Rheumatoid forefoot reconstruction: 1st metatarsophalangeal fusion and excision arthroplasty of lesser metatarsal heads.

This is a retrospective review of 66 feet (mean follow-up of 3 years) in 43 patients with painful severe rheumatoid forefoot deformities. All were treated by arthrodesis of the first metatarsophalangeal (MTP) joint through a dorsomedial incision and excision of the lesser metatarsal heads through a separate plantar approach. The mean post-operative AOFAS scores were 65.94 (range: 32 to 82). The mean post-operative Foot Function Index (FFI) was 0.47 (range: 0.23 to 0.63). Eighty five percent (57/67 feet) reported excellent or good pain relief, improved cosmetic appearance, and improved footwear comfort. The mean hallux valgus angles improved from 39 degrees to 16 degrees and the intermetatarsal angle from 16 degrees to 8 degrees. Five feet had nonunion of the 1st MTP joint arthrodesis. There were five re-operations for non-union of the 1st MTP joint arthrodesis. The success of the operation as evidenced by this study depends upon attention to metatarsal length harmonisation, stabilisation of the 1st MTP joint and thereby even distribution of loading of the forefoot. The poor results in this study were as a result of a failure to secure the stability of the 1st MTP joint.