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RHEUMATIOD ARTHRITIS Dr Abhishek Shetty PATHOLOGY Stage 1 - Synovitis • Vascular congestion • Proliferation of synoviocytes • Infiltration of subsynovial layers by polymorphs, lymphocytes & plasma cells • Thickening of capsular structures, • Villous formation of synovium, • Cell-rich effusion into joints & tendon sheaths Stage 2 - Destruction • Persistent synovitis causes joint & tendon destruction • Articular cartilage is eroded 1. Proteolytic enzymes 2. Vascular tissue in fold of synovial reflections 3. Direct invasion of cartilage by pannus of granulation tissue • Joint margin erosion – Granulation tissue – Osteoclastic resorption – Synovial hyperplasia • Tendon sheaths – Similar changes – Tenosynovitis – Invasion of collagen bundles – Partial / complete rupture of tendons Stage 3 - Deformity • Articular destruction, Capsular stretching, Tendon rupture leads to…. • Progressive instability & deformity of joint • Disruption of normal architecture of hand & wrist • Loss of delicate balance of flexor & extensor forces across adjacent joints of hand-wrist unit • Rheumatoid hand deformities usually are bilateral and symmetrical. • Each deformity must be analyzed in detail before surgery is considered. • Although combinations of deformities occur, involvement of the fingers, thumb, and wrist is typical. • The metacarpophalangeal joints and the wrist are affected early in rheumatoid arthritis, whereas the distal two joints usually are affected later. • The metacarpophalangeal is the most important joint affecting finger function in rheumatoid disease. • Ulnar deviation with metacarpophalangeal palmar subluxation or dislocation of the finger typifies the rheumatoid hand deformity RHEUMATOID HAND DEFORMITIES • Wrist • Abduction & volar subluxation (radial tilt) • Radial deviation of hand • DRUJ • Dorsal Subluxation DRUJ (piano key sign) • Caput Ulnae • Fingers / thumb • Ulnar drift deformity (ulnar deviations of digits) • Swan neck & Boutonniere deformity& trigger finger • Tendons • Tenosynovitis & Tendon ruptures) RHEUMATOID HAND DEFORMITIES • • • • TENDON RUPTURES JOINT DESTRUCTION COMRESSIVE NEUROPATHIES VASCULITIS THE WRIST & DRUJ • Disturbance of WRIST is common in RA – Initial presentation of wrist unusual ~ 2% – Hand affected 5 x more frequently – Chronic: 90% have functional difficulties due to problems at the wrist KEYSTONE OF THE HAND • Pain-free, stable, mobile wrist is necessary for normal function of hand • Power generated in finger flexors / extensors – Crosses wrist in order to act fully – Appropriate grasp & motion THE WRIST & DRUJ • Painful, unstable, deformed wrist Impair hand function regardless of status of fingers • Wrist deformity Contributes to development of finger deformities Worsens preexistent deformity Compromises surgical correction • Unless wrist deformity is preserved/restored Maintaining correction of finger deformity is difficult / impossible THE WRIST & DRUJ • Rheumatoid synovitis of wrist follows predictable patterns • Frequently earliest to be involved • Ulnar styloid • Ulnar head • Midportion of scaphoid • Progressive synovial proliferation in these areas leads to various patterns of wrist deformity RHEUMATOID HAND DEFORMITIES Specific Problems at the Wrist • 1. Carpal Collapse • 2. Translation / translocation of Carpus • 3. Volar subluxation • 4. Dislocation & supination of carpus • 5. DRUJ instability • 6. Flexor & Extensor tendon ruptures COLLAPSE DEFORMITY • RADIAL SIDE OF WRIST – Attenuation of Ligaments • Deep radioscapholunate lig. • Radioscaphocapitate lig. – Instability of scaphoid proximal pole – Rotary subluxation of scaphoid – Scaphoid assumes volar flexed position • Secondary loss of carpal height • Radial rotation of carpus &metacarpals on the radius • Scapholunate dissociation ULNAR SIDE OF WRIST – Attenuation of Ligaments • Ulnolunate • Ulnotriquetral – Triangular fibrocartilage – Triquetro-lunate dissociation TRANSLOCATION & TRANSLATION TRANSLOCATION OF CARPUS • Movement of carpus wholly