Rheumatoid Forefoot Reconstruction

Indication. Reconstruction is offered for the symptomatic rheumatoid forefoot that has failed at least six months of appropriate non-operative care — wide toe-box, rocker-bottom footwear, custom moulded orthoses with a metatarsal dome or bar, optimised medical management (DMARDs and biologics), podiatric callus care, and intra-articular corticosteroid injection for acute flares. Absolute indications for surgery: - Intractable plantar metatarsalgia with painful callosities beneath dislocated or subluxated lesser MTP joints causing significant functional limitation

• Severe hallux valgus with first MTP joint destruction (joint-space loss, erosions, subluxation) producing pain unresponsive to shoe modification
• Fixed lesser toe deformities (claw or hammer toes with MTP dislocation) interfering with footwear or causing ulceration Relative indications: progressive hallux valgus with early medial column collapse despite medical management; lesser MTP synovitis with dorsal subluxation that is not yet dislocated (correction before fixed dislocation yields better outcomes); painful callosities recurring despite regular podiatric care; patient preference for reconstruction to return to enclosed footwear. Contraindications. Absolute: active foot or systemic infection; inadequate soft-tissue envelope (ulceration, active rheumatoid vasculitis); critical ischaemia with absent pedal pulses not restorable by vascular intervention; medical unfitness for anaesthesia or prolonged rehabilitation. Relative: severe osteopenia or fractures through osteoporotic metatarsals (consider staging); an active rheumatoid flare (optimise medical management first); likely non-compliance with non-weight-bearing; the non-ambulatory or bedbound patient (conservative care preferred). The four-part decision. Every reconstruction pairs a first-ray operation with a lesser-ray operation. The choices, and who each suits:

Consent specifically for nonunion of the first MTP fusion (5-10%), transfer metatarsalgia (5-15%), wound infection (2-5%, higher when immunosuppressed), prolonged swelling over 3-6 months, vascular compromise of the lesser toes, and the possibility of subsequent procedures for recurrent or residual deformity. Setup & perioperative preparation. Supine with a sandbag under the ipsilateral buttock to internally rotate the foot into neutral or slight valgus. A calf tourniquet is preferred (allows bilateral access without repositioning), inflated to 250 mmHg (300 mmHg thigh) after Esmarch exsanguination, maximum two hours. - Anaesthesia: regional (spinal, or popliteal sciatic plus ankle block) is strongly preferred to avoid the cervical spine at intubation. If general anaesthesia is unavoidable, flexion-extension cervical radiographs must already have been reviewed and intubation performed awake, fibreoptic, with cervical precautions.

• Antibiotics: single intravenous dose of cefazolin at induction (clindamycin if penicillin-allergic); redose if tourniquet time exceeds four hours.
• Perioperative immunosuppression: coordinate with rheumatology. Continue methotrexate perioperatively — withholding it increases disease flare without clearly reducing wound complications. Leflunomide, sulfasalazine and hydroxychloroquine are generally continued. Hold biologics (TNF inhibitors, rituximab, tocilizumab, abatacept, JAK inhibitors) — plan surgery roughly four to six weeks after the last TNF-inhibitor dose (two to three half-lives); rituximab timing is individualised.
• Cervical spine: flexion-extension films are mandatory before any general anaesthetic. An anterior atlantodens interval greater than 3 mm is abnormal and greater than 9 mm is a relative contraindication to standard intubation; obtain MRI for any neurological symptoms.
• Bilateral disease: one-stage bilateral reconstruction is feasible under regional anaesthesia but demands strict non-weight-bearing on both feet (wheelchair for six weeks); two-stage surgery six to twelve weeks apart suits patients with significant comorbidities or poor balance.

The goal: fuse the first MTP in a functional position through the dorsomedial approach, restore the metatarsal parabola across the lesser rays (by Hoffmann resection or Weil shortening), correct the claw toes, and close thin rheumatoid skin without devascularising it. The exposure is laid out in full below — and in depth on the dorsomedial approach to the first MTP joint and the dorsal approach to the lesser metatarsals pages.

