Treating Severe Deformity In Young Patients With Rheumatoid Arthritis
A very difficult patient for me to treat is a young patient who has rheumatoid arthritis with severe deformity of the foot and ankle. This is typically a patient whose age may range from the late 20s to late 50s and is active except for his or her foot pain. With this in mind, let’s consider the following case study. A 27-year-old female presented with a 12-year history of rheumatoid arthritis and extreme pain and deformity of the forefoot. While both feet are painful, she says the left foot is more severe than the right. The patient says the pain is in the region of the lateral fourth and fifth metatarsal heads and in the metatarsophalangeal joints (MPJ) of toes two through five. The pain has gotten worse in the past two years and she has trouble with shoes that are not soft and very cushioned. She has tried custom insoles to accommodate the plantar fourth and fifth metatarsal region without much relief. She is currently taking methotrexate and NSAIDs for her pain and rheumatoid arthritis control. What Does The Examination Reveal? An examination of the patient reveals stable and intact neurovascular testing. The forefoot is slightly laterally deviated and there is severe hammertoe deformity of toes two through five of both feet. The main pain is located plantar to the fourth and fifth metatarsal heads with mild pain in the region of a hallux valgus deformity. The contraction of the toes is mildly reducible, yet the main deforming force occurs with dorsal contracture of the extensor tendons and skin on the dorsum of the foot. Attempting to reduce the digits relieves much of the plantar MPJ contraction and deformity yet there is continued plantar prominence of the metatarsal heads, especially on the lateral side of the foot. There is a mild equinus deformity of the ankle with a tight Achilles tendon noted on both the straight and bent knee exam. There is a high arch with midfoot contracture yet this does not seem to be excessive and reduces well with dorsal midfoot pressure and a standing position. The patient’s gait pattern reveals severe extensor substitution with dorsal pull of the extensor tendons at the associated MPJ. Radiographs show mild MPJ dislocation with severe hammertoes and associated hallux valgus deformity of the digits. There is also some osteopenia of the metatarsal heads. Her foot alignment reveals a mild anterior cavus with excellent rearfoot alignment and no signs of degenerative joint disease. What Are The Potential Treatment Options? • Pan metatarsal head resection and hammertoe correction • Hammertoe and bunion correction • Hammertoe, bunion and metatarsal length correction • Hammertoe, bunion and metatarsal correction with extensor tendon transfer • Hammertoe, bunion and metatarsal correction with extensor tendon transfer and skin lengthening at the MPJ • Rearfoot osteotomy and Achilles lengthening in addition to above procedures Diagnostic Answers It is very difficult to correct both the rearfoot and forefoot at the same time when treating patients who have rheumatoid arthritis. This is often too much surgery. In the case of this patient, her rearfoot was stable except for an underlying mild equinus deformity. The main part of the patient consent was for the underlying hallux valgus correction with osteotomy, hammertoe correction of all toes with extensor tendon transfer to the metatarsal heads and a V-Y lengthening of the dorsal skin contracture. The consent also included possible metatarsal osteotomies of metatarsals two through five as needed for correction of the deformity and parabola. We also discussed the possibility of an open Achilles lengthening with the patient. Step-By-Step Pearls We began by making a medial incision to correct the hallux valgus deformity. It is essential to have bone graft on hand for such cases as the osteopenic bone may result in large cystic defects that need grafting. A good option for graft material is the medial eminence or bone from the proximal phalynx distal aspect that is resected with the hammertoe corrections of the lesser toes. In this patient, you would use the medial eminence to fill a small defect in the first metatarsal head following an osteotomy and use two screw fixation to stabilize the osteotomy. V to Y lengthening of the dorsal skin was the second procedure. The procedure was designed to place one V to Y between the second and third metatarsals and one between the fourth and fifth metatarsals. This allowed us to reduce the dorsal contracture and decrease the dorsal stretch on the soft tissue with relocation of the digits. We employed transverse incisions at the proximal interphalangeal joints for hammertoe correction. We proceeded to perform fusion of the second and third toes to increase stability and found arthroplasty of the fourth and fifth toes to be sufficient for correcting the lateral deformity. Following the release of the MPJ of toes two through five, we noted that the fourth metatarsal was still prominent. In order to facilitate reduced length and dorsiflexion of the metatarsal with minimal need for stable fixation, we performed a V osteotomy of the fourth metatarsal and resected a small parallel section of bone for shortening. We slightly transposed the fourth metatarsal dorsally and employed K-wire fixation through the fourth toe into the metatarsal head. Then we transferred the extensor tendons to the metatarsal head through the dorsal V-Y incisions and stabilized them through the bone with suture. We stabilized the second through fourth toes across the MPJ with K-wires in order to prevent long extensor pull and facilitate healing of the fusion/arthroplasty sites and the tendon transfers. Upon examining the equinus and midfoot cavus, we did not think further surgery was warranted and thought the patient may do well with continued stretching to relieve the Achilles tightness. We proceeded to emphasize the appropriate dressings, placed the patient in a below the knee walker and told her to limit ambulation for the first two weeks. We had the patient discontinue methotrexate one week prior to surgery and continued to emphasize NSAIDs after surgery. Notes On Postoperative Care After five weeks, we took the patient out of the walking boot and placed her in a surgical shoe to allow greater weight transfer to the foot. We proceeded to remove the K-wire fixation and started physical therapy in order to reduce scarring and initiate her range of motion. At three months, the patient was in tennis shoes and had a reduction of pain and symptoms. There was dramatic improvement in the appearance of the foot and minimal discomfort with ambulation. Final Notes It is essential to attempt reconstructive instead of destructive procedures on young rheumatoid patients. While it is a far more difficult surgical procedure, it is very rewarding when done well. I have begun to do this type of surgery on patients with moderate arthritic deformity now, substituting a fusion of the first MPJ at times for increased stability and pain reduction. I now reserve pan metatarsal head resection for severe deformity with no chance of reconstruction or for patients who are not strong and healthy enough to handle the reconstruction period. The key to this type of surgery is to tell the patient of all the possible procedures and judge what is needed after each sequential step of the reconstruction. Furthermore, it should be noted that the V-Y skin incision allows for better deformity reduction. I hope this type of procedure stirs some ideas in the treatment of the young patient with rheumatoid arthritis. Let your creative juices flow and do not get stuck in the thought process that surgical reconstruction is not possible. Dr. Baravarian is an Assistant Clinical Professor in the Department of Surgery / Division of Podiatric Surgery of the UCLA School of Medicine. His email address is Bbaravarian@mednet.ucla.edu.