towards the ulnar side • Rupture of volar radio-luno-triquetral ligaments • Exacerbated by removal of ulnar head TRANSLATION • Radial deviation of carpus • Wrist is in a position whereby fingers are mal-aligned • Leading to ulnar deviation of fingers VOLAR SUBLUXATION • • • • • • Lunate subluxes from its fossa anteriorly Starts to encroach into carpal tunnel Radius responds by developing shelf of bone Secondary degenerative changes Distortion of carpus & relationship to radius ↑ risk of carpal tunnelsyndrome SUPINATION OF CARPUS Failure of lunate to remain within its fossa – Rupture of dorsal ulnar carpal ligaments – Dropping of ulnar side of hand – Apparent very prominent ulnar head Which may actually be in its normal anatomic position – Significant distortion of extensor retinaculum – This presses extensor tendons firmly up against the ulnar head • Erosions within ulnar head • Instability of DRUJ • Progressive tendon rupture from ulnar side – Ext Dig Minimus – Ext Dig to 5th, 4th, 3rd , 2nd SUPINATION OF CARPUS SUPINATION OF CARPUS • XRAY – Scalloping around ulnar head &distal radius at sigmoid notch – Highly indicative of very unstable DRUJ – Heightened risk of developmentof ruptures of extensor tendons DISTAL RADIO-ULNAR INSTABILITY • Erosion around insertion oftriangular cartilage • Attenuation of volar & dorsalulnar carpal ligaments • Chronic synovitis with stretching of capsule • Attenuation of extensor retinaculum – True dorsal displacement of ulna – Becomes painful (persisting synovitis & crepitus) – Caput ulnae syndrome DISTAL RADIO-ULNAR INSTABILITY CAPUT ULNA SYNDROME • Significant disability • Complain of – Weakness – Pain – Aggravated by forearm rotation CAPUT ULNA SYNDROME Examination – Prominence of distal ulna – Instability of DRUJ – Limited wrist dorsiflexion – Supination of carpus on forearm – Piano Key Sign • Wrist collapse – Imbalance of extensor tendons – Radial shift of metacarpals – Ulnar deviation of fingers – Important factor in initiating ulnar deviation of MP joints – Recurrence of ulnar deviation following MP joint arthroplasty PATTERNS OF JOINT DESTRUCTION Radiographic appearance of significant rheumatoid disease Type 1 Ankylotic Type 2 Arthrotic Type 3 Unstable LARSEN RADIOGRAPHIC SCALE Grading joint involvement in RA Grade O No changes Grade 1 Slight changes,Periarticular swelling Grade 2 Erosions,with definitive joint-space narrowing Grade 3 Medium destructive changes, With erosions & joint spaces poorly defined Grade 4 Severe destructive changes, collapse with significant erosions Grade 5 Mutilating changes SURGICAL INTERVENTIONS AIMS OF SURGERY • To remove diseased synovium via synovectomy • To prevent or repair tendon ruptures • To provide painless stable wrist joint in functional position. METHODS • Synovectomy • Distal ulna resection • Dorsal stabilization • Wrist Arthrodesis • Arthroplasty SYNOVECTOMY • To remove diseased synovium before tendon damage occurs. • Better results in early stage. • Combined with other procedures in later stage. DISTAL ULNA RESECTION • Inflamed radio ulnar joint causes pain in pronation and supination. • Diseased ulna roughened by erosive effect of inflammatory synovium rodes the extensor tendons above it. • Goal of this surgery to remove this noxious force while maintaining stability DISTAL ULNA RESECTION • Indications DRUJ involvement with pain on pronation and supination or extensor tendon rupture. • Contra-indication pre-op evidence of ulnar translocation with displacement of lunate from lunate fossa. DORSAL STABILIZATION • Goal is to stabilise progressive volar and ulnar displacement of radio-carpal joint and remove all diseased synovium. • Indications painful synovitis with or without bone destruction , painful minor sublaxation with weakness of grip. WRIST ARTHRODESIS • To correct deformity • Obtain a painless wrist • To allow the wrist to function in optimal position. • Indications advanced fixed volar carpal dislocation , wrist instability caused by severe bony deformity. • Contra-indications ipsilateral shoulder and