Rheumatoid Forefoot Reconstruction

Reconstruction of Rheumatoid Forefoot

Some people with rheumatoid arthritis get destruction of the metatarsalphalangeal (MTP) joints in the ball of the foot. This will lead to a bunion and hallux valgus, and hammered lesser toes, often with dislocations. Large and painful callouses form under the ball of the foot, and the tops and ends of the toes. These deformities are usually painful.

A standard surgical reconstruction for this type of foot includes Arthrodesis of the 1st MTP joint, and excision of the bone at the ends of the 2nd, 3rd, 4th and 5th metatarsal bones. Excision of the lesser metatarsal heads is called a Clayton procedure. If there are fixed hammertoe deformities, they are corrected at the same time.

This straightens out the toes, gives a solid first ray to walk on, and allows the normal fat pad in the ball of the foot to once again rest under the weightbearing area. This operation will significantly improve a painful and deformed rheumatoid forefoot.

Surgery

The surgery is usually done as an outpatient if one side is to be operated on, or as an inpatient if it will be done bilaterally. You may have a general anesthesia, spinal anesthesia, or ankle block. You will be allowed to walk on the foot after the surgery that day.

During this surgery an arthrodesis of the 1st MTP is done, a metal plate and screws, or threaded Steinmann pins are used to fix the great toe. The lesser four toes will each have a K-wire protruding from its end. You will have a 3 inch scar on the top of the great toe, and a scar across the ball of the foot on the weightbearing surface. If hammertoes are corrected there may be scars on the tops of the lesser toes.

Day of Surgery

At the end of the surgical procedure the wound is covered and the foot is wrapped with a dressing that is securely taped into place. That dressing gives support to the foot, acting like a cast to hold it securely. That dressing should be left in place until I change it at the first post-operative office visit.

You should try to keep your foot elevated as much as possible to minimize swelling.

You will be given a post-operative shoe, and you may put all of your weight on the foot if you have that shoe on. You must not walk on the operated foot unless you are wearing the post-operative shoe.

Post-Operative Course

Dealing with post-operative pain will be your major concern for the first few days. The first post-operative visit is usually 7 – 10 days after surgery. I will remove the dressings, wash your foot, and take out the skin stitches.

You will continue to use the post-operative shoe until 6 weeks have passed after the surgery. You may bathe the foot and keep a clean sock on it. You should not sit in a hot tub until 2 weeks after surgery. If your surgery was on the right side you should not drive until 6 weeks after surgery.

I will see you the second time 4 weeks after surgery. At that time I will remove the K-wires form the lesser toes.

I will usually have an x-ray taken of the foot at the thrid postoperative visit, 6 weeks after surgery. This is done to evaluate the fusion, and make sure that healing is occurring well. Generally you will be allowed to resume wearing a regular shoe at the six-week point after surgery.

Swelling is generally present for about four months after the surgery. It usually takes 4 – 6 months for the foot to settle down.

Final Results

The goal of surgery is to give you a painless foot that will allow you to wear a flat, over-the-counter shoe, and not have pain. How successful that will be is variable. It is usually possible to make the foot pain-free for daily activities. Some patients will have some mild soreness still. Most patients will notice discomfort when the weather changes.

You will find that the great toe will be about ½ inch shorter after the surgery because of the bone that is cut out about the joint. You will have a scar on the top of the toe that is 2 - 3 inches long.

Because of stiffness at the base of the great toe, you will not be able to wear a shoe with a heel higher than about 1 inch.

The lesser toes generally are flexible, but you will have little ability to actively move them.

Complications

Complications can occur with any surgery. Go here for a general discussion of Surgical Complications.

Specific risks of this surgery include the possibility of the 1st MTP bone not healing, or non-union and implant problems.

As the swelling goes down sometimes the ends of the screws or plate can be felt along the top of the foot. Generally those are well-tolerated, but in some instances they do bother people with shoewear. If that is the case, once the fusion has occurred it may be necessary to remove the plate and screws with a second operation. Generally, they should stay in the rest of your life if they do not bother you.