forefoot deformities. Surgical interventions include hallux metatarsophalangeal (MTP) joint fusion with lesser toe metatarsal head and/or proximal phalanx base excisions. Here we describe our experience of combining first MTP joint fusion using a plate with Weil metatarsal osteotomies (WMO) of the lesser toes. WMO preserve and reduce lesser MTP joints thus enhancing stability and relocating the plantar fat pads. Plate fusion of the first MTP joint protects against recurrent deformity. Our aim was to assess the outcome of this procedure.

Method Twelve female patients (21 feet) underwent the procedure with no loss to follow up. Informed consent was given and ethics approval obtained. American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scale and visual analogue scale scores were recorded post-operatively only. Pre- and post-operative plain radiographs were compared.

Results Mean age at operation was 62.5 years (range 48–75). Mean follow up was 25.9 months (range 2–54). The mean post-operative AOFAS scale score was 70.6/100 (range 34–90).

The mean hallux valgus angle was reduced from 39.6 degrees to 31.8 degrees and the second MTP angle from 28.3 degrees to 19.4 degrees. Pre-operatively 28% of the lesser toe MTP joints were aligned compared with 83% post-operatively. All of the WMOs fused. Two first MTP joint fusions resulted in non-unions and required successful revision surgery. In five cases metalwork was removed from the hallux because of discomfort. In two cases, metalwork was removed because of superficial wound infection. Infection subsequently resolved after a course of oral antibiotics. Nine patients stated they would recommend the procedure.

Conclusion First MTP joint plate arthrodesis and WMOs of the lesser toes provides good symptomatic relief and restoration of forefoot mechanics. It is a useful procedure in delaying more radical and final surgery for this progressive, destructive disease.