elbow involvement. ARTHROPLASTY • • • • To improve alignment . To retain mobility of the wrist. To provide a stable painless joint. Indications an alternative to arthrodesis when wrist extensors are intact with severe joint destruction , especially in complete upper extremity involvement • Contra-indications absent wrist extensor power , severe flexion contracture , dislocated wrist and previous infection with any implant arthroplasty. METACARPOPHALANGEAL JOINT • MCPJ – Keystones of both longitudinal & transverse skeletal arches of the hand – Frequently site of intense synovitis – Ulnar deviation of digits – Volar subluxation of proximal phalanx – Dislocation of MCPJ METACARPOPHALANGEAL JOINT METACARPOPHALANGEAL JOINT • FACTORS LEADING TO DEFORMITIES 1. Normal Forces 2. Normal anatomy 3. Pathological changes 1. Normal forces a) Gravity b) Power grasp METACARPOPHALANGEAL JOINT 2. Normal anatomy a) Asymmetrical shape of metacarpal heads (smaller sloping ulnar condyle) b) Unequal collateral ligament length & their differing orientation c) Asymmetry of intrinsic muscles to the small finger (hypothenars are stronger than 3rd volar interosseous) METACARPOPHALANGEAL JOINT 3. Rheumatoid Changes – bony erosions of the metacarpal head & base of proximal phalanx leading to ↓ joint stability – Attrition & stretching of the collateral ligaments – Stretching of accessory collateral ligaments, allowing ulnar & palmar displacement of palmar plate & flexor tendons at base of finger – Flexor tenosynovitis with resultant stretching of the flexor tendon sheath pulley system -Rupture of extensor digitorum creating unopposed imbalance at the MCPJ – Contracture of intrinsic muscles,with volar subluxation & ulnar deviation of digits • Surgical procedures that are indicated are intrinsic release or transfer for balance, extensor tendon realignment, and metacarpophalangeal joint synovectomy in mild ulnar drift. • In severe ulnar drift, often one or more metacarpophalangeal joints have dislocated. Interposition arthroplasty of the metacarpophalangeal joint reliably relieves pain, maintains stability and alignment, and permits acceptable motion • Subluxation of metacarpophalangeal joints of fingers in severe rheumatoid arthritis. B, Subluxations have been treated by resecting metacarpal heads. Because at surgery articular cartilage of joints was eroded, intrinsic release would have been insufficient treatment. FINGER DEFORMITIES • • • • • Deformities of the finger can be caused by the normal forces applied to damaged joints by the extrinsic flexors and extensors, tightness of the intrinsic muscles, displacement of the lateral bands of the extensor hood, rupture of the central slip of the hood, or rupture of the long extensor or long flexor tendons. FINGER DEFORMITIES • Intrinsic Plus Deformity The intrinsic plus deformity is caused by tightness and contracture of the intrinsic muscles. In hands with intrinsic plus deformity, the proximal interphalangeal joint cannot be flexed while the metacarpophalangeal joint is fully extended. FINGER DEFORMITIES • INTRINSIC PLUS DEFORMITY When indicated, intrinsic tightness may be released in conjunction with synovectomy by mobilization of the lateral band. FINGER DEFORMITIES SWAN-NECK DEFORMITY • Swan-neck deformity is described as a flexion posture of the distal interphalangeal joint and hyperextension posture of the proximal interphalangeal joint • It is caused by muscle imbalance and may be passively correctable, depending on the fixation of the original and secondary deformities • Although usually associated with rheumatoid arthritis, swan-neck deformity may occur in patients with lax joints and in patients with conditions such as Ehlers-Danlos syndrome • Rheumatoid swanneck deformities of varying severity in all fingers. Metacarpophalangeal subluxation and flexion contractures also are present. SWAN-NECK DEFORMITY. • Terminal tendon rupture may be associated with synovitis of distal interphalangeal joint, leading to distal interphalangeal joint flexion and subsequent proximