Summary
One of the most common ways that Rheumatoid Arthritis (RA) is initially diagnosed is due to a problem in the foot. There is a large spectrum of problems associated with RA in the forefoot. There is often a classic presentation of a rheumatoid deformity. Although the RA may be under control, the patient still must deal with any resulting deformities.
Clinical Presentation and Symptoms
There are multiple deformities associated with RA. These include a bunion deformity with arthritis of the first MTP joint, clawing of all the lesser toes, and subluxation or dislocation of the lesser MTP joints. Patients with clawed toes that result in dislocation often complain of feeling like they are walking on a pebble. This is due to a prominent metatarsal head on the plantar side of the foot. Obvious deformities and their associated pain are usually obvious upon physical examination.
Imaging Studies
Although a diagnosis can often be made clinically, x-rays may be helpful to help confirm the extent of the pathology.
Operation
Non-Operative Treatment
The goal of non-operative treatment is to make the deformed part of the foot as comfortable as possible. Comfort shoe wear can be extremely helpful in managing the pain associated with a RA deformity. Inserts that are custom-made or bought over the counter can be used to help off load the prominent area. Additionally, corn pads or basic padding can be used to protect bony prominences. There are also devices available to help improve claw toe position.
Activity modification can also be helpful in managing pain due to RA in the forefoot. In some instances, physical therapy or a stretching program may be recommended in order to helpmaintain joint mobility. Most importantly, the RA itself must be managed to prevent further damage and deformations.
Operative Treatment
Operative treatment must be appropriate to the patient’s condition. For mild to moderate deformations, procedures to correct claw toes can be very helpful. For moderate to severe forefoot deformities, the surgicaloptions vary. For a bunion deformity, it is common for the great toe to be straightened and fuse the first MTP joint. This procedure greatly reduces the pain in the great toe. If the MTP joint is well preserved, then the patient may be able to undergo a basic bunion correction surgery.
The various toe deformities caused by RA in the forefoot can be addressed indifferent ways. A standard Clayton-Hoffmann procedure, which involves a resection of all of the lesser metatarsal heads with an associated correction of the claw toes, can be very effective for pain relief of the forefoot. While this lessens the pain, it does not address the dysfunction of the foot. With this procedure, the toes will no longer be able to articulate, greatly limiting a patient’s activity. If a joint is not yet dislocated and has reasonably well preserved cartilage, it may be possible to preserve the MTP joints by reducing the subluxed joint and correcting the claw toes. This procedure will not be as successful if the joint already has marked arthritis. Additionally, treatment of each claw toe can be individualized.
Recovery
Although specific recovery directions will accompany each procedure, in most cases weightbearing will be limited for the first six weeks. Following the initial six weeks, a gradual increase of activity can be made and physical therapy will generally be prescribed. Relief is usually noticeable by the 6th week and about 80% of recovery can be expected by three months.It is important to keep in mind that it can take 9-12 months to reach a point of maximal improvement.
Complications
Common surgical complications are applicable to any of these procedures. More specifically, blood supply to the tip of the toe can be compromised with the previously mentioned procedures. RA medication must be stopped 2-6 weeks prior to any surgical procedure, which can increase the chance of infection and wound healing problems. Blood clots, pulmonary embolism, persistence of symptoms, and recurrence of deformity are also possible with any of these procedures.
