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Rheumatoid Forefoot

- See:
       - Hyperpronation of Rheumatoid Foot;
       - Rheumatoid Arthrtis
       - Rheumatoid Foot

- Discussion:
    - most commonly affected portion of the rheumatoid foot;
    - typical forefoot deformities are hallux valgus, hyperextension of MP joints, and flexion ofthe IP joints of the lesser toes;
    - plantar fat pad migrates distally with the toes;
            - loss of effectiveness of plantar fat pad causes painful plantar callosities to develop under the metatarsal heads, & w/ flexion  of IP joints dorsal callosities form because of shoe pressure;
    - often involves claw toe or hammer toe of the lateral four toes, severe hallux valgus, and plantar keratosis beneath subluxed or dislocated MTP joint;

- Associated Conditions:
    - peripheral neuropathy
    - vasculitis
    - raynaud phenomenon

- Physical Exam:
    - Acute:
            - nonspecific forefoot swelling
            - MTP joint tenderness
            - bursal enlargement
            - rheumatoid nodules
            - periarticular osteopenia
    - Chronic:
            - hallux valgus
            - clawing of the lesser toes with dorsal corns
            - MTP joint dislocation;
            - plantar keratoses
            - metatarsal head erosions

- Non Operative Treatment:
       - see: orthotics for the foot
       - mild deformity:
            - metatarsal arch supports, and soft soled shoes or rocker bottom shoes;
            - if hammer toes are present, then an extra depth shoe w/ Plastazote line may be necessary;
            - plastazote inserts will redistribute pressure bearing areas;
       - moderate deformity:
            - depth inlay shoe w/ thermoplast;
       - severe deformity:
            - custom molded shoe may be the only option;

- Indications for Surgery:
       - pain which does not respond to inserts and medications;
       - progressive deformity;

- Surgical Treatment:
     - need to realign metatarsals & phalanges & restoration of adequate padding on the plantaar surface of foot, & correction of deformed position of IP joints;
     - Hoffman procedure (excision of the metatarsal heads thru plantar incision) or metatarsal head trimming or resection thru a dorsal incision w/ or w/o excision of all or part of the proximal phalanx may resolve the symptoms;
     - Dwyer procedure (excision of the lateral four MT heads with 1st MTP and second thru fifth PIP fusions combined with interposition of divided extensor tendon at the second thru fifth MTP joints) is very successful in the rheumatoid foot;
     - 1st MTP Fusion is procedure of choice for hallux valgus in rheumatoid foot because it butresses the other toes;
           - this is usually required before or in conjuction with lesser toe correction;
     - IP joint involvement is addressed w/ resection arthroplasty (Keller) or replacement arthroplasty;
     - maintenance of lesser toe alignment:
           - consider K wire fixation or webbing procedures;
           - failure to stabilize lesser toes will cause them to individually become malaligned;
           - webbing procedure:
                - Y shaped incision is made between toes, and is closed in a manner to syndactylize the toes

Arthrodesis of the first metatarsophalangeal joint for hallux valgus in rheumatoid arthritis.

Metatarsal head resection for rheumatoid deformities of the forefoot.

Surgery of the forepart of the foot in rheumatoid arthritis.

Surgical treatment for mild deformities of the rheumatoid forefoot by partial phalangectomy and syndactylization.

Treatment of painful subluxation or dislocation at the second and third metatarsophalangeal joints by partial proximal phalanx excision and subtotal webbing.

Forefoot surgery in rheumatoid arthritis: subjective assessment of outcome.