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Rheumatoid forefoot deformity: a comparison study of 2 functional methods of reconstruction.

OBJECTIVE
To compare the functional, radiographic, and pedobarographic results of different reconstructive methods for severe rheumatoid forefoot deformities.


METHODS
A total of 138 feet in 79 patients with RA forefoot reconstructions between 1978 and 1997 were reviewed through a detailed questionnaire, clinical examination, standardized radiographs, and pedobarographic analysis. Five subgroups based on procedure to the 1st ray were identified, then divided into 2 functional categories: Group 1: stable 1st ray by means of arthrodesis or no surgery; and Group 2: a resection procedure to 1st metatarsophalangeal (MTP) joint.


RESULTS
Sixty-one patients (106 feet) attended clinical review; 18 returned the questionnaire. There were 65 women and 14 men, with a mean age of 59 years (range 24-80): with 52 feet in Group 1 and 86 feet in Group 2. Mean age at surgery for both groups was 52 years (range 23-79). Mean age at the time of review was 55 years (Group 1) and 60.5 years (Group 2). Length of followup was significantly different: Group 1 averaged 36 months; Group 2, 102 months (p < 0.001). At review, no significant difference was noted in SF-36, comorbidities, WOMAC, or Foot Function Index. The disability score as defined by the American Rheumatological Society was significantly different: Group 1, 2.1 +/- 0.5; and Group 2, 2.4 +/- 0.6 (p = 0.006). Group 1 did significantly better in terms of walking distance, satisfaction with postoperative appearance of foot, relief of plantar pain, less plantar calluses, and higher AOFAS HMIP and LMIP scores. Postoperative complications occurred in 16 feet (11%); 15 feet required reoperation (10.6%). Major resection of the 1st MTP joint was associated with a significant increase in the 1st and 2nd intermetatarsal angle on radiographic review. The pattern of pressure distribution on the plantar aspect was similar regardless of the surgical procedure. The maximum contact area, maximum peak pressure, and maximum pressure time integral were located under the region of the 1st metatarsal, with a progressive decrease in values under the more lateral rays and under the lesser toes. Significantly higher pressures were seen under the 1st, 2nd, and 3rd metatarsal regions in Group 2 (1st MTP joint resection). Toe function was absent or minimal in the majority of Group 2.


CONCLUSION
Forefoot arthroplasty by means of a resection or stabilization provides significant pain relief. Maintenance of a stable 1st MTP joint and resection of the lesser metatarsal heads with K-wire stabilization will result in a more cosmetic forefoot, more even distribution of forefoot pressures, and more satisfied patients.