JBJS | Rheumatoid Forefoot Reconstruction. A Long-Term Follow-up Study*

The Journal of Bone & Joint Surgery, Volume 82, Issue 3

Articles | March 01, 2000

Rheumatoid Forefoot Reconstruction. A Long-Term Follow-up Study*

MICHAEL J. COUGHLIN, M.D.†, BOISE, IDAHO

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Investigation performed at St. Alphonsus Regional Medical Center, Boise

The Journal of Bone & Joint Surgery. 2000; 82:322-41

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Abstract

Background: The purpose of the present study was to assess the results of reconstruction of the rheumatoid forefoot with arthrodesis of the metatarsophalangeal joint of the great toe, resection arthroplasty of the metatarsal heads of the lesser toes, and open repair of hammer-toe deformity (arthrodesis of the proximal interphalangeal joint) of the lesser toes when this deformity was present.

Methods: A retrospective study of forty-three consecutive patients (fifty-eight feet) with severe rheumatoid forefoot deformities was performed. Six patients (six feet) died before the most recent follow-up, and five patients (five feet) were excluded because a subtotal procedure had been performed. No patient was lost to follow-up. Thus, the study included thirty-two patients (forty-seven feet) in whom reconstruction of a rheumatoid forefoot had been performed by the author.

Results: All first metatarsophalangeal joints had successfully fused at an average of seventy-four months (range, thirty-seven to 108 months) postoperatively. The average postoperative hallux valgus angle was 20 degrees and the average postoperative angle subtended by the axes of the proximal phalanx and the metatarsal of the second ray (the MTP-2 angle) was 14 degrees, demonstrating that a stable first ray protected the lateral rays from later subluxation. One hundred and thirty-two (70 percent) of the 188 lesser metatarsophalangeal joints were dislocated preoperatively, compared with thirteen (7 percent) postoperatively. The result of the procedure (as rated subjectively by the patient) was excellent for twenty-three feet, good for twenty-two, and fair for two. There were no poor results. The average postoperative score according to the system of the American Orthopaedic Foot and Ankle Society was 69 points. Postoperative pain was rated as absent in eighteen feet, mild in twenty-five, moderate in four, and severe in none. Fifteen feet were not associated with any functional limitations, twenty-eight were associated with limitation of recreational activities, and four were associated with limitation of daily activities. At the time of the most recent follow-up, no special shoe requirements were reported. Fourteen feet (30 percent) had a reoperation for the removal of hardware from the first metatarsophalangeal joint, a procedure on the interphalangeal joint of the great toe, or additional procedures on the lesser toes or lesser metatarsophalangeal joints.

Conclusions: In the present study, arthrodesis of the first metatarsophalangeal joint, resection arthroplasty of the lesser metatarsal heads, and repair of fixed hammer-toe deformities with intramedullary Kirschner-wire fixation resulted in a stable repair with a high percentage of successful results at an average of six years after the procedures.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

The prevalence of forefoot deformities in adults with chronic rheumatoid arthritis has been reported to approach 90 percent (848 of 955 feet)⁷⁴. Chronic metatarsophalangeal joint inflammation leads to capsular distention and eventually to a loss of capsular and collateral ligament integrity. Continued walking in the presence of soft-tissue instability, articular cartilage destruction, and subchondral bone resorption leads to the common rheumatoid forefoot deformities of hallux valgus, fixed hammering of the lesser toes, and subluxation and dislocation of the lesser metatarsophalangeal joints. As the proximal phalanges are displaced dorsally, the plantar fat pad is drawn distally, leaving a thin, relatively insufficient soft-tissue cushion beneath the metatarsal heads, where painful, thickened plantar keratoses frequently develop and impair the ability to walk. These fixed forefoot deformities generally make it necessary for the patient to wear a customized shoe.

Various operative procedures designed to correct components of the rheumatoid forefoot have been described. Methods for the treatment of a symptomatic hallux valgus deformity have included resection of the first metatarsal head^{1,4,10,11,21,36,57}, resection of the base of the proximal phalanx (Keller procedure)^{1,4,21,44,48,73,78}, and arthrodesis of the metatarsophalangeal joint^23,47,53,55. Subluxation or dislocation of the lesser metatarsophalangeal joints has been treated with a variety of resection arthroplasty techniques; these have included metatarsal head resection^{1,4,8,22,24,31,36,38,39,41,47,55,58,66,70,75,76,78}, proximal phalangeal base excision^22,61,66, proximal phalangeal base excision with beveling of the metatarsal condyles^{6,28,42-45,62}, and excision of both the base of the proximal phalanx and the metatarsal head^{1,4,10,11,21,34,41,48,51,53,55,57,58}.

While relocation of the plantar fat pad can be achieved by excising an elliptical segment of redundant plantar skin^{4,24,28,39,59,61,75,78}, some investigators have suggested that this procedure is unnecessary and that the plantar fat pad relocates proximally after the correction of metatarsophalangeal joint malalignment^22,53,55.

Fixed hammer-toe deformities of the lesser toes associated with metatarsophalangeal joint deformation have been treated with partial proximal phalangectomy^{4,28,43,48,61,66,78}, closed osteoclasis^{10,19,32,41,53,55,62,67}, and, uncommonly, with either forefoot amputation^2,3,27 or open hammer-toe repair (resection of the distal condyles of the proximal phalanx)^{16,19,32,38,41,47}.

Although the prevalence of satisfactory subjective results has been reported to be 80 percent or higher in several series ranging in size from eighteen to 169 feet^{1,4,10,24,28,31,39,45,47,53,55,61,67,75,76,78}, the methods of assessment have varied greatly, from a purely subjective assessment by the authors to an in-depth objective evaluation. There is little clinical evidence or quantitative information to support the rate of satisfactory subjective and objective results reported in the six largest studies that I am aware of, which comprised a total of 1006 forefoot arthroplasties. Specifically, Amuso et al.¹ reported an 88 percent rate of successful results in a study of 169 feet; Brattstrom and Brattstrom⁸, a 75 percent rate in a study of 138 feet; Marmor⁵⁷, an 85 percent rate in a study of 272 feet; Newman and Fitton⁶¹, a 91 percent rate in a study of 130 feet; Schwartzmann⁶⁷, an 82 percent rate in a study of 150 feet; and van Loon et al.⁷⁶, a 90 percent rate in a study of 147 feet. None of those authors quantitated the results of postoperative radiographs or gave specific criteria for the final postoperative evaluation.

Several of the investigators who have claimed a high level of satisfactory results reported on both rheumatoid and nonrheumatoid patients^28,39,78, described the results of subtotal procedures^{4,6,8,34,44,53,59,61,67}, or included the results of several different procedures in the same study^{1,4,21,61,67,76,78}. Some investigators reported the results from multiple surgeons^1,34,75 or reached their conclusions on the basis of written questionnaires or telephone surveys^8,45,48,61. Relatively few studies have included a description of objective postoperative findings or a comparison of preoperative and postoperative radiographs in the final assessment^53,55,66,78. The high levels of success reported in several studies that had a limited duration of follow-up (six months or less)^1,4,24,39,45 are countered by the findings of Craxford et al.²¹ and others^34,48,73, who reported deteriorating results over time. However, some authors, including Ananthakrishnan and Wiedel² and others^53,55, have reported on the durability of the results of forefoot arthroplasty over time.

Of the seven studies on rheumatoid forefoot procedures in which the average duration of follow-up was more than five years, two dealt with amputation^2,27, one dealt with silicone arthroplasty of the first metatarsophalangeal joint⁵⁸, and four dealt with excisional arthroplasty of the first metatarsophalangeal joint in conjunction with resection arthroplasty of the lateral metatarsophalangeal joints^66,73,75,76. I am not aware of any studies in which the results of lateral forefoot arthroplasty combined with metatarsophalangeal arthrodesis were evaluated after more than five years of follow-up.

The purpose of the present study is to present the long-term results of reconstruction of the rheumatoid forefoot with arthrodesis of the first metatarsophalangeal joint, resection arthroplasty of the lesser metatarsal heads, and open hammer-toe repair (arthrodesis of the proximal interphalangeal joint) of the lesser toes.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†901 North Curtis Road, Suite 503, Boise, Idaho 83706. E-mail address: footmd@aol.com.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†901 North Curtis Road, Suite 503, Boise, Idaho 83706. E-mail address: footmd@aol.com.

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TABLE I: DATA ON THE PATIENTS

*AOFAS = American Orthopaedic Foot and Ankle Society.

Case

Gender, Age at Op. (yrs.)

Continuous Drug Therapy

Side of Op.

Durat. of Follow-up (mos.)

Previous Failed Procedures

Preoperative Complaints

Location of Pain

Postop. AOFAS Score⁴⁰* (points)

Additional Procedures (no. of feet)

Postop. Subjective Rating

Pain

Callus or Intractable Plantar Keratosis

Shoe Problems

Plantar Aspect of Forefoot

Other

Arthrodesis or Disarticulat. at 1^st Inter- phalangeal Joint

Removal of Hardware from 1^st Metatarsopha- langeal Joint

Repeat Op. on Lesser Toes

Repeat Resection Arthroplasty of Lesser Metatarsopha- langeal Joint

Total Joint Replacement or Procedure on Ankle, Hindfoot, or Midfoot

F, 71/72

Methotrexate

L/R

108/101

Yes

Bunion

64/59

Good/good

F, 53

108

Yes

Instep

Excellent

F, 62/63

Prednisone

L/R

102/100

Yes

Lesser toes

60/60

Excellent/excellent

F, 63

Prednisone

108

Yes

Lesser toes

Good

F, 64

102

Forefoot arthroplasty (R)

Yes

Lesser toes

Good

M, 18/18

L/R

103/85

Yes

Lesser toes

59/59

Fair/fair

M, 59/60

Prednisone

L/R

104/950

Arthrodesis and forefoot arthroplasty (L, R)

Yes

Lesser toes

52/57

Good/good

F, 37/37

L/R

89/87

Yes

70/70

Excellent/excellent

F, 60/66

Prednisone, methotrexate

L/R

90/98

Bunionectomy (L)

Yes

Lesser toes

60/65

Good/good

M, 76

Prednisone, methotrexate

Lesser toes (R)

Yes

Lesser toes

Good

M, 50/52

L/R

82/69

Yes

85/85

Excellent/excellent

F, 69

Prednisone

Yes

Excellent

F, 51/51

Methotrexate

L/R

81/84

Yes

80/80

Excellent/excellent

M, 43

Methotrexate

Yes

Bunion, lesser toes

Excellent

F, 78

Yes

Bunion, lesser toes

Excellent

F, 55/57

Methotrexate

L/R

79/48

Yes

Lesser toes

72/70

Excellent/excellent

F, 72

Prednisone, methotrexate

Yes

Good

F, 70/70

Prednisone, methotrexate

L/R

68/68

Keller procedure and forefoot arthroplasty (L, R)

Yes

57/57

Good/good

F, 55/53

L/R

38/66

Yes

75/70

Excellent/excellent

F, 40/40

Prednisone

L/R

78/76

Yes

Lesser toes

55/62

Good/good

M, 60

Prednisone, methotrexate

Yes

Lesser toes

Excellent

F, 42/42

Methotrexate

L/R

56/64

Yes

Bunion

72/72

Good/good

F, 48

Prednisone, methotrexate

Bunionectomy (R)

Yes

Bunion

Excellent

M, 70

Prednisone, methotrexate

Lesser toes (L)

Yes

Lesser toes

Excellent

F, 67

Methotrexate

Lesser toes (L)

Yes

Lesser toes

Excellent

F, 49/51

Prednisone, methotrexate

L/R

55/36

Forefoot arthroplasty (L, R)

Yes

80/80

Good/good

F, 47/48

Methotrexate

L/R

52/40

Yes

62/62

Good/good

F, 46

Prednisone, methotrexate

Yes

Bunion

Good

F, 25

Prednisone, methotrexate

Yes

Excellent

F, 74

Keller procedure and forefoot arthroplasty (L)

Yes

Lesser toes

Excellent

M, 70

Prednisone, methotrexate

Yes

Bunion

Excellent

F, 50

Prednisone

Yes

Lesser toes

Good

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TABLE I: DATA ON THE PATIENTS

*AOFAS = American Orthopaedic Foot and Ankle Society.

Case

Gender, Age at Op. (yrs.)

Continuous Drug Therapy

Side of Op.

Durat. of Follow-up (mos.)

Previous Failed Procedures

Preoperative Complaints

Location of Pain

Postop. AOFAS Score⁴⁰* (points)

Additional Procedures (no. of feet)

Postop. Subjective Rating

Pain

Callus or Intractable Plantar Keratosis

Shoe Problems

Plantar Aspect of Forefoot

Other

Arthrodesis or Disarticulat. at 1^st Inter- phalangeal Joint

Removal of Hardware from 1^st Metatarsopha- langeal Joint

Repeat Op. on Lesser Toes

Repeat Resection Arthroplasty of Lesser Metatarsopha- langeal Joint

Total Joint Replacement or Procedure on Ankle, Hindfoot, or Midfoot

F, 71/72

Methotrexate

L/R

108/101

Yes

Bunion

64/59

Good/good

F, 53

108

Yes

Instep

Excellent

F, 62/63

Prednisone

L/R

102/100

Yes

Lesser toes

60/60

Excellent/excellent

F, 63

Prednisone

108

Yes

Lesser toes

Good

F, 64

102

Forefoot arthroplasty (R)

Yes

Lesser toes

Good

M, 18/18

L/R

103/85

Yes

Lesser toes

59/59

Fair/fair

M, 59/60

Prednisone

L/R

104/950

Arthrodesis and forefoot arthroplasty (L, R)

Yes

Lesser toes

52/57

Good/good

F, 37/37

L/R

89/87

Yes

70/70

Excellent/excellent

F, 60/66

Prednisone, methotrexate

L/R

90/98

Bunionectomy (L)

Yes

Lesser toes

60/65

Good/good

M, 76

Prednisone, methotrexate

Lesser toes (R)

Yes

Lesser toes

Good

M, 50/52

L/R

82/69

Yes

85/85

Excellent/excellent

F, 69

Prednisone

Yes

Excellent

F, 51/51

Methotrexate

L/R

81/84

Yes

80/80

Excellent/excellent

M, 43

Methotrexate

Yes

Bunion, lesser toes

Excellent

F, 78

Yes

Bunion, lesser toes

Excellent

F, 55/57

Methotrexate

L/R

79/48

Yes

Lesser toes

72/70

Excellent/excellent

F, 72

Prednisone, methotrexate

Yes

Good

F, 70/70

Prednisone, methotrexate

L/R

68/68

Keller procedure and forefoot arthroplasty (L, R)

Yes

57/57

Good/good

F, 55/53

L/R

38/66

Yes

75/70

Excellent/excellent

F, 40/40

Prednisone

L/R

78/76

Yes

Lesser toes

55/62

Good/good

M, 60

Prednisone, methotrexate

Yes

Lesser toes

Excellent

F, 42/42

Methotrexate

L/R

56/64

Yes

Bunion

72/72

Good/good

F, 48

Prednisone, methotrexate

Bunionectomy (R)

Yes

Bunion

Excellent

M, 70

Prednisone, methotrexate

Lesser toes (L)

Yes

Lesser toes

Excellent

F, 67

Methotrexate

Lesser toes (L)

Yes

Lesser toes

Excellent

F, 49/51

Prednisone, methotrexate

L/R

55/36

Forefoot arthroplasty (L, R)

Yes

80/80

Good/good

F, 47/48

Methotrexate

L/R

52/40

Yes

62/62

Good/good

F, 46

Prednisone, methotrexate

Yes

Bunion

Good

F, 25

Prednisone, methotrexate

Yes

Excellent

F, 74

Keller procedure and forefoot arthroplasty (L)

Yes

Lesser toes

Excellent

M, 70

Prednisone, methotrexate

Yes

Bunion

Excellent

F, 50

Prednisone

Yes

Lesser toes

Good

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Table II: RATING SCALE OF THE AMERICAN ORTHOPAEDIC FOOT AND ANKLE SOCIETY*

*Reproduced, with modification, from: Kitaoka, H. B.; Alexander, I. J.; Adelaar, R. S.; Nunley, J. A.; Myerson, M. S.; and Sanders, M.: Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot and Ankle Internat., 15: 351, 1994. Reprinted with permission.

Category	Score (points)
Pain (40 points)
None	40
Mild, occasional	30
Moderate, daily	20
Severe, almost always present	0
Function (45 points)
Activity limitations
No limitations	10
No limitation of daily activities, limitation of recreational activities	7
Limitation of daily and recreational activities	4
Severe limitation of daily and recreational activities	0
Footwear requirements
Fashionable, conventional shoes, no insert required	10
Comfort footwear, shoe insert	5
Modified shoes or brace	0
Metatarsophalangeal joint motion (dorsiflexion plus plantar flexion)
Normal or mild restriction (at least 75 degrees of motion)	10
Moderate restriction (30 to 74 degrees of motion)	5
Severe restriction (less than 30 degrees of motion)	0
Interphalangeal joint motion (plantar flexion)
No restriction	5
Severe restriction (less than 10 degrees of motion)	0
Metatarsal-interphalangeal stability (all directions)
Stable	5
Definitely unstable or able to dislocate	0
Callus related to lesser metatarsophalangeal or interphalangeal joints
No callus or asymptomatic callus	5
Symptomatic callus	0
Alignment (15 points)
Good, lesser toes well aligned	15
Fair, some degree of lesser-toe malalignment, no symptoms	8
Poor, severe malalignment, symptoms present	0

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Table II: RATING SCALE OF THE AMERICAN ORTHOPAEDIC FOOT AND ANKLE SOCIETY*

Category	Score (points)
Pain (40 points)
None	40
Mild, occasional	30
Moderate, daily	20
Severe, almost always present	0
Function (45 points)
Activity limitations
No limitations	10
No limitation of daily activities, limitation of recreational activities	7
Limitation of daily and recreational activities	4
Severe limitation of daily and recreational activities	0
Footwear requirements
Fashionable, conventional shoes, no insert required	10
Comfort footwear, shoe insert	5
Modified shoes or brace	0
Metatarsophalangeal joint motion (dorsiflexion plus plantar flexion)
Normal or mild restriction (at least 75 degrees of motion)	10
Moderate restriction (30 to 74 degrees of motion)	5
Severe restriction (less than 30 degrees of motion)	0
Interphalangeal joint motion (plantar flexion)
No restriction	5
Severe restriction (less than 10 degrees of motion)	0
Metatarsal-interphalangeal stability (all directions)
Stable	5
Definitely unstable or able to dislocate	0
Callus related to lesser metatarsophalangeal or interphalangeal joints
No callus or asymptomatic callus	5
Symptomatic callus	0
Alignment (15 points)
Good, lesser toes well aligned	15
Fair, some degree of lesser-toe malalignment, no symptoms	8
Poor, severe malalignment, symptoms present	0

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TABLE III: RADIOGRAPHIC FINDINGS

*The numbers 2, 3, 4, and 5 refer to the second, third, fourth, and fifth metatarsophalangeal joints, respectively. ‡Grade 1 = no degenerative changes; grade 2 = mild degenerative changes with less than one millimeter of chondrolysis; grade 3 = moderate degenerative changes with one to two millimeters of chondrolysis; and grade 4 = severe degenerative changes with malalignment, cyst formation, or joint destruction. ‡A = aligned, S = subluxated, and D = dislocated. The first, second, third, and fourth letters in each sequence pertain to the second, third, fourth, and fifth metatarsophalangeal joints, respectively. §A previous forefoot arthroplasty had been performed.

Case	Preoperative						Postoperative
Hallux Valgus Angle (degrees)		Dislocated Lesser Metatarsophalangeal Joints*		Severity of Interphalangeal Joint Arthritis† (grade)		Hallux Valgus Angle (degrees)		Dorsiflexion Angle (degrees)		MTP-2 Angle (degrees)		Severity of Interphalangeal Joint Arthritis† (grade)		Axial Alignment of Lesser Metatarsophalangeal Joints‡		Sagittal Alignment of Lesser Metatarsophalangeal Joints‡
Left	Right	Left	Right	Left	Right	Left	Right	Left	Right	Left	Right	Left	Right	Left	Right	Left	Right
1	35	20	2, 3, 4	2, 3, 5	2	2	18	18	17	28	16	14	3	3	AAAA	AASS	AAAA	AAAA
2	50				1		23		33		13		1		AAAA		AAAA
3	30	45	2, 5	5	1	1	25	40	25	25	25	25	4	4	SASA	AAAA	AAAA	AAAA
4	40		2, 3		2		27		24		19		2		AASA		AAAA
5		49		2, 3		2		12		28		19		2		SASS		AAAA
6	49	54	4, 5	4, 5	1	1	27	18	30	18	35	15	1	1	AASA	AASS	AAAA	AAAA
7	20	25	2, 3, 4, 5	2, 3, 4, 5	2	1	17	12	28	25	0	0	2	1	AAAA	AAAS	DAAA§	AAAA
8	40	40	2, 3, 4, 5	2, 3, 4, 5	2	2	16	13	20	22	32	0	3	3	AAAA	DAAA	AAAA	DAAA
9	54	55	2, 3	2, 3, 4	2	2	30	20	25	22	17	20	4	4	AAAA	AAAA	AAAA	AADA
10		30		2, 3, 4, 5		3		19		24		20		3		AAAA		AADA
11	28	5	2, 3, 4, 5	2, 3, 4, 5	1	1	22	15	21	25	22	3	1	1	SSAA	AAAA	AAAA	AAAA
12	43		2, 3, 4, 5		1		23		15		0		2		SAAA		AAAA
13	35	48	2, 3, 4, 5	2, 3, 4, 5	2	2	22	22	25	15	22	15	2	2	AAAA	AAAA	AAAA	DAAA
14	50		2, 3, 4, 5		1		20		23		10		1		AASA		DAAA
15		75		2, 3, 4, 5		1		25		26		10		1		SSAS		AAAA
16	20	20	2, 3		1	1	12	17	17	19	7	13	4	3	AAAA	AAAA	AAAA	AAAA
17		20		2		1		23		27		12		1		AAAA		AAAA
18	45	20	4, 5	2, 3, 4, 5	1	2	15	8	20	20	20	0	2	2	AAAA	DDDD	AAAA	DDDD§
19	54	49	3, 4, 5	2, 4, 5	2	2	13	21	24	26	10	19	2	2	AAAA	AAAA	AADA	AAAA
20	43	30	2, 3, 4, 5	4, 5	2	2	23	20	24	20	28	20	2	2	AAAA	AAAA	AAAA	AAAA
21	43		2, 3, 4, 5		1		24		20		7		4		AAAA		AAAA
22	39	37	2, 3, 4, 5	2, 3, 4, 5	2	2	16	16	24	15	8	8	2	2	AAAA	AAAA	AAAA	AAAA
23		37		5		1		23		24		12		1		ASSS		AAAA
24	38		2, 3, 4		2			20	22		27		2		AAAA		AAAA
25	10		2, 3		2		6		28		14		3		AAAA		AAAA
26	75	50	2, 3, 4	2, 3	3	2	4	15	21	10	7	10	4	2	AAAA	ASAA	AAAA	AAAA
27	47	38	2, 3, 4, 5	2, 3, 4, 5	2	1	25	28	15	20	16	11	4	2	AAAA	ASAS	AAAA	AAAA
28	30		3, 4, 5		1		18		24		3		1		AAAA		AAAA
29		39		2, 3, 4		2		24		20		7		2		AAAA		AAAA
30	13		2, 3, 4, 5		2		20		23		6		2		AAAD		AADD§
31	35				1		20		23		7		2		AAAA		AAAA
32	52				2		22		18		11		2		AAAA		AAAA

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TABLE III: RADIOGRAPHIC FINDINGS

Case	Preoperative						Postoperative
Hallux Valgus Angle (degrees)		Dislocated Lesser Metatarsophalangeal Joints*		Severity of Interphalangeal Joint Arthritis† (grade)		Hallux Valgus Angle (degrees)		Dorsiflexion Angle (degrees)		MTP-2 Angle (degrees)		Severity of Interphalangeal Joint Arthritis† (grade)		Axial Alignment of Lesser Metatarsophalangeal Joints‡		Sagittal Alignment of Lesser Metatarsophalangeal Joints‡
Left	Right	Left	Right	Left	Right	Left	Right	Left	Right	Left	Right	Left	Right	Left	Right	Left	Right
1	35	20	2, 3, 4	2, 3, 5	2	2	18	18	17	28	16	14	3	3	AAAA	AASS	AAAA	AAAA
2	50				1		23		33		13		1		AAAA		AAAA
3	30	45	2, 5	5	1	1	25	40	25	25	25	25	4	4	SASA	AAAA	AAAA	AAAA
4	40		2, 3		2		27		24		19		2		AASA		AAAA
5		49		2, 3		2		12		28		19		2		SASS		AAAA
6	49	54	4, 5	4, 5	1	1	27	18	30	18	35	15	1	1	AASA	AASS	AAAA	AAAA
7	20	25	2, 3, 4, 5	2, 3, 4, 5	2	1	17	12	28	25	0	0	2	1	AAAA	AAAS	DAAA§	AAAA
8	40	40	2, 3, 4, 5	2, 3, 4, 5	2	2	16	13	20	22	32	0	3	3	AAAA	DAAA	AAAA	DAAA
9	54	55	2, 3	2, 3, 4	2	2	30	20	25	22	17	20	4	4	AAAA	AAAA	AAAA	AADA
10		30		2, 3, 4, 5		3		19		24		20		3		AAAA		AADA
11	28	5	2, 3, 4, 5	2, 3, 4, 5	1	1	22	15	21	25	22	3	1	1	SSAA	AAAA	AAAA	AAAA
12	43		2, 3, 4, 5		1		23		15		0		2		SAAA		AAAA
13	35	48	2, 3, 4, 5	2, 3, 4, 5	2	2	22	22	25	15	22	15	2	2	AAAA	AAAA	AAAA	DAAA
14	50		2, 3, 4, 5		1		20		23		10		1		AASA		DAAA
15		75		2, 3, 4, 5		1		25		26		10		1		SSAS		AAAA
16	20	20	2, 3		1	1	12	17	17	19	7	13	4	3	AAAA	AAAA	AAAA	AAAA
17		20		2		1		23		27		12		1		AAAA		AAAA
18	45	20	4, 5	2, 3, 4, 5	1	2	15	8	20	20	20	0	2	2	AAAA	DDDD	AAAA	DDDD§
19	54	49	3, 4, 5	2, 4, 5	2	2	13	21	24	26	10	19	2	2	AAAA	AAAA	AADA	AAAA
20	43	30	2, 3, 4, 5	4, 5	2	2	23	20	24	20	28	20	2	2	AAAA	AAAA	AAAA	AAAA
21	43		2, 3, 4, 5		1		24		20		7		4		AAAA		AAAA
22	39	37	2, 3, 4, 5	2, 3, 4, 5	2	2	16	16	24	15	8	8	2	2	AAAA	AAAA	AAAA	AAAA
23		37		5		1		23		24		12		1		ASSS		AAAA
24	38		2, 3, 4		2			20	22		27		2		AAAA		AAAA
25	10		2, 3		2		6		28		14		3		AAAA		AAAA
26	75	50	2, 3, 4	2, 3	3	2	4	15	21	10	7	10	4	2	AAAA	ASAA	AAAA	AAAA
27	47	38	2, 3, 4, 5	2, 3, 4, 5	2	1	25	28	15	20	16	11	4	2	AAAA	ASAS	AAAA	AAAA
28	30		3, 4, 5		1		18		24		3		1		AAAA		AAAA
29		39		2, 3, 4		2		24		20		7		2		AAAA		AAAA
30	13		2, 3, 4, 5		2		20		23		6		2		AAAD		AADD§
31	35				1		20		23		7		2		AAAA		AAAA
32	52				2		22		18		11		2		AAAA		AAAA

