Definition
Disorder of immune system characterized by antigen-antibody complexes
www.boneschool.com/rheumatoid-arthritis
Epidemiology
Incidence declining worldwide
Pharmaceutical treatment decreasing severity
90% will have foot problems, most commonly forefoot
Pathology
| Forefoot | Midfoot | Hindfoot |
|---|---|---|
|
Hallux Valgus / Rigidus |
TNJ OA |
Planovalgus |
|
MTPJ synovitis Dorsal subluxation MTPJ |
Achilles tendonitis |
|
| Clawing of toes | Ankle joint / subtalar joint OA |
Forefoot
Great toe
Hallux valgus / rigidus
Operative Options
Osteotomy / Arthrodesis / Arthroplasty / Keller's procedure (excision arthroplasty)
www.boneschool.com/hallux-rigidus
Results
Dai et al Zhongguo Gu Shang 2012
- 1st MTPJ fusion in 129 feet with RA
- 3% nonunion
He et al J Foot Ankle Surg 2021
- systematic review of 1st MTPJ arthrodesis v arthroplasty in RA
- no difference in pain score, outcome, or reoperation rates
- complications of Keller procedure
- hallux valgus, cock up, flail toe
- reserve for salvage only
Metatarsalgia
Pathology
Synovitis of MTPJ with capsular destruction
- dorsal subluxation MTPJ
- claw toes develop (MTPJ hyperextended, PIPJ flexed)
- plantar fat pad displaced distally and metatarsal heads exposed to plantar skin
Operative Options
Synovectomy / Weil's osteotomy / Fowler's procedure (excision arthroplasty)
www.boneschool.com/metatarsalgia
Results
- Weil osteotomy in 72 RA feet
- 88% good or excellent results
- recurrent / persistent subluxation in 14%
Horita et al Foot Ankle Int 2018
- 16 resection arthroplasty v 18 Weil osteotomy in RA
- resection: outcome score 84, recurrence 3 feet
- osteotomy: outcome score 90, recurrence 1 foot
Fowler's Procedure - metatarsal head excision
Dorsal transverse skin excision just proximal to toe webs
- can be performed via transverse plantar ellipse
- with severe dislocation may be easier to approach through plantar aspect
Extensor tenotomy
Cascading excision of II - V metatarsal heads
- dorsal distal to plantar proximal
- contoured on plantar surface to give rounded surface
Claw toes
Options
Extensor tenotomy / PIPJ fusion
www.boneschool.com/lesser-toes
Midfoot
TNJ osteoarthritis
Talonavicular Arthrodesis
Indication
- erosion confined to this joint
- correct valgus deformity
Technique
- dorsomedial incision
- protect saphenous nerve and vein
Result
- will lose 80% STJ motion
Hindfoot
Insertional Achilles Tendonitis
Rheumatoid involvement of bursa at T Achilles insertion
- nodules may develop within the tendon
- can weaken attachment & precipitate rupture
Treatment
- excision of nodules
- may need tendon augmentation / reconstruction
Tibialis Posterior Tendonitis / Rupture
Synovitis of sheaths of T post & Peroneal tendons common
- treat with tenosynovectomy
Rupture of TP with flatfoot
- FDL transfer in Stage 2
- triple arthrodesis in Stage 3
- pan talar arthrodesis in Stage 4
Planovalgus
Causes
- STJ OA
- TNJ OA
- tibialis posterior rupture
- synovitis and rupture of the talocalcaneal interosseous ligament
- tight T Achilles
Pathology
- subtalar joint valgus angulation
- talar head drops into plantarflexion
- navicular subluxes laterally
- get planovalgus foot with forefoot abduction
Non Operative
Brace
- double upright with square ferrule
Operative
Triple Arthrodesis
Indication
- fixed painful hindfoot
- TNJ and STJ OA
- AKJ preserved
Ankle joint OA
Total Ankle Replacement
Attractive concept
- reduces loading across other joints
- results similar to OA
Ankle Arthrodesis
Treatment of choice
Complicated by
- prolonged period to union - 6/12
- non-union in 10%