Forefoot Reconstruction for Rheumatoid Disease

Indications

Indications Pitfalls

Active infection or ulceration should be eradicated prior to surgery.
Severe skin fragility may preclude operative intervention.
Medications that interfere with bone and wound healing, especially methotrexate and tumor necrosis factor antagonists, should be stopped 2 weeks prior to surgery. They can be started again when the wounds have healed.
Cervical spine stability should be established preoperatively (flexion and extension views may be required).
Patients on prednisone will often need perioperative supplementation.
A preoperative physical therapy evaluation is very helpful, both to determine a patient’s ability to ambulate after surgery and to provide training with ambulatory aids.

Indications Controversies

New medical management has altered the previously inevitable progression of autoimmune disease.
While patients with extensive forefoot involvement require the reconstruction discussed in this procedure, others may benefit from a more limited procedure (e.g., isolated great toe fusion, single MTP synovectomy, or a metatarsal osteotomy to reduce a dislocated joint).

All patients require a comprehensive preoperative history and physical examination.
A detailed examination of the foot and ankle is required, including skin condition, joint stability, tendon function, neurovascular status, and gait.
Specifically evaluate the function of the posterior tibial tendon.
Synovitis, subluxation, or dislocation of the metatarsophalangeal (MTP) joints should be documented. If dislocated, determine if the joints are passively reducible.
The most common symptomatic deformity includes hallux valgus, claw toes, dislocations of the lesser MTP joints, and metatarsalgia from pressure on the metatarsal heads ( Fig. 14.1 ).
Radiographs should include standing anteroposterior ( Fig. 14.2A ) and lateral ( Fig. 14.2B ) views of the foot. Oblique views of the foot will help visualize arthritic changes of the MTP and midfoot joints. Standing views of the ankle can be obtained to make sure there is no medial laxity of the joint.
Magnetic resonance imaging is helpful in detecting early joint involvement.

Arthritic change of the great toe MTP. Erosion of the lesser metatarsal head often associated with MTP dislocation ( Fig. 14.3 ).

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