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TABLE IV: HALLUX VALGUS ANGLE OF FUSION

Severity of Arthritis (grade)	No. of Feet	Angles =20 Degrees (degrees)	Angles >20 Degrees (degrees)	Average (Range) of Angles (degrees)
1	12	12, 15, 16, 18, 18, 20	22, 23, 23, 23, 25, 27	20 (12—27)
2	20	8, 12, 13, 15, 15, 16, 17, 20, 20, 20, 20	21, 22, 22, 22, 23, 23, 24, 27, 28	19 (8—28)
3	7	6, 13, 16, 17, 18, 18, 19		15 (6—19)
4	8	4, 12, 20	24, 25, 25, 30, 40	23 (4—40)

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TABLE IV: HALLUX VALGUS ANGLE OF FUSION

Severity of Arthritis (grade)	No. of Feet	Angles =20 Degrees (degrees)	Angles >20 Degrees (degrees)	Average (Range) of Angles (degrees)
1	12	12, 15, 16, 18, 18, 20	22, 23, 23, 23, 25, 27	20 (12—27)
2	20	8, 12, 13, 15, 15, 16, 17, 20, 20, 20, 20	21, 22, 22, 22, 23, 23, 24, 27, 28	19 (8—28)
3	7	6, 13, 16, 17, 18, 18, 19		15 (6—19)
4	8	4, 12, 20	24, 25, 25, 30, 40	23 (4—40)

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TABLE V: DORSIFLEXION ANGLE OF FUSION

Severity of Arthritis (grade)	No. of Feet	Angles =20 Degrees (degrees)	Angles >20 Degrees (degrees)	Average (Range) of Angles (degrees)
1	12	18	21, 23, 24, 24, 24, 25, 25, 26, 27, 30, 33	25 (18—33)
2	20	10, 15, 15, 15, 18, 20, 20, 20, 20, 20	22, 23, 23, 24, 24, 24, 25, 26, 28, 28	21 (10—28)
3	7	17, 19, 20	22, 24, 28, 28	23 (17—28)
4	8	15, 17, 20	21, 22, 25, 25, 25	21 (15—25)

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TABLE V: DORSIFLEXION ANGLE OF FUSION

Severity of Arthritis (grade)	No. of Feet	Angles =20 Degrees (degrees)	Angles >20 Degrees (degrees)	Average (Range) of Angles (degrees)
1	12	18	21, 23, 24, 24, 24, 25, 25, 26, 27, 30, 33	25 (18—33)
2	20	10, 15, 15, 15, 18, 20, 20, 20, 20, 20	22, 23, 23, 24, 24, 24, 25, 26, 28, 28	21 (10—28)
3	7	17, 19, 20	22, 24, 28, 28	23 (17—28)
4	8	15, 17, 20	21, 22, 25, 25, 25	21 (15—25)

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FIG1:: Fig. 1 Diagram demonstrating the hallux valgus angle, the first-second intermetatarsal angle, and the MTP-2 angle. On the anteroposterior radiograph, reference points are placed at the midpoint of the proximal and distal aspects of the diaphyses of the proximal phalanges and the first and second metatarsals. The hallux valgus angle is subtended by the axes of the proximal phalanx and the first metatarsal. The MTP-2 angle is the angle subtended by the axes of the proximal phalanx and the metatarsal of the second toe. The first-second intermetatarsal angle is the angle subtended by the axes of the first and second metatarsals.

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FIG2:: Fig. 2 Diagram demonstrating the dorsiflexion angle of fusion. On the lateral postoperative radiograph, reference points are placed at the midpoint of the proximal and distal aspects of the diaphyses of the proximal phalanx and the first metatarsal. The angle subtended by these axes is the dorsiflexion angle of fusion⁵⁵.

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FIG3-A:: Fig. 3-A Diagram and radiograph demonstrating the medial-lateral position of the lesser metatarsophalangeal joints. On the anteroposterior radiograph, points are placed at the midpoint of the proximal and distal aspects of the diaphysis of the proximal phalanx. If the axis of the proximal phalanx was centered within the diaphysis of the corresponding metatarsal, it was rated as aligned (Figs. 3-A and 3-B, second ray); if it was displaced by one diaphyseal width or less either medially or laterally, it was rated as subluxated (Figs. 3-A and 3-B, third ray); and if it was displaced by more than one diaphyseal width either medially or laterally, it was rated as dislocated (Figs. 3-A and 3-B, fourth ray).

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FIG3-B:: Fig. 3-B Diagram and radiograph demonstrating the medial-lateral position of the lesser metatarsophalangeal joints. On the anteroposterior radiograph, points are placed at the midpoint of the proximal and distal aspects of the diaphysis of the proximal phalanx. If the axis of the proximal phalanx was centered within the diaphysis of the corresponding metatarsal, it was rated as aligned (Figs. 3-A and 3-B, second ray); if it was displaced by one diaphyseal width or less either medially or laterally, it was rated as subluxated (Figs. 3-A and 3-B, third ray); and if it was displaced by more than one diaphyseal width either medially or laterally, it was rated as dislocated (Figs. 3-A and 3-B, fourth ray).

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FIG4:: Fig. 4 Diagram demonstrating regular resection of the lesser metatarsals. A transverse arc is drawn from the distalmost aspect of the second metatarsal to the distalmost aspect of the fifth metatarsal. If a metatarsal extended beyond this line, the resection was deemed irregular.

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FIG5-A:: Fig. 5-A Preoperative radiograph demonstrating hallux valgus deformity and dislocation of the second, third, and fourth metatarsophalangeal joints.

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FIG5-B:: Fig. 5-B Intraoperative photograph showing the dorsal longitudinal incisions and the dorsal plate used for internal fixation at the site of the arthrodesis of the first metatarsophalangeal joint.

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FIG5-C:: Fig. 5-C: Postoperative radiograph demonstrating arthrodesis of the first metatarsophalangeal joint, resection arthroplasty of the lesser metatarsophalangeal joints, hammer-toe repairs of the lesser toes, and intramedullary Kirschner-wire fixation.

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FIG5-D:: Fig. 5-D: Radiograph, made at the time of the three-year follow-up, demonstrating anatomical alignment of the lesser metatarsophalangeal joints.

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FIG5-E:: Fig. 5-E Lateral radiograph demonstrating fusion of the first metatarsophalangeal joint.

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FIG6-A:: Fig. 6-A: Radiograph, made five years after an unsuccessful Keller resection arthroplasty, demonstrating fixed dislocation of the lesser metatarsophalangeal joints with hammer-toe deformities.

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FIG6-B:: Fig. 6-B: Radiograph, made five years and eight months after arthrodeses of the metatarsophalangeal joint and the interphalangeal joint, demonstrating alignment of the lesser metatarsophalangeal joints. A large exostosis (arrows) (more than three millimeters in size) of the second metatarsal was asymptomatic.

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FIG7:: Fig. 7 Radiograph, made approximately eight years postoperatively, demonstrating successful arthrodesis of the first metatarsophalangeal joint and severe degenerative changes with joint destruction and subchondral cyst formation (grade-4 arthritis) of the interphalangeal joint.

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FIG8-A:: Fig. 8-A: Radiograph, made two years preoperatively, demonstrating severe hallux valgus with dislocation of the first and second metatarsophalangeal joints. At the time of the operation, the third and fourth metatarsophalangeal joints had also dislocated.

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FIG8-B:: Fig. 8-B: Following arthrodesis, the first metatarsophalangeal joint is realigned.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

From January 1988 through January 1995, I operated on forty-three consecutive patients (fifty-eight feet) who had severe forefoot deformities secondary to chronic rheumatoid arthritis. The indication for the procedure in all patients was disabling foot pain secondary to intractable plantar keratoses beneath the lesser metatarsal heads, painful hallux valgus deformities, and pressure over lesser toes with hammer-toe deformities. Diminished walking capacity, characterized by reduced standing tolerance or an inability to walk more than one-eighth mile (0.2 kilometer), was an indication for the procedure as well. A previous failed arthroplasty of the forefoot was also a relative indication for the procedure when pain and diminished walking capacity were unrelieved by nonoperative treatment (Table I).

Six patients (six feet) died before the most recent follow-up, and five patients (five feet) were excluded because a subtotal procedure had been performed (four patients had had an arthrodesis of the first metatarsophalangeal joint without an arthroplasty of the lateral aspect of the forefoot, and one had had an arthroplasty of the lateral aspect of the forefoot without an arthrodesis of the first metatarsophalangeal joint), leaving thirty-two patients (forty-seven feet) who had complete reconstruction of the forefoot. Twenty-four women (thirty-six feet) and eight men (eleven feet) had the reconstruction at an average age of fifty-five years (range, eighteen to seventy-eight years). Thirteen feet (28 percent) had had one or more previous unsuccessful procedures, including hallux valgus correction, resection arthroplasty of the lesser metatarsophalangeal joints, or hammer-toe correction. Twenty-four (75 percent) of the thirty-two patients were using prednisone or methotrexate, or both, on a chronic basis at the time of the procedure.

Each patient returned for a personal interview by an independent investigator and a clinical examination by both the independent investigator and the author. A postoperative forefoot score was calculated, according to the system of the American Orthopaedic Foot and Ankle Society⁴⁰, on the basis of data derived during the interview and physical examination (Table II). This 100-point scale includes items related to pain, level of activity, deformity, and motion. Components of this score, including pain and function, were quantitated by the patients at the time of the most recent follow-up. Pain was characterized as severe, moderate, mild, or absent, and functional activity was quantified according to whether the patient had severe limitations in daily activities, limitations in daily activities, limitations in recreational activities, or no limitations.

The patients also subjectively rated the result of the procedure on each foot. A rating of excellent indicated that the patient had no problems, was very satisfied with the result, had mild or no pain, and could walk without difficulty. A rating of good meant that the patient had few problems, was satisfied with the result, had mild pain, could walk without difficulty or with mild difficulty, and would have the same procedure again. A rating of fair meant that the patient had moderate pain in the foot, had some difficulty with walking, and had reservations about the success of the operation. A rating of poor meant that the patient continued to have pain in the foot, had noted little improvement in walking, and regretted having had the procedure.

A chart review was used to establish the initial preoperative complaint and the location of pain. Areas of continued pain were identified by the patient and evaluated at the time of the physical examination.

At the time of the most recent follow-up, the feet were examined by the independent investigator and the author, with the patient in both a sitting and a supine position, in order to assess the alignment and position of the toes, the prominence of the metatarsals on the plantar surface of the foot, the presence or absence of callosities, and whether the pulp of the lesser toes touched the ground. A Harris-mat pressure study was performed and evaluated for all feet according to the technique described by Mann and Thompson⁵³. The results of the pressure study were assessed in relation to the presence or absence of areas of pressure beneath the lesser metatarsals and the great toe during walking.

Standard anteroposterior and lateral weight-bearing radiographs of each foot were made preoperatively and postoperatively. The preoperative and postoperative radiographs were compared, according to the method of Smith et al.⁶⁹, to evaluate the hallux valgus angle, the first-second intermetatarsal angle (Fig. 1), and the dorsiflexion angle of fusion⁵⁵ (Fig. 2). In addition, the angular relationship between the proximal phalanx and the metatarsal of the second toe was quantitated postoperatively by measurement of the metatarsophalangeal-2 (MTP-2) angle (Fig. 1). All radiographs were evaluated by the author.

The interphalangeal joint of the hallux was assessed on the preoperative and postoperative radiographs and was graded with regard to the extent of arthritic degeneration. Grade 1 indicated no degenerative changes; grade 2, mild degenerative changes with less than one millimeter of chondrolysis; grade 3, moderate degenerative changes with one to two millimeters of chondrolysis; and grade 4, severe degenerative changes with malalignment, cyst formation, or joint destruction.

Sagittal malalignment of the lesser metatarsophalangeal joints was determined on the anteroposterior radiograph by assessment of the overlap of the base of the proximal phalanx on the metatarsal head preoperatively and on the distal part of the metatarsal diaphysis postoperatively. If the base of the proximal phalanx overlapped the metatarsal head or shaft, it was judged to be dislocated. If there was no overlap, the proximal phalanx was judged to be aligned. (Lateral radiographs were not helpful in assessing subluxation or dislocation because of overlap of the phalanges and metatarsals.) Preoperatively, 132 (70 percent) of the 188 lesser metatarsophalangeal joints were dislocated (Table III).

Axial malalignment of the lesser metatarsophalangeal joints was assessed on the postoperative anteroposterior radiograph to quantitate the medial-lateral position of the proximal phalanx in relation to the diaphyseal shaft of the metatarsal. If the axis of the proximal phalanx was centered within the metatarsal diaphyseal shaft, it was rated as aligned; if it was displaced by one diaphyseal width or less, it was rated as subluxated; and if it was displaced by more than one diaphyseal width, it was rated as dislocated (Figs. 3-A and 3-B).

A transverse arc connecting the distalmost points of the second through fifth metatarsals was drawn on the postoperative anteroposterior radiograph (Fig. 4). The goal at the time of the operation was to transect the metatarsal shafts so that each metatarsal was left slightly shorter than the next medially adjacent metatarsal. If a metatarsal diaphyseal shaft protruded beyond this arc, the resection was judged to be irregular. Areas of irregular resection were assessed to determine whether they corresponded to areas of intractable plantar keratosis on physical examination or to areas of increased pressure as determined with the Harris-mat imprint study.

The postoperative radiographs of the lesser metatarsophalangeal joints also were inspected for the presence of areas of heterotopic bone formation that were more than three millimeters in size. These areas also were assessed to determine whether they corresponded to areas of intractable plantar keratosis on physical examination or to increased pressure on the Harris-mat study. In addition, the proximal interphalangeal joints of the lesser toes were assessed for the presence of fusion following open hammer-toe repair or closed osteoclasis.