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Rehabilitation | Phase | Timing | Immobilisation | Milestones | |-------|--------|-----------------|------------| | Immediate | 0-2 weeks | Below-knee non-weight-bearing cast or rigid shoe, crutches | Elevate above heart for 48-72 hours; pin-site care; multimodal analgesia | | Early | 2-6 weeks | Below-knee cast boot, strict non-weight-bearing | Wound review and suture removal at 2 weeks; K-wires remain 4-6 weeks | | Intermediate | 6-12 weeks | Progressive weight-bearing in cast boot as consolidation allows | 6-week weight-bearing AP and lateral radiographs; lesser-MTP range-of-motion exercises | | Late | 3-12 months | Wide supportive shoe; night splint if needed | Gait re-education, proprioception, scar management; custom orthoses | Most patients return to a wide, supportive shoe by 8-12 weeks. Full recovery — resolution of oedema and functional adaptation — takes 6-12 months; rheumatoid patients commonly have mild forefoot swelling for 6-9 months. Custom moulded insoles with metatarsal support and a wide, deep toe-box, rocker-bottom shoe are often needed long-term. Complications

Epidemiology. Forefoot involvement is the most common foot presentation of rheumatoid arthritis and is frequently bilateral; the lesser MTP joints are the earliest sites of rheumatoid erosion in the foot. Deformity is most prevalent in long-standing seropositive disease and is the symptom complex — painful plantar callosities and deformed toes — that most often drives the patient to seek surgical reconstruction. Pathophysiology — the cascade of deformity. MTP synovitis is the initiating event: pannus erodes articular cartilage, distends the joint capsule, and destroys the collateral ligaments and plantar plate. Volar plate attenuation then allows the proximal phalanx to subluxate dorsally; the extensor tendons migrate dorsolaterally and reinforce the deformity. The MTP joint progresses from dorsal subluxation to dislocation — the proximal phalanx rides dorsally over the metatarsal head, the plantar fat pad is dragged distally with it, and the metatarsal head is exposed to direct plantar pressure, producing intractable keratoses. Loss of intrinsic stabilisation (interossei and lumbricals) produces the claw toe posture (MTP extension with PIP and DIP flexion). Hallux valgus of the first ray is driven by MTP synovitis and medial capsular failure, and the resulting first-ray instability transfers load to the lesser metatarsals, worsening the cycle. Surgical anatomy that matters. At the first MTP, the dorsalis pedis artery and deep peroneal nerve run in the EHL–EDL interval and must be protected on every dorsal approach; the sesamoid complex within the flexor hallucis brevis forms the plantar fulcrum for push-off and is preserved during arthrodesis preparation. Across the lesser rays, the metatarsal parabola — the second metatarsal longest with a symmetric decline to the fifth — distributes plantar pressure evenly and is the structure every lesser-ray operation must restore. The plantar fat pad, held by the plantar aponeurosis septa, is displaced distally by chronic MTP dislocation and is not fully restored by reconstruction. At the craniocervical junction, rheumatoid pannus destroys the transverse ligament (the primary restraint to anterior C1-on-C2 translation) in up to 30% of patients; granulomatous tissue around the odontoid can compress the cord, and neck extension at intubation narrows the canal further. Radiographic assessment. Weight-bearing AP, lateral and oblique views are mandatory. Measure the hallux valgus angle (pathological greater than 15-20 degrees), the intermetatarsal angle (pathological greater than 9-10 degrees), and the degree of lesser MTP subluxation (dislocation when greater than 75% of the proximal phalanx base lies dorsal to the metatarsal head). The lateral view shows dorsal subluxation, sesamoid position and first-ray dorsiflexion; the oblique view reveals lateral metatarsal head erosions and cysts. Arthrodesis versus Keller — the evidence. First MTP arthrodesis is the gold standard for the ambulatory rheumatoid patient: it restores a stable plantigrade medial column, corrects hallux valgus, and offloads the lesser rays, with sustained pain relief in 85-95%. Keller excision arthroplasty — resection of the metatarsal head and proximal half of the proximal phalanx — gives reliable pain relief but a shortened weak hallux, loss of push-off, and transfer metatarsalgia in 15-30%, and is reserved for elderly low-demand or non-ambulatory patients.

Hoffmann versus Weil for the lesser rays. The choice rests on whether the lesser MTP joint is dislocated (Hoffmann) or subluxated-but-reducible (Weil). Hoffmann head resection is simple and reliable for advanced dislocation but sacrifices the joint and risks transfer lesions from uneven resection. Weil shortening preserves the articular surface and gives better motion in less severe disease, at the cost of avascular necrosis and stiffness.