All statistical analyses were performed with SAS software (version 6.12; SAS Institute, Cary, North Carolina). A chi-square test of independence was used to analyze contingency tables expressing the severity of arthritis and the angles of hallux valgus and dorsiflexion. The preoperative and postoperative severity of arthritis initially was categorized into four grades for analysis. The preoperative and postoperative severity levels were further categorized into a binary outcome depending on whether arthritis was absent (grade 1) or present (grades 2, 3, and 4). Logistic regression analysis was used to evaluate the simultaneous role of the duration of follow-up and the angle of hallux valgus or dorsiflexion in the postoperative severity of arthritis. For these results, the p value of the coefficient predicting the probability of arthritis is reported at a 95 percent confidence interval.

Operative Technique (Figs. 5-A, 5-B, 5-C, 5-D and 5-E)

The four lesser metatarsophalangeal joints are exposed through two three-centimeter dorsal longitudinal incisions in the second and fourth intermetatarsal spaces. The collateral ligaments, the dorsal aspect of the capsule, the plantar plate, and the interossei are released in a circumferential fashion around the base of the proximal phalanx and the head and metaphysis of the metatarsal. The long extensor tendon is left intact. Once the base of the proximal phalanx has been freed, the toe is pulled distally and plantar flexed, increasing the exposure of the metatarsal head. A bone-cutting rongeur is used to transect the second metatarsal in the region of the distal metaphysis. The amount of metatarsal bone that is resected depends on the magnitude of overlap of the proximal phalanx on the metatarsal head. The most important aspect of the excisional arthroplasty is the achievement of adequate decompression at the metatarsophalangeal joint. Usually, with minimal longitudinal tension on the toe, a one-centimeter space between the base of the proximal phalanx and the osteotomized metatarsal surface is sufficient. The metatarsal head is grasped with a rongeur and removed, ideally as a single fragment, as this helps to avoid leaving bone remnants that may later lead to heterotopic ossification and recurrent callosities. The plantar aspect of the remaining portion of the metatarsal shaft is beveled to minimize the risk of a prominent surface. The procedure is first performed for the second metatarsal head and then is repeated for each of the remaining lateral metatarsal heads. The final length of the lesser metatarsals is related to the length of the second metatarsal, with the third metatarsal being slightly (two to three millimeters) shorter than the second metatarsal and the fourth and fifth metatarsals being progressively shorter in order to leave a smooth arc of resection. Once the metatarsophalangeal soft-tissue contracture is released, it is possible to relocate the displaced plantar fat pad beneath the distal aspect of the metatarsal remnants.

Attention is then directed to any fixed hammer-toe deformities of the lesser toes. With a moderate or severe fixed hammer-toe deformity, the distal condyles of the proximal phalanx are resected in the metaphyseal region and the articular surface of the middle phalanx is excised. A 0.045-inch (0.114-centimeter) Kirschner wire is introduced at the proximal interphalangeal joint and driven in a distal direction out the tip of the toe. With the toe held in proper alignment, the Kirschner wire is then advanced into the proximal phalanx across the site of the metatarsophalangeal resection arthroplasty and into the proximal aspect of the diaphysis of the metatarsal. The pin is bent at the tip of the toe to prevent proximal migration, and any excess pin material is removed.

The first metatarsophalangeal joint is treated last. A five-centimeter dorsal longitudinal incision is centered over the first metatarsophalangeal joint and deepened along the medial aspect of the extensor hallucis longus tendon. The collateral ligaments and the capsule are released, and proliferative synovial tissue is resected. The base of the proximal phalanx, the head of the metatarsal, and the medial eminence are resected. The amount of bone that is eventually resected depends on the amount of shortening that was achieved with the lateral metatarsophalangeal joint arthroplasties. At the conclusion of the procedure, the length of the first ray should be equal to or slightly (two to four millimeters) greater than that of the second ray. Cannulated cup-shaped reamers are then used to prepare the phalangeal and metatarsal surfaces for arthrodesis^14,54. A dorsal six-hole mini-compression plate and a cross-compression screw (or Kirschner wire) are used to stabilize the arthrodesis site. A slight dorsal bend is placed in the plate to enable it to conform to the dorsal surfaces of the proximal phalanx and the metatarsal. The arthrodesis is performed with the metatarsophalangeal joint in 15 to 20 degrees of valgus, 20 to 30 degrees of dorsiflexion, and neutral rotation. The skin is approximated, and a gauze-and-tape compression dressing is applied. The dressing is changed twenty-four hours after the procedure. (In three feet in which the index procedure was a revision, the arthrodesis site was fixed with two intramedullary Steinmann pins that crossed both the metatarsophalangeal joint and the interphalangeal joint^18,53,55.)

In all patients, fixation was thought to be satisfactory and walking was permitted in a wooden-soled shoe, with initial weight-bearing on the heel and the lateral aspect of the foot, within the first postoperative week. The dressing was changed every ten days for eight to twelve weeks and was no longer used once there was radiographic evidence of fusion of the first metatarsophalangeal joint. The sutures and Kirschner wires were removed three weeks after the operation. No patient had a simultaneous bilateral procedure. A second, contralateral procedure was performed as early as six weeks and as late as thirty-one months after the initial operation.

Results

Introduction | Materials and Methods | Results | Discussion | References

All forty-seven feet were treated with an arthrodesis of the first metatarsophalangeal joint and resection arthroplasties of the lesser metatarsal heads. Of the 188 lesser toes, 142 had a hammer-toe repair, two had a mallet-toe repair, and forty-four had no other corrective procedure.

History and Physical Examination

The subjective result of the procedure (as rated by the patient), at an average of seventy-four months (range, thirty-seven to 108 months) postoperatively, was excellent for twenty-three feet, good for twenty-two, and fair for two (Table I). No patient reported a poor result. The major reasons for rating the result as good or fair as opposed to excellent included lesser toe malalignment (six feet), generalized pain (two feet), recurrent metatarsophalangeal joint synovitis (two feet), numbness in one digit or more (one foot), and midfoot or hindfoot pain (one foot). The postoperative score according to the system of the American Orthopaedic Foot and Ankle Society averaged 69 points (range, 52 to 90 points). Eighteen feet were rated as pain-free; twenty-five had mild, occasional pain; and four had moderate or daily pain. No foot had severe pain. Two patients (three feet) had symptoms of systemic rheumatoid arthritis; one of these patients received no pharmacological treatment and continued to complain of generalized foot pain.

Twelve patients had had difficulty with the use of over-the-counter shoes and required modifications or extra-depth shoes preoperatively, whereas all patients were able to wear over-the-counter shoes postoperatively. Fifteen feet were not associated with any functional limitations, twenty-eight were associated with limitation of recreational activities, and four were associated with limitation of daily activities.

No foot had pain with passive manipulation of the first metatarsophalangeal joint; however, three feet had pain with manipulation of the first interphalangeal joint. Two feet had lateral deviation at the first interphalangeal joint.

The plantar fat pad was relocated beneath the distal aspect of the metatarsal diaphyseal shafts in all feet. All feet left a clear imprint of the hallux on the Harris-mat pressure study. Ten feet had increased pressure in the region of the lesser metatarsophalangeal joints on the Harris-mat study, although in only two of these feet did the area of increased pressure correspond with the formation of a plantar keratotic lesion. Fourteen feet had a plantar keratotic lesion on physical examination. Eleven lesions were located beneath the interphalangeal joint of the hallux, and three were located beneath a lesser metatarsophalangeal joint. The latter three lesions were associated either with the formation of a postoperative metatarsal exostosis or with recurrent dislocation of the lesser metatarsophalangeal joint.

Physical examination revealed that six mallet-toe deformities (five of which were in toes that had had a hammer-toe repair) and five hammer-toe deformities (three of which were recurrent and two of which were in toes that had not had a previous procedure) had developed postoperatively. The pulp of ninety-one of the 188 lesser toes, including seventy-six (53 percent) of the 142 toes that had had an open hammer-toe repair and fifteen (33 percent) of the forty-six toes that had not, touched the ground. None of the lesser toes appeared to be a source of pain, regardless of whether they had a fibrous union or a successful arthrodesis.

Radiographic Results

All forty-seven feet had radiographic evidence of fusion of the first metatarsophalangeal joint. The hallux valgus angle was corrected from an average of 38 degrees (range, 5 to 75 degrees) preoperatively to an average of 20 degrees (range, 4 to 40 degrees) at the time of the most recent follow-up (Table III). The first-second intermetatarsal angle was corrected from an average of 11 degrees (range, 5 to 25 degrees) preoperatively to an average of 8 degrees (range, 2 to 17 degrees) at the time of the most recent follow-up. The dorsiflexion angle was an average of 22 degrees (range, 10 to 33 degrees) postoperatively. The hallux was fused in neutral rotation in all feet.

Assessment of sagittal alignment on the most recent anteroposterior radiographs demonstrated that thirteen (7 percent) of the 188 lesser metatarsophalangeal joints, in nine patients, had redislocated. Seven of the thirteen dislocations occurred in toes that had had a previous metatarsophalangeal arthroplasty with partial proximal phalangectomy. The base of the proximal phalanx was intact in only six of the thirteen toes. Only two of the thirteen joints demonstrated mildly increased pressure on the Harris-mat study. No intractable plantar keratoses developed beneath any of the thirteen joints.

Assessment of axial alignment demonstrated that the axis of the base of the proximal phalanx was centered within the intramedullary canal in 157 (84 percent) of the 188 lesser toes, was displaced less than one metatarsal diaphyseal width in twenty-five (13 percent), and was displaced more than one metatarsal diaphyseal width in six (3 percent).

The MTP-2 angle averaged 14 degrees (range, 0 to 35 degrees). Inspection of the distal parts of the lesser metatarsal shafts on anteroposterior radiographs revealed that an irregular resection had been performed in only two of the forty-seven feet (one fourth metatarsal and one third metatarsal extended approximately two millimeters beyond the transverse arc). Neither of these feet had a plantar keratotic lesion beneath the prominent metatarsal shaft or demonstrated increased pressure on the Harris-mat study.

Heterotopic bone formation or exostosis formation at the distal metatarsal resection surface (Fig. 6-B) occurred in sixteen (9 percent) of the 188 lesser metatarsophalangeal joints; most (thirteen) of these areas were relatively small, measuring three millimeters or less in size. Three of these joints demonstrated increased pressure on the Harris-mat study, but only two had a plantar keratotic lesion. Five of the 188 joints, including three fifth metatarsophalangeal joints, one fourth metatarsophalangeal joint, and one second metatarsophalangeal joint, required repeat resection.

Of the 142 proximal interphalangeal joints that had had an open hammer-toe repair, 127 (89 percent) fused and fifteen (11 percent) did not. Another twenty-nine lesser toes went on to spontaneous fusion of the proximal interphalangeal joint after intramedullary Kirschner-wire fixation. Five lesser toes eventually required a repeat hammer-toe repair because of recurrent deformity.

On preoperative radiographs, the interphalangeal joint of the hallux was rated as grade 1 (normal) in twenty feet, grade 2 (mild arthritis) in twenty-five, grade 3 (moderate arthritis) in two, and grade 4 (severe arthritis) in none. On postoperative radiographs, the interphalangeal joint of the hallux was rated as grade 1 in twelve feet, grade 2 in twenty, grade 3 in seven, and grade 4 in eight (Fig. 7). When the preoperative and postoperative radiographs were compared, twenty-nine interphalangeal joints were found to have no change in the grade, ten had progressed one grade, four had progressed two grades, and four had progressed three grades. Three of the eight interphalangeal joints with grade-4 arthritis postoperatively were symptomatic and required arthrodesis (two feet) or disarticulation (one foot) at the level of the joint. Both of the interphalangeal joints that required arthrodesis had been treated with intramedullary Steinmann-pin fixation to salvage a failed resection arthroplasty of the first metatarsophalangeal joint in which the internal fixation device crossed the interphalangeal joint.

A callus developed beneath the hallux interphalangeal joint in eleven feet, although none of these feet were symptomatic. Postoperatively, the average subjective pain score for these eleven feet was 1 point (on a scale of 0 to 10 points, with 0 points indicating no pain and 10 points indicating severe pain). Of the eight feet in which the severity of arthritis had progressed either two or three grades, five were rated as excellent and three were rated as good at the time of the most recent subjective assessment by the patient. Twelve of the fifteen feet in which the interphalangeal joint was rated as having grade-3 or 4 arthritis were asymptomatic.

The angle of valgus and the angle of dorsiflexion at which the hallux was fused were assessed with regard to the development of interphalangeal joint arthritis (Tables IV and V). With the numbers available, the hallux valgus angle appeared to have no relationship to the postoperative severity of arthritis (p = 0.078). Similarly, no significant relationship could be detected between the hallux valgus angle and the binary arthritis outcome (p = 0.545). These results did not change when the hallux valgus angle was categorized as 20 degrees or less or as more than 20 degrees (p = 0.656). However, feet in which the dorsiflexion angle was 20 degrees or less were approximately nine times more likely to have development of interphalangeal joint arthritis than were feet in which the dorsiflexion angle was more than 20 degrees (p = 0.02; odds ratio, 9.3; 95 percent confidence interval, 1.4 to 61.7). The mean duration of follow-up did not differ among the four groups with the different grades of arthritis (p = 0.228).

Complications and Reoperations

There were no systemic complications (such as pulmonary embolism or sepsis) and no long-term local complications. No broken Kirschner wires or plates were noted. There was one instance of ischemia of a lesser toe that resolved with pin removal within two hours after the operation, one pin-track infection that resolved with pin removal within three weeks after the operation, and one instance of local wound necrosis that healed uneventfully. Three patients had postoperative numbness of a digit (the hallux in one patient and a lesser toe in two) that did not resolve.

Eleven patients (fourteen feet; 30 percent) had a reoperation on the forefoot (Table I). Several patients had more than one procedure at the time of the reoperation. The procedures included removal of hardware from the first metatarsophalangeal joint (seven feet), a repeat of the procedure on a lesser toe (five feet, one of which also had removal of hardware), a repeat resection arthroplasty of a lesser metatarsophalangeal joint (five feet, three of which had either hardware removal or a repeat of the procedure on a lesser toe as well), and arthrodesis (two feet) or disarticulation (one foot) at the level of the hallux interphalangeal joint because of severe arthritis. Six of the eleven patients who had an additional procedure on the forefoot had other procedures such as total joint replacement or a procedure on the ankle, hindfoot, or midfoot for the treatment of concomitant progressive rheumatoid disease. Eight of these eleven patients were receiving continuous combination drug therapy with prednisone or methotrexate, or both. Early in the series, a high-profile mini-fragment plate was used for internal fixation at the site of the arthrodesis of the first metatarsophalangeal joint. Six of the seven reoperations that were done for the removal of hardware were performed in the first fifteen feet in the series. In comparison, only one such procedure was necessary in the remaining thirty-two feet in the series, in which a low-profile Vitallium plate had been used (Fig. 5-B).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The key factor in the reconstruction of a rheumatoid forefoot is the achievement of stable realignment of the first ray (Figs. 8-A and 8-B). Arthrodesis of the first metatarsophalangeal joint increases weight-bearing along the medial column of the foot, minimizes stress on the lateral metatarsophalangeal joints, and protects the relocated plantar fat pad.

While arthrodesis of the first metatarsophalangeal joint has been recommended for the treatment of rheumatoid arthritis^{5,6,9,14,15,17,22,35,44,46,47,51-53,55,60,71,72,77-79}, postoperative radiographic alignment of the first ray has been quantitated in only two small series (fifteen and eighteen feet)^53,55, in which the average correction of the hallux valgus angle was reported to be 23 and 30 degrees. The average correction of the hallux valgus angle in the current series was 18 degrees (from 38 degrees preoperatively to 20 degrees postoperatively). In one of the small series⁵⁵ just mentioned, the average reduction of the first-second intermetatarsal angle was 3 degrees and the average dorsiflexion angle of fusion was 21 degrees⁵⁵. In the current series, the average reduction of the first-second intermetatarsal angle was 3 degrees and the average dorsiflexion angle of fusion was 22 degrees.

The average rate of successful metatarsophalangeal arthrodesis has been reported to be more than 90 percent (1341 of 1451)^{5,7,9,13-15,25,29,33,35,37,49,53,64,71,72,77,79-82}. The 100 percent rate of fusion in the current series probably was related to both the technique of preparation of the metatarsophalangeal joint and the specific means of internal fixation.

The postoperative alignment of the hallux plays a key role in the satisfaction of the patient. Excessive valgus angulation at the fusion site results in a widened forefoot with a less desirable cosmetic appearance. The suggested angle of valgus for arthrodesis of the first metatarsophalangeal joint has ranged from 15 to 30 degrees^{7,12,13,25,26,53,56,60,64,65,68,77}. Fitzgerald²⁵ reported that the prevalence of interphalangeal joint arthritis tripled following arthrodesis performed with the first metatarsophalangeal joint in less than 20 degrees of valgus; however, that report did not focus on correction of the rheumatoid forefoot. The prevalence of arthritis of the first interphalangeal joint following arthrodesis of the first metatarsophalangeal joint in a rheumatoid foot has been quite variable; it was reported in six of twenty feet by Vahvanen et al.⁷³, in nine of fifteen feet by Mann and Schakel⁵⁵, and in eleven of seventeen feet by Mann and Thompson⁵³. Although Mann and Thompson⁵³ reported a high prevalence of interphalangeal joint arthritis, they noted that few patients complained of discomfort. In a later report, Mann and Schakel⁵⁵ noted that only one-third of interphalangeal joints with arthritic changes were symptomatic. In both of those series^53,55, the internal fixation devices (threaded Steinmann pins) crossed the interphalangeal joint; this factor may have contributed to the high reported rates of interphalangeal joint arthritis. In the current series, arthritis progressed by one grade in ten joints, by two grades in four, and by three grades in four, for a 38 percent prevalence of progression. Both of the interphalangeal joints that required an arthrodesis had been treated with intramedullary Steinmann-pin fixation to salvage a failed resection arthroplasty of the first metatarsophalangeal joint in which the internal fixation device crossed the interphalangeal joint. The third foot that was treated with intramedullary Steinmann-pin fixation did not require an additional procedure and was asymptomatic. Although Fitzgerald²⁵ reported an association between fusion of the hallux in less than 20 degrees of valgus and the development of interphalangeal joint arthritis, there appeared to be no relationship between the angle of hallux valgus and postoperative arthritis in the current series. The size of the sample used for the analysis of categorical data in the current study was small (about half the size of the sample in the study by Fitzgerald²⁵). Because of the small sample size, the chi-square test simply may have lacked the power to identify a significant relationship.

The recommended dorsiflexion angle of arthrodesis has ranged from 15 to 40 degrees (in relation to the first metatarsal shaft)^25,55,60,64. Insufficient dorsiflexion may cause increased pressure at the tip of the toe⁶⁰ or a sensation that the tip of the toe is pushing into the ground. Excessive dorsiflexion may lead to increased pressure beneath the first metatarsal head⁵ or pressure over the dorsal aspect of the interphalangeal joint. The recommended dorsiflexion angle of arthrodesis has varied depending on the degree of pes planus, the presence of metatarsocuneiform joint hypermobility, and the desire to wear an elevated heel. It also has varied depending on whether the first metatarsal shaft or the plantar surface of the foot was used as the point of reference for the measurement of dorsiflexion. The plantar inclination of the first metatarsal averages 15 degrees¹⁸, and, with dorsiflexion of the phalanx of 5 to 15 degrees, a dorsiflexion angle of arthrodesis of 20 to 30 degrees (in relation to the first metatarsal shaft) is recommended. In the present study, with use of the first metatarsal shaft as the point of reference, the average dorsiflexion angle of fusion was 22 degrees (range, 10 to 33 degrees). Feet in which the dorsiflexion angle of fusion was 20 degrees or less had a significantly higher prevalence of interphalangeal joint arthritis than those in which the angle was more than 20 degrees (p = 0.02).

While resection arthroplasty of the first ray has frequently been recommended in association with resection arthroplasty of the lateral part of the forefoot^{1,4,10,11,21,28,36,39,44,46,57,62,67,75}, a high level of recurrent hallux valgus, metatarsalgia, and recurrent intractable plantar keratosis has been reported at the time of follow-up. The prevalence of recurrent hallux valgus or subtotal correction was reported to be higher than 50 percent in four of the largest series^30,48,73,75, all of which involved resection arthroplasty of the first metatarsophalangeal joint; the rate was 53 percent (twenty-six of forty-nine feet) in the study by McGarvey and Johnson⁴⁸, 59 percent (thirty-four of fifty-eight feet) in the study by Goldie et al.³⁰, 61 percent (109 of 179 feet) in the study by Vahvanen et al.⁷³, and 68 percent (twenty-eight of forty-one patients) in the study by van der Heijden et al.⁷⁵. A lateral metatarsophalangeal resection arthroplasty weakens support for the hallux⁷⁸ and, although it initially relieves lateral plantar pressure and allows for realignment of the lesser metatarsophalangeal joints, Hasselo et al.³⁴ and others^21,48,73 reported deterioration of results with time, recurrent deformity, pain, and an unacceptable cosmetic appearance. With an unstable first metatarsophalangeal joint following excisional arthroplasty, lateral pressure from the hallux may cause lateral deviation or malalignment of the lesser metatarsophalangeal joints⁷³. In the current series, the MTP-2 angle was thought to be the most appropriate measurement with which to assess lateral pressure from the hallux. With a stable hallux following metatarsophalangeal arthrodesis, the average hallux valgus angle of 20 degrees compared closely with the average MTP-2 angle of 14 degrees. Recurrent intractable lateral plantar keratoses frequently have been reported to occur following resection arthroplasty of the first ray, with the prevalence ranging from 36 to 61 percent in four of the largest series (36 percent [twenty-one of fifty-eight feet] in the study by Goldie et al.³⁰, 36 percent [twenty-seven of seventy-four feet] in the study by van der Heijden et al.⁷⁵, 45 percent [twenty-two of forty-nine feet] in the study by McGarvey and Johnson⁴⁸, and 61 percent [109 of 179 feet] in the study by Vahvanen et al.⁷³). Maintenance of the alignment of the first metatarsophalangeal joint with arthrodesis protects not only the hallux but also the lesser metatarsophalangeal joints from recurrent deformity.

The high level of satisfaction in the current series, in which 96 percent (forty-five) of forty-seven feet were rated as good or excellent, compares closely with the rates of 89 percent (sixteen of eighteen feet)⁵³ and 95 percent (nineteen of twenty feet)⁵⁵ that have been reported in previous studies in which a first metatarsophalangeal arthrodesis and lateral resection arthroplasty were performed. Mann and Schakel⁵⁵ observed that the results of forefoot arthroplasty did not deteriorate over time. In the current series, there was an equal distribution of good and excellent results between the group of twenty-four feet with the shortest durations of follow-up and the group of twenty-three feet with the longest durations of follow-up. Thus, the duration of follow-up did not appear to affect the overall outcome. The high level of patient satisfaction also did not appear to have any association with the average postoperative score (69 points) according to the system of the American Orthopaedic Foot and Ankle Society⁴⁰. Many of the patients in the current study reported limitation of functional activity, loss of motion of the metatarsophalangeal joint due to the fusion, an inability to wear fashionable shoes, and some degree of residual foot pain. These limitations resulted in an average loss of 30 points in the score, placing a ceiling on the highest score that could be achieved postoperatively. The high level of patient satisfaction in the current series is in contradistinction to the rates of satisfactory results reported in three of the largest studies in which forefoot resection arthroplasty was combined with first metatarsophalangeal excision arthroplasty (32 percent [thirteen of forty-one patients] in the study by van der Heijden et al.⁷⁵, 51 percent [ninety-one of 179 feet] in the study by Vahvanen et al.⁷³, and 67 percent [thirty-nine of fifty-eight feet] in the study by Goldie et al.³⁰).

All forty-seven feet in the current series left a positive imprint of the hallux on the Harris-mat study, demonstrating increased weight-bearing capacity. This finding substantiates that of Mann and Thompson⁵³, who reported that sixteen of eighteen feet left an imprint of the hallux on a Harris-mat study. However, these findings are in contradistinction to those described by van der Heijden et al.⁷⁵, who reported that thirty-seven (50 percent) of seventy-four great toes did not touch the ground. Henry and Waugh³⁵ and others^60,64 reported frequent metatarsalgia following excisional arthroplasty of the first metatarsophalangeal joint. Henry and Waugh³⁵ evaluated postoperative weight-bearing in a study of 170 feet, half of which had been treated with excisional arthroplasty and half of which had been treated with metatarsophalangeal arthrodesis. Substantial weight-bearing on the first ray was noted in 80 percent of the eighty-five feet that had been treated with metatarsophalangeal arthrodesis compared with only 40 percent of the eighty-five feet that had been treated with excisional arthroplasty. The low rate of metatarsalgia in the current series (6 percent; three of forty-seven feet) is attributable to the increased weight-bearing on the first ray, which diminished lateral translation pressure beneath the lesser metatarsals.

While 132 (70 percent) of 188 lesser metatarsophalangeal joints were dislocated preoperatively, only thirteen joints (7 percent) redislocated in the sagittal plane following excision of the metatarsal head. Seven of these thirteen joints redislocated after a repeat resection arthroplasty, and thus only six joints redislocated after a primary resection arthroplasty. Preservation of the base of the proximal phalanx at the metatarsophalangeal joint appears to be advantageous in that it helps to preserve the alignment and relocation of the lesser metatarsophalangeal joints following metatarsal head excision. The assessment of axial alignment following resection arthroplasty of the lesser metatarsophalangeal joints demonstrated that the axis of the base of the proximal phalanx was centered within the intramedullary diaphyseal canal in 157 (84 percent) of the 188 toes, was subluxated in twenty-five (13 percent), and was dislocated in six (3 percent). While only six lesser metatarsophalangeal joints were considered to be dislocated in the axial plane, these six joints and another seven were clearly dislocated in the sagittal plane. The low rate of redislocation in the current series is in contradistinction to the findings of Vahvanen et al.⁷³, who reported redislocation of at least one lesser metatarsophalangeal joint in 121 (68 percent) of 179 feet that had been treated with forefoot arthroplasty.

Heterotopic bone formation occurred in sixteen (9 percent) of the 188 lesser metatarsophalangeal joints (Fig. 6-B), although most (thirteen) of the involved areas were three millimeters or less in size. Increased plantar pressure developed in only three of these sixteen joints, and one patient eventually required repeat resection of two lesser metatarsophalangeal joints. This is in contradistinction to the findings of Vahvanen et al.⁷³, who reported that intractable plantar keratoses or osseous proliferation developed in 109 (61 percent) of 179 feet. Meticulous resection of bone with removal of accessory fragments minimizes the occurrence of heterotopic bone formation and symptomatic plantar keratoses in the postoperative period.

Recurrence of plantar callosities is probably the most common complication of forefoot arthroplasty and is frequently due to incomplete, inadequate, or irregular resection^1,24,75,78. In six of the largest series found in the literature, the prevalence of postoperative intractable plantar keratoses ranged from 12 to 66 percent; specifically, the rate was 12 percent (twenty of 169 feet) in the study by Amuso et al.¹, 14 percent (fifteen of 108 feet) in the study by van Loon et al.⁷⁶, 12 percent (seventeen of 147 feet) in the study by Faithful and Savill²⁴, 29 percent (nineteen of sixty-five feet) in the study by Barton⁴, 38 percent (forty-nine of 130 feet) in the study by Newman and Fitton⁶¹, and 66 percent (forty-one of sixty-two feet) in the study by Watson⁷⁸. The necessity for a repeat forefoot operation has been reported to range from 8 to 36 percent; the rate was 8 percent (fourteen of 169 feet) in the study by Amuso et al.¹, 10 percent (fifteen of 147 feet) in the study by Faithful and Savill²⁴, 36 percent (twenty-one of fifty-eight feet) in the study by Goldie et al.³⁰, and 22 percent (sixteen of seventy-four feet) in the study by van der Heijden et al.⁷⁵. These findings are in contradistinction to those in the present series, in which recurrent plantar callosities beneath the lesser metatarsophalangeal joints occurred in three feet (6 percent) and an additional procedure was required for five feet (11 percent). Although an irregular resection was noted in two feet in the current series, neither foot had an intractable plantar keratosis or demonstrated increased pressure on the Harris-mat study. Adequate decompression of the lesser metatarsophalangeal joints at the time of the operation is extremely important because when a metatarsal is substantially longer than an adjacent metatarsal there is a high risk of recurrent intractable plantar keratosis.

Operative approaches for reconstruction of the rheumatoid forefoot have included a transverse plantar incision^1,8,36,43,76, a transverse dorsal incision^{1,4,11,28,41,57,67}, multiple longitudinal dorsal incisions^{1,4,22,42,45-48,50,53,55,61,63,67,76}, and an elliptical excision of plantar skin just proximal to the metatarsal heads^{4,24,28,39,59,61,75,78}. In the current investigation, three dorsal longitudinal incisions were used to perform the resection arthroplasties of the lesser metatarsophalangeal joints and the arthrodesis of the first metatarsophalangeal joint. A major criticism of dorsal longitudinal incisions is that the lesser metatarsals are not exposed within a single wound and thus a regular resection of the lesser metatarsals is difficult³⁶. In the present study, a regular resection along a curved arc was achieved in forty-five feet (96 percent). After the decompression and realignment of the lesser metatarsophalangeal joints and the correction of hammer-toe deformities, the plantar fat pad was relocated in all feet. The rate of postoperative intractable plantar keratoses beneath the lesser metatarsals in this series (6 percent; three of forty-seven feet) confirms the success of a dorsal approach. The reported prevalence of wound problems associated with the use of a plantar approach was reported to be 8 percent (six of seventy-four feet) in the study by van der Heijden et al.⁷⁵, 13 percent (ten of seventy-seven feet) in the study by Faithful and Savill²⁴, and 39 percent (twenty-two of fifty-seven feet) in the study by Barton⁴. A major disadvantage of a plantar approach is that weight-bearing is delayed for three to four weeks after the procedure. In the current series, there was one instance of delayed wound-healing; all other patients began early weight-bearing within one week after the procedure.

The treatment of associated fixed hammer-toe deformities depends on the severity of the deformity. Passive manipulation of mild-to-moderate hammer-toe deformities at the time of forefoot reconstruction has been advocated^{10,19,32,41,53,55,62,67}. Mann and Schakel⁵⁵ used closed osteoclasis and noted that only two (10 percent) of twenty patients had recurrence of hammer-toe deformity in at least one digit at the time of the most recent follow-up. While proximal phalangeal condylectomy or interphalangeal arthrodesis^{16,19,32,38,41} has been recommended, Watson⁷⁸ observed that previous interphalangeal fusion of lesser toes was often the cause of later metatarsophalangeal joint dislocation and the formation of intractable plantar keratoses. This conclusion was based, however, on the observation of only six feet. In the current series, successful fusion was observed in 127 (89 percent) of 142 toes that were treated with an open hammer-toe repair and the pulp of ninety-one (48 percent) of the 188 lesser toes touched the ground.

To my knowledge, there have been no reports on the outcome of either closed manipulation (osteoclasis) or open correction of hammer-toe deformities performed in combination with forefoot arthroplasty for the treatment of rheumatoid arthritis; in most reports on arthroplasty of the rheumatoid forefoot, hammer toes either were not treated or were treated indirectly with partial proximal phalangectomy^{8,10,11,39,53,55,57,67}. Partial proximal phalangectomy, while decompressing the dislocated metatarsophalangeal joint, is an indirect treatment of a fixed hammer-toe deformity that leaves either some degree of fixed deformity or, with more extensive resection, marked shortening of the toes^30,55. The highest rates of postoperative intractable plantar keratoses (22 percent [twenty-nine of 130 feet] in the study by Newman and Fitton⁶¹, 23 percent [seven of thirty feet] in the study by Fowler²⁸, and 66 percent [forty-one of sixty-two feet] in the study by Watson⁷⁸) have been reported in studies in which partial proximal phalangectomy was used as a component of the forefoot repair. Operative repair and realignment of fixed hammer-toe deformities is a key element in achieving and maintaining alignment of the lateral part of the forefoot. An uncorrected or inadequately corrected hammer toe places the proximal phalanx in a hyperextended position, which places the lesser metatarsophalangeal joint at risk for recurrent deformity and recurrent intractable plantar keratoses.

Intramedullary fixation with Kirschner wire has been advocated for the treatment of hammer toes and following excisional arthroplasty of the metatarsophalangeal joints for the correction of rheumatoid forefoot deformities^{31,41,45,47,55}. Mann and Schakel⁵⁵ as well as others^32,45 recommended the use of 0.045-inch (0.114-centimeter) Kirschner wires, and the recommended duration of placement has ranged from three to six weeks^20,31,46,55. Complications associated with Kirschner-wire fixation have included pin-track infections^47,55, broken wires¹⁶, and decreased vascular flow necessitating wire removal¹⁶. Mann and Schakel⁵⁵ found that the use of Kirschner wires was beneficial because it decreased the reliance on dressing changes postoperatively and helped to maintain alignment; however, alignment was not quantitated postoperatively in that study. The use of intramedullary Kirschner-wire fixation for three weeks appears to be sufficient both for stabilization of the proximal interphalangeal arthroplasty sites and for maintenance of metatarsophalangeal alignment on a long-term basis.

A number of authors have noted that the need for special (extra-depth or custom-fabricated) shoes increases following operative correction of the rheumatoid forefoot. Specifically, Craxford et al.²¹, in a study of thirty-eight patients, reported an increase from 29 percent preoperatively to 45 percent postoperatively; McGarvey and Johnson⁴⁸, in a study of twenty-nine patients (forty-nine feet), reported an increase from 27 to 71 percent; and Saltzman et al.⁶⁶, in a study of thirteen patients (fourteen feet), reported an increase from 63 to 91 percent. In all three series, a resection arthroplasty of the first metatarsophalangeal joint was performed. In the current series, twelve of the thirty-two patients required special shoes preoperatively whereas no patient required such shoes postoperatively. This finding supports that reported by Mann and Schakel⁵⁵, who noted no special shoe requirements in a study of twenty patients (twenty-eight feet) who had been managed with arthrodesis of the first metatarsophalangeal joint in conjunction with resection arthroplasties of the lesser metatarsophalangeal joints.

The findings of the present study suggest that arthrodesis of the first metatarsophalangeal joint corrects malalignment of the first ray and creates a permanent angular correction that provides stability to the first ray, increases weight-bearing on the first ray, and protects the lesser metatarsophalangeal joints from redeformation. Decreased weight-bearing on the lateral metatarsophalangeal joints diminishes the development of recurrent intractable plantar keratoses beneath the lesser metatarsal heads.

A meticulous operative technique that ensures a smooth arc of resection of the lesser metatarsal heads and meticulous débridement in the area of the resection is necessary in order to prevent the formation of metatarsal diaphyseal exostoses or an irregular resection, both of which may lead to recurrent plantar keratoses. Maintenance of alignment with the axis of the proximal phalanx directly centered within the metatarsal diaphysis demonstrates that, following decompression and realignment with intramedullary Kirschner-wire fixation, a repair can be achieved and maintained in a high percentage of patients. Correction of fixed hammer-toe deformities is an integral part of the realignment process because it helps to maintain the alignment of the lesser metatarsophalangeal joints.

The major problem related to metatarsophalangeal fusion is the development of interphalangeal joint arthritis. While interphalangeal joint arthritis was not associated with a diminished postoperative hallux valgus angle in the current series, the small sample size may have influenced the statistical analysis. Interphalangeal joint arthritis was associated with a smaller dorsiflexion angle (20 degrees or less). Nonetheless, although fifteen (32 percent) of the forty-seven feet in this series had grade-3 or 4 interphalangeal joint arthritis, only three were symptomatic and required additional operative intervention. Eleven patients (fourteen feet; 30 percent) had a reoperation on the forefoot; however, most of these procedures were minor procedures on the lesser toes (five feet) and repeat resection arthroplasties of the lesser metatarsophalangeal joints (five feet). It is of interest that, of the eleven patients who had an additional operation on the forefoot, eight were receiving continuous combination drug therapy with methotrexate or prednisone, or both, and six required other major joint procedures such as total joint arthroplasty or reconstruction of the midfoot or hindfoot as well. After an average duration of follow-up of six years, there was excellent pain relief and improved function and 96 percent of the feet had a subjective rating of excellent or good. Maintenance of first metatarsophalangeal alignment with a metatarsophalangeal arthrodesis and resultant fusion protects not only the hallux but also the lesser metatarsophalangeal joints from recurrent deformity and subsequent recurrent metatarsalgia.

Note: The author thanks Eben Polk, B.S., for his work associated with this study.

References

Introduction | Materials and Methods | Results | Discussion | References

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Cracchiolo, A., III: Management of the arthritic forefoot. Foot and Ankle,3: 17-23, 1982.317 1982 [PubMed]

Cracchiolo, A.: Rheumatoid arthritis of the forefoot. In Operative Foot Surgery, pp. 141-159. Edited by J. S. Gould. Philadelphia, W. B. Saunders, 1994.

Craxford, A. D.; Stevens, J.; and Park, C.: Management of the deformed rheumatoid forefoot. A comparison of conservative and surgical methods. Clin. Orthop.,166: 121-126, 1982.166121 1982 [PubMed]

DuVries, H. L.: Arthritides. In Surgery of the Foot, edited by H. L. DuVries. Ed. 2, pp. 318-329. St. Louis, C. V. Mosby, 1965.

Dwyer, A. F.: Correction of severe toe deformities. In Proceedings of the South African Orthopaedic Association. J. Bone and Joint Surg.,52-B(1): 192, 1970.52-B(1)192 1970

Faithful, D. K., and Savill, D. L.: Review of the results of excision of the metatarsal heads in patients with rheumatoid arthritis. Ann. Rheumat. Dis.,30: 201-202, 1971.30201 1971 [PubMed]

Fitzgerald, J. A. W.: A review of long-term results of arthrodesis of the first metatarso-phalangeal joint. J. Bone and Joint Surg.,51-B(3): 488-493, 1969.51-B(3)488 1969

Fitzgerald, J. A. W., and Wilkinson, J. M.: Arthrodesis of the metatarsophalangeal joint of the great toe. Clin. Orthop.,157: 70-77, 1981.15770 1981 [PubMed]

Flint, M., and Sweetnam, R.: Amputation of all toes. A review of forty-seven amputations. J. Bone and Joint Surg.,42-B(1): 90-96, 1960.42-B(1)90 1960

Fowler, A. W.: A method of forefoot reconstruction. J. Bone and Joint Surg.,41-B(3): 507-513, 1959.41-B(3)507 1959

Gimple, K.; Amspacher, J. C.; and Kopta, J. A.: Metatarsophalangeal joint fusion of the great toe. Orthopedics,1: 462-467, 1978.1462 1978

Goldie, I.; Bremell, T.; Althoff, B.; and Irstam, L.: Metatarsal head resection in the treatment of the rheumatoid forefoot. Scandinavian J. Rheumatol.,12: 106-112, 1983.12106 1983

Gould, N.: Surgery of the forepart of the foot in rheumatoid arthritis. Foot and Ankle,3: 173-180, 1982.3173 1982 [PubMed]

Hanyu, T.; Yamazaki, H.; Murasawa, A.; and Tohyama, C.: Arthroplasty for rheumatoid forefoot deformities by a shortening oblique osteotomy. Clin. Orthop.,338: 131-138, 1997.338131 1997 [PubMed]

Harrison, M. H., and Harvey, F. J.: Arthrodesis of the first metatarsophalangeal joint for hallux valgus and rigidus. J. Bone and Joint Surg.,45-A: 471-480, April 1963.45-A471 1963

Hasselo, L. G.; Willkens, R. F.; Toomey, H. E.; Karges, D. E.; and Hansen, S. T.: Forefoot surgery in rheumatoid arthritis: subjective assessment of outcome. Foot and Ankle,8: 148-151, 1987.8148 1987 [PubMed]

Henry, A. P. J., and Waugh, W.: The use of footprints in assessing the results of operations for hallux valgus. A comparison of Keller's operation and arthrodesis. J. Bone and Joint Surg.,57-B(4): 478-481, 1975.57-B(4)478 1975

Hoffman, P.: An operation for severe grades of contracted or clawed toes. Am. J. Orthop. Surg.,9: 441-449, 1912.9441 1912

Johannsson, J. E., and Barrington, T. W.: Cone arthrodesis of the first metatarsophalangeal joint. Foot and Ankle,4: 244-248, 1984.4244 1984 [PubMed]

Joplin, R. J.: Surgery of the forefoot in the rheumatoid arthritic patient. Surg. Clin. North America,49: 847-878, 1969.49847 1969

Kates, A.; Kessel, L.; and Kay, A.: Arthroplasty of the forefoot. J. Bone and Joint Surg.,49-B(3): 552-557, 1967.49-B(3)552 1967

Kitaoka, H. B.; Alexander, I. J.; Adelaar, R. S.; Nunley, J. A.; Myerson, M. S.; and Sanders, M.: Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot and Ankle Internat.,15: 349-353, 1994.15349 1994

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Leavitt, D. G.: Surgical treatment of arthritic feet. Northwest Med.,55: 1086-1088, 1956.551086 1956 [PubMed]

Lipscomb, P. R.: Surgery for rheumatoid arthritis—timing and techniques: summary. J. Bone and Joint Surg.,50-A: 614-617, April 1968.50-A614 1968

Lipscomb, P. R.; Benson, G. M.; and Sones, D. A.: Resection of proximal phalanges and metatarsal condyles for deformities of the forefoot due to rheumatoid arthritis. Clin. Orthop.,82: 24-31, 1972.8224 1972 [PubMed]

Lipscomb, P. R.: Arthrodesis of the first metatarsophalangeal joint for severe bunions and hallux rigidus. Clin. Orthop.,142: 48-54, 1979.14248 1979 [PubMed]

MacClean, C. R., and Silver, W. A.: Dwyer's operation for the rheumatoid forefoot. Foot and Ankle,1: 343-347, 1981.1343 1981 [PubMed]

McGarvey, S. R., and Johnson, K. A.: Keller arthroplasty in combination with resection arthroplasty of the lesser metatarsophalangeal joints in rheumatoid arthritis. Foot and Ankle,9: 75-80, 1988.975 1988 [PubMed]

McKeever, D. C.: Arthrodesis of the first metatarsophalangeal joint for hallux valgus, hallux rigidus, and metatarsus primus varus. J. Bone and Joint Surg.,34-A: 129-134, Jan. 1952.34-A129 1952

Mankey, M. G., and Mann, R. A.: Arthrodesis of the first metatarso-phalangeal joint utilizing a dorsal plate. Orthop. Trans.,16: 782-783, 1992-1993.16782 1992-1993

Mann, R. A., and Coughlin, M. J.: The rheumatoid foot. Review of literature and method of treatment. Orthop. Rev.,8: 105-112, 1979.8105 1979

Mann, R. A., and Oates, J. C.: Arthrodesis of the first metatarsophalangeal joint. Foot and Ankle,1: 159-166, 1980.1159 1980 [PubMed]

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Mann, R. A., and Coughlin, M. J.: Rheumatoid arthritis and arthrodeses about the foot. In The Video Textbook of Foot and Ankle Surgery, pp. 105-144. Edited by R. A. Mann and M. J. Coughlin. St. Louis, Medical Video Productions, 1991.

Mann, R. A., and Schakel, M. E., II: Surgical correction of rheumatoid forefoot deformities. Foot and Ankle Internat.,16: 1-6, 1995.161 1995

Marin, G. A.: Arthrodesis of the metatarsophalangeal joint of the big toe for hallux valgus and hallux rigidus. A new method. Internat. Surg.,50: 175-180, 1968.50175 1968

Marmor, L.: Resection of the forefoot in rheumatoid arthritis. Clin. Orthop.,108: 223-227, 1975.108223 1975 [PubMed]

Moeckel, B. H.; Sculco, T. P.; Alexiades, M. M.; Dossick, P. H.; Inglis, A. E.; and Ranawat, C. S.: The double-stemmed silicone-rubber implant for rheumatoid arthritis of the first metatarsophalangeal joint. Long-term results. J. Bone and Joint Surg.,74-A: 564-570, April 1992.74-A564 1992

Morrison, P.: Complications of forefoot operations in rheumatoid arthritis. Proc. Roy. Soc. Med.,67: 110-111, 1974.67110 1974 [PubMed]

Moynihan, F. J.: Arthrodesis of the metatarso-phalangeal joint of the great toe. J. Bone and Joint Surg.,49-B(3): 544-551, 1967.49-B(3)544 1967

Newman, R. J., and Fitton, J. M.: Conservation of metatarsal heads in surgery of rheumatoid arthritis of the forefoot. Acta Orthop. Scandinavica,54: 417-421, 1983.54417 1983

Peterson, L. F. A.: Surgery for rheumatoid arthritis—timing and techniques: the lower extremity. J. Bone and Joint Surg.,50-A: 587-604, April 1968.50-A587 1968

Phillipson, A.; Dhar, S.; Linge, K.; McCabe, C.; and Klenerman, L.: Forefoot arthroplasty and changes in plantar foot pressures. Foot and Ankle,15: 595-598, 1994.15595 1994 [PubMed]

Raymakers, R., and Waugh, W.: The treatment of metatarsalgia with hallux valgus. J. Bone and Joint Surg.,53-B(4): 684-687, 1971.53-B(4)684 1971

Riggs, S. A., Jr., and Johnson, E. W., Jr.: McKeever arthrodesis for the painful hallux. Foot and Ankle,3: 248-253, 1983.3248 1983 [PubMed]

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Smith, N. R.: Hallux valgus and rigidus treated by arthrodesis of the metatarso-phalangeal joint. British Med. J.,2: 1385-1387, 1952.21385 1952

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Thomas, W. H.: Surgery of the foot in rheumatoid arthritis. Orthop. Clin. North America,6: 831-835, 1975.6831 1975

Tupman, S.: Arthrodesis of the first metatarso-phalangeal joint. In Proceedings of the Regional Orthopaedic Clubs. J. Bone and Joint Surg.,40-B(4): 826, 1958.40-B(4)826 1958

Turan, I., and Lindgren, U.: Compression-screw arthrodesis of the first metatarsophalangeal joint of the foot. Clin. Orthop.,221: 292-295, 1987.221292 1987 [PubMed]

Vahvanen, V.; Piirainen, H.; and Kettunen, P.: Resection arthroplasty of the metatarsophalangeal joints in rheumatoid arthritis. A follow-up study of 100 patients. Scandinavian J. Rheumatol.,9: 257-265, 1980.9257 1980

Vainio, K.: Rheumatoid foot. Clinical study with pathological and roentgenological comments. Ann. Chir. Gynaecol. Fenniae,45 (Supplement): 1-107, 1956.45 (Supplement)1 1956

van der Heijden, K. W.; Rasker, J. J.; Jacobs, J. W.; and Dey, K.: Kates forefoot arthroplasty in rheumatoid arthritis. A 5-year followup study. J. Rheumatol.,19: 1545-1550, 1992.191545 1992 [PubMed]

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von Salis-Soglio, G., and Thomas, W.: Arthrodesis of the metatarsophalangeal joint of the great toe. Arch. Orthop. and Traumatic Surg.,95: 7-12, 1979.957 1979

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FIG5-A:: Fig. 5-A Preoperative radiograph demonstrating hallux valgus deformity and dislocation of the second, third, and fourth metatarsophalangeal joints.

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FIG5-D:: Fig. 5-D: Radiograph, made at the time of the three-year follow-up, demonstrating anatomical alignment of the lesser metatarsophalangeal joints.

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FIG5-E:: Fig. 5-E Lateral radiograph demonstrating fusion of the first metatarsophalangeal joint.

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FIG8-B:: Fig. 8-B: Following arthrodesis, the first metatarsophalangeal joint is realigned.

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TABLE I: DATA ON THE PATIENTS

*AOFAS = American Orthopaedic Foot and Ankle Society.

Case

Gender, Age at Op. (yrs.)

Continuous Drug Therapy

Side of Op.

Durat. of Follow-up (mos.)

Previous Failed Procedures

Preoperative Complaints

Location of Pain

Postop. AOFAS Score⁴⁰* (points)

Additional Procedures (no. of feet)

Postop. Subjective Rating

Pain

Callus or Intractable Plantar Keratosis

Shoe Problems

Plantar Aspect of Forefoot

Other

Arthrodesis or Disarticulat. at 1^st Inter- phalangeal Joint

Removal of Hardware from 1^st Metatarsopha- langeal Joint

Repeat Op. on Lesser Toes

Repeat Resection Arthroplasty of Lesser Metatarsopha- langeal Joint

Total Joint Replacement or Procedure on Ankle, Hindfoot, or Midfoot

F, 71/72

Methotrexate

L/R

108/101

Yes

Bunion

64/59

Good/good

F, 53

108

Yes

Instep

Excellent

F, 62/63

Prednisone

L/R

102/100

Yes

Lesser toes

60/60

Excellent/excellent

F, 63

Prednisone

108

Yes

Lesser toes

Good

F, 64

102

Forefoot arthroplasty (R)

Yes

Lesser toes

Good

M, 18/18

L/R

103/85

Yes

Lesser toes

59/59

Fair/fair

M, 59/60

Prednisone

L/R

104/950

Arthrodesis and forefoot arthroplasty (L, R)

Yes

Lesser toes

52/57

Good/good

F, 37/37

L/R

89/87

Yes

70/70

Excellent/excellent

F, 60/66

Prednisone, methotrexate

L/R

90/98

Bunionectomy (L)

Yes

Lesser toes

60/65

Good/good

M, 76

Prednisone, methotrexate

Lesser toes (R)

Yes

Lesser toes

Good

M, 50/52

L/R

82/69

Yes

85/85

Excellent/excellent

F, 69

Prednisone

Yes

Excellent

F, 51/51

Methotrexate

L/R

81/84

Yes

80/80

Excellent/excellent

M, 43

Methotrexate

Yes

Bunion, lesser toes

Excellent

F, 78

Yes

Bunion, lesser toes

Excellent

F, 55/57

Methotrexate

L/R

79/48

Yes

Lesser toes

72/70

Excellent/excellent

F, 72

Prednisone, methotrexate

Yes

Good

F, 70/70

Prednisone, methotrexate

L/R

68/68

Keller procedure and forefoot arthroplasty (L, R)

Yes

57/57

Good/good

F, 55/53

L/R

38/66

Yes

75/70

Excellent/excellent

F, 40/40

Prednisone

L/R

78/76

Yes

Lesser toes

55/62

Good/good

M, 60

Prednisone, methotrexate

Yes

Lesser toes

Excellent

F, 42/42

Methotrexate

L/R

56/64

Yes

Bunion

72/72

Good/good

F, 48

Prednisone, methotrexate

Bunionectomy (R)

Yes

Bunion

Excellent

M, 70

Prednisone, methotrexate

Lesser toes (L)

Yes

Lesser toes

Excellent

F, 67

Methotrexate

Lesser toes (L)

Yes

Lesser toes

Excellent

F, 49/51

Prednisone, methotrexate

L/R

55/36

Forefoot arthroplasty (L, R)

Yes

80/80

Good/good

F, 47/48

Methotrexate

L/R

52/40

Yes

62/62

Good/good

F, 46

Prednisone, methotrexate

Yes

Bunion

Good

F, 25

Prednisone, methotrexate

Yes

Excellent

F, 74

Keller procedure and forefoot arthroplasty (L)

Yes

Lesser toes

Excellent

M, 70

Prednisone, methotrexate

Yes

Bunion

Excellent

F, 50

Prednisone

Yes

Lesser toes

Good

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TABLE I: DATA ON THE PATIENTS

*AOFAS = American Orthopaedic Foot and Ankle Society.

Case

Gender, Age at Op. (yrs.)

Continuous Drug Therapy

Side of Op.

Durat. of Follow-up (mos.)

Previous Failed Procedures

Preoperative Complaints

Location of Pain

Postop. AOFAS Score⁴⁰* (points)

Additional Procedures (no. of feet)

Postop. Subjective Rating

Pain

Callus or Intractable Plantar Keratosis

Shoe Problems

Plantar Aspect of Forefoot

Other

Arthrodesis or Disarticulat. at 1^st Inter- phalangeal Joint

Removal of Hardware from 1^st Metatarsopha- langeal Joint

Repeat Op. on Lesser Toes

Repeat Resection Arthroplasty of Lesser Metatarsopha- langeal Joint

Total Joint Replacement or Procedure on Ankle, Hindfoot, or Midfoot

F, 71/72

Methotrexate

L/R

108/101

Yes

Bunion

64/59

Good/good

F, 53

108

Yes

Instep

Excellent

F, 62/63

Prednisone

L/R

102/100

Yes

Lesser toes

60/60

Excellent/excellent

F, 63

Prednisone

108

Yes

Lesser toes

Good

F, 64

102

Forefoot arthroplasty (R)

Yes

Lesser toes

Good

M, 18/18

L/R

103/85

Yes

Lesser toes

59/59

Fair/fair

M, 59/60

Prednisone

L/R

104/950

Arthrodesis and forefoot arthroplasty (L, R)

Yes

Lesser toes

52/57

Good/good

F, 37/37

L/R

89/87

Yes

70/70

Excellent/excellent

F, 60/66

Prednisone, methotrexate

L/R

90/98

Bunionectomy (L)

Yes

Lesser toes

60/65

Good/good

M, 76

Prednisone, methotrexate

Lesser toes (R)

Yes

Lesser toes

Good

M, 50/52

L/R

82/69

Yes

85/85

Excellent/excellent

F, 69

Prednisone

Yes

Excellent

F, 51/51

Methotrexate

L/R

81/84

Yes

80/80

Excellent/excellent

M, 43

Methotrexate

Yes

Bunion, lesser toes

Excellent

F, 78

Yes

Bunion, lesser toes

Excellent

F, 55/57

Methotrexate

L/R

79/48

Yes

Lesser toes

72/70

Excellent/excellent

F, 72

Prednisone, methotrexate

Yes

Good

F, 70/70

Prednisone, methotrexate

L/R

68/68

Keller procedure and forefoot arthroplasty (L, R)

Yes

57/57

Good/good

F, 55/53

L/R

38/66

Yes

75/70

Excellent/excellent

F, 40/40

Prednisone

L/R

78/76

Yes

Lesser toes

55/62

Good/good

M, 60

Prednisone, methotrexate

Yes

Lesser toes

Excellent

F, 42/42

Methotrexate

L/R

56/64

Yes

Bunion

72/72

Good/good

F, 48

Prednisone, methotrexate

Bunionectomy (R)

Yes

Bunion

Excellent

M, 70

Prednisone, methotrexate

Lesser toes (L)

Yes

Lesser toes

Excellent

F, 67

Methotrexate

Lesser toes (L)

Yes

Lesser toes

Excellent

F, 49/51

Prednisone, methotrexate

L/R

55/36

Forefoot arthroplasty (L, R)

Yes

80/80

Good/good

F, 47/48

Methotrexate

L/R

52/40

Yes

62/62

Good/good

F, 46

Prednisone, methotrexate

Yes

Bunion

Good

F, 25

Prednisone, methotrexate

Yes

Excellent

F, 74

Keller procedure and forefoot arthroplasty (L)

Yes

Lesser toes

Excellent

M, 70

Prednisone, methotrexate

Yes

Bunion

Excellent

F, 50

Prednisone

Yes

Lesser toes

Good

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Table II: RATING SCALE OF THE AMERICAN ORTHOPAEDIC FOOT AND ANKLE SOCIETY*

Category	Score (points)
Pain (40 points)
None	40
Mild, occasional	30
Moderate, daily	20
Severe, almost always present	0
Function (45 points)
Activity limitations
No limitations	10
No limitation of daily activities, limitation of recreational activities	7
Limitation of daily and recreational activities	4
Severe limitation of daily and recreational activities	0
Footwear requirements
Fashionable, conventional shoes, no insert required	10
Comfort footwear, shoe insert	5
Modified shoes or brace	0
Metatarsophalangeal joint motion (dorsiflexion plus plantar flexion)
Normal or mild restriction (at least 75 degrees of motion)	10
Moderate restriction (30 to 74 degrees of motion)	5
Severe restriction (less than 30 degrees of motion)	0
Interphalangeal joint motion (plantar flexion)
No restriction	5
Severe restriction (less than 10 degrees of motion)	0
Metatarsal-interphalangeal stability (all directions)
Stable	5
Definitely unstable or able to dislocate	0
Callus related to lesser metatarsophalangeal or interphalangeal joints
No callus or asymptomatic callus	5
Symptomatic callus	0
Alignment (15 points)
Good, lesser toes well aligned	15
Fair, some degree of lesser-toe malalignment, no symptoms	8
Poor, severe malalignment, symptoms present	0

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Table II: RATING SCALE OF THE AMERICAN ORTHOPAEDIC FOOT AND ANKLE SOCIETY*

Category	Score (points)
Pain (40 points)
None	40
Mild, occasional	30
Moderate, daily	20
Severe, almost always present	0
Function (45 points)
Activity limitations
No limitations	10
No limitation of daily activities, limitation of recreational activities	7
Limitation of daily and recreational activities	4
Severe limitation of daily and recreational activities	0
Footwear requirements
Fashionable, conventional shoes, no insert required	10
Comfort footwear, shoe insert	5
Modified shoes or brace	0
Metatarsophalangeal joint motion (dorsiflexion plus plantar flexion)
Normal or mild restriction (at least 75 degrees of motion)	10
Moderate restriction (30 to 74 degrees of motion)	5
Severe restriction (less than 30 degrees of motion)	0
Interphalangeal joint motion (plantar flexion)
No restriction	5
Severe restriction (less than 10 degrees of motion)	0
Metatarsal-interphalangeal stability (all directions)
Stable	5
Definitely unstable or able to dislocate	0
Callus related to lesser metatarsophalangeal or interphalangeal joints
No callus or asymptomatic callus	5
Symptomatic callus	0
Alignment (15 points)
Good, lesser toes well aligned	15
Fair, some degree of lesser-toe malalignment, no symptoms	8
Poor, severe malalignment, symptoms present	0

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TABLE III: RADIOGRAPHIC FINDINGS

Case	Preoperative						Postoperative
Hallux Valgus Angle (degrees)		Dislocated Lesser Metatarsophalangeal Joints*		Severity of Interphalangeal Joint Arthritis† (grade)		Hallux Valgus Angle (degrees)		Dorsiflexion Angle (degrees)		MTP-2 Angle (degrees)		Severity of Interphalangeal Joint Arthritis† (grade)		Axial Alignment of Lesser Metatarsophalangeal Joints‡		Sagittal Alignment of Lesser Metatarsophalangeal Joints‡
Left	Right	Left	Right	Left	Right	Left	Right	Left	Right	Left	Right	Left	Right	Left	Right	Left	Right
1	35	20	2, 3, 4	2, 3, 5	2	2	18	18	17	28	16	14	3	3	AAAA	AASS	AAAA	AAAA
2	50				1		23		33		13		1		AAAA		AAAA
3	30	45	2, 5	5	1	1	25	40	25	25	25	25	4	4	SASA	AAAA	AAAA	AAAA
4	40		2, 3		2		27		24		19		2		AASA		AAAA
5		49		2, 3		2		12		28		19		2		SASS		AAAA
6	49	54	4, 5	4, 5	1	1	27	18	30	18	35	15	1	1	AASA	AASS	AAAA	AAAA
7	20	25	2, 3, 4, 5	2, 3, 4, 5	2	1	17	12	28	25	0	0	2	1	AAAA	AAAS	DAAA§	AAAA
8	40	40	2, 3, 4, 5	2, 3, 4, 5	2	2	16	13	20	22	32	0	3	3	AAAA	DAAA	AAAA	DAAA
9	54	55	2, 3	2, 3, 4	2	2	30	20	25	22	17	20	4	4	AAAA	AAAA	AAAA	AADA
10		30		2, 3, 4, 5		3		19		24		20		3		AAAA		AADA
11	28	5	2, 3, 4, 5	2, 3, 4, 5	1	1	22	15	21	25	22	3	1	1	SSAA	AAAA	AAAA	AAAA
12	43		2, 3, 4, 5		1		23		15		0		2		SAAA		AAAA
13	35	48	2, 3, 4, 5	2, 3, 4, 5	2	2	22	22	25	15	22	15	2	2	AAAA	AAAA	AAAA	DAAA
14	50		2, 3, 4, 5		1		20		23		10		1		AASA		DAAA
15		75		2, 3, 4, 5		1		25		26		10		1		SSAS		AAAA
16	20	20	2, 3		1	1	12	17	17	19	7	13	4	3	AAAA	AAAA	AAAA	AAAA
17		20		2		1		23		27		12		1		AAAA		AAAA
18	45	20	4, 5	2, 3, 4, 5	1	2	15	8	20	20	20	0	2	2	AAAA	DDDD	AAAA	DDDD§
19	54	49	3, 4, 5	2, 4, 5	2	2	13	21	24	26	10	19	2	2	AAAA	AAAA	AADA	AAAA
20	43	30	2, 3, 4, 5	4, 5	2	2	23	20	24	20	28	20	2	2	AAAA	AAAA	AAAA	AAAA
21	43		2, 3, 4, 5		1		24		20		7		4		AAAA		AAAA
22	39	37	2, 3, 4, 5	2, 3, 4, 5	2	2	16	16	24	15	8	8	2	2	AAAA	AAAA	AAAA	AAAA
23		37		5		1		23		24		12		1		ASSS		AAAA
24	38		2, 3, 4		2			20	22		27		2		AAAA		AAAA
25	10		2, 3		2		6		28		14		3		AAAA		AAAA
26	75	50	2, 3, 4	2, 3	3	2	4	15	21	10	7	10	4	2	AAAA	ASAA	AAAA	AAAA
27	47	38	2, 3, 4, 5	2, 3, 4, 5	2	1	25	28	15	20	16	11	4	2	AAAA	ASAS	AAAA	AAAA
28	30		3, 4, 5		1		18		24		3		1		AAAA		AAAA
29		39		2, 3, 4		2		24		20		7		2		AAAA		AAAA
30	13		2, 3, 4, 5		2		20		23		6		2		AAAD		AADD§
31	35				1		20		23		7		2		AAAA		AAAA
32	52				2		22		18		11		2		AAAA		AAAA

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TABLE III: RADIOGRAPHIC FINDINGS

Case	Preoperative						Postoperative
Hallux Valgus Angle (degrees)		Dislocated Lesser Metatarsophalangeal Joints*		Severity of Interphalangeal Joint Arthritis† (grade)		Hallux Valgus Angle (degrees)		Dorsiflexion Angle (degrees)		MTP-2 Angle (degrees)		Severity of Interphalangeal Joint Arthritis† (grade)		Axial Alignment of Lesser Metatarsophalangeal Joints‡		Sagittal Alignment of Lesser Metatarsophalangeal Joints‡
Left	Right	Left	Right	Left	Right	Left	Right	Left	Right	Left	Right	Left	Right	Left	Right	Left	Right
1	35	20	2, 3, 4	2, 3, 5	2	2	18	18	17	28	16	14	3	3	AAAA	AASS	AAAA	AAAA
2	50				1		23		33		13		1		AAAA		AAAA
3	30	45	2, 5	5	1	1	25	40	25	25	25	25	4	4	SASA	AAAA	AAAA	AAAA
4	40		2, 3		2		27		24		19		2		AASA		AAAA
5		49		2, 3		2		12		28		19		2		SASS		AAAA
6	49	54	4, 5	4, 5	1	1	27	18	30	18	35	15	1	1	AASA	AASS	AAAA	AAAA
7	20	25	2, 3, 4, 5	2, 3, 4, 5	2	1	17	12	28	25	0	0	2	1	AAAA	AAAS	DAAA§	AAAA
8	40	40	2, 3, 4, 5	2, 3, 4, 5	2	2	16	13	20	22	32	0	3	3	AAAA	DAAA	AAAA	DAAA
9	54	55	2, 3	2, 3, 4	2	2	30	20	25	22	17	20	4	4	AAAA	AAAA	AAAA	AADA
10		30		2, 3, 4, 5		3		19		24		20		3		AAAA		AADA
11	28	5	2, 3, 4, 5	2, 3, 4, 5	1	1	22	15	21	25	22	3	1	1	SSAA	AAAA	AAAA	AAAA
12	43		2, 3, 4, 5		1		23		15		0		2		SAAA		AAAA
13	35	48	2, 3, 4, 5	2, 3, 4, 5	2	2	22	22	25	15	22	15	2	2	AAAA	AAAA	AAAA	DAAA
14	50		2, 3, 4, 5		1		20		23		10		1		AASA		DAAA
15		75		2, 3, 4, 5		1		25		26		10		1		SSAS		AAAA
16	20	20	2, 3		1	1	12	17	17	19	7	13	4	3	AAAA	AAAA	AAAA	AAAA
17		20		2		1		23		27		12		1		AAAA		AAAA
18	45	20	4, 5	2, 3, 4, 5	1	2	15	8	20	20	20	0	2	2	AAAA	DDDD	AAAA	DDDD§
19	54	49	3, 4, 5	2, 4, 5	2	2	13	21	24	26	10	19	2	2	AAAA	AAAA	AADA	AAAA
20	43	30	2, 3, 4, 5	4, 5	2	2	23	20	24	20	28	20	2	2	AAAA	AAAA	AAAA	AAAA
21	43		2, 3, 4, 5		1		24		20		7		4		AAAA		AAAA
22	39	37	2, 3, 4, 5	2, 3, 4, 5	2	2	16	16	24	15	8	8	2	2	AAAA	AAAA	AAAA	AAAA
23		37		5		1		23		24		12		1		ASSS		AAAA
24	38		2, 3, 4		2			20	22		27		2		AAAA		AAAA
25	10		2, 3		2		6		28		14		3		AAAA		AAAA
26	75	50	2, 3, 4	2, 3	3	2	4	15	21	10	7	10	4	2	AAAA	ASAA	AAAA	AAAA
27	47	38	2, 3, 4, 5	2, 3, 4, 5	2	1	25	28	15	20	16	11	4	2	AAAA	ASAS	AAAA	AAAA
28	30		3, 4, 5		1		18		24		3		1		AAAA		AAAA
29		39		2, 3, 4		2		24		20		7		2		AAAA		AAAA
30	13		2, 3, 4, 5		2		20		23		6		2		AAAD		AADD§
31	35				1		20		23		7		2		AAAA		AAAA
32	52				2		22		18		11		2		AAAA		AAAA

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TABLE IV: HALLUX VALGUS ANGLE OF FUSION

Severity of Arthritis (grade)	No. of Feet	Angles =20 Degrees (degrees)	Angles >20 Degrees (degrees)	Average (Range) of Angles (degrees)
1	12	12, 15, 16, 18, 18, 20	22, 23, 23, 23, 25, 27	20 (12—27)
2	20	8, 12, 13, 15, 15, 16, 17, 20, 20, 20, 20	21, 22, 22, 22, 23, 23, 24, 27, 28	19 (8—28)
3	7	6, 13, 16, 17, 18, 18, 19		15 (6—19)
4	8	4, 12, 20	24, 25, 25, 30, 40	23 (4—40)

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TABLE IV: HALLUX VALGUS ANGLE OF FUSION

Severity of Arthritis (grade)	No. of Feet	Angles =20 Degrees (degrees)	Angles >20 Degrees (degrees)	Average (Range) of Angles (degrees)
1	12	12, 15, 16, 18, 18, 20	22, 23, 23, 23, 25, 27	20 (12—27)
2	20	8, 12, 13, 15, 15, 16, 17, 20, 20, 20, 20	21, 22, 22, 22, 23, 23, 24, 27, 28	19 (8—28)
3	7	6, 13, 16, 17, 18, 18, 19		15 (6—19)
4	8	4, 12, 20	24, 25, 25, 30, 40	23 (4—40)

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TABLE V: DORSIFLEXION ANGLE OF FUSION

Severity of Arthritis (grade)	No. of Feet	Angles =20 Degrees (degrees)	Angles >20 Degrees (degrees)	Average (Range) of Angles (degrees)
1	12	18	21, 23, 24, 24, 24, 25, 25, 26, 27, 30, 33	25 (18—33)
2	20	10, 15, 15, 15, 18, 20, 20, 20, 20, 20	22, 23, 23, 24, 24, 24, 25, 26, 28, 28	21 (10—28)
3	7	17, 19, 20	22, 24, 28, 28	23 (17—28)
4	8	15, 17, 20	21, 22, 25, 25, 25	21 (15—25)

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TABLE V: DORSIFLEXION ANGLE OF FUSION

Severity of Arthritis (grade)	No. of Feet	Angles =20 Degrees (degrees)	Angles >20 Degrees (degrees)	Average (Range) of Angles (degrees)
1	12	18	21, 23, 24, 24, 24, 25, 25, 26, 27, 30, 33	25 (18—33)
2	20	10, 15, 15, 15, 18, 20, 20, 20, 20, 20	22, 23, 23, 24, 24, 24, 25, 26, 28, 28	21 (10—28)
3	7	17, 19, 20	22, 24, 28, 28	23 (17—28)
4	8	15, 17, 20	21, 22, 25, 25, 25	21 (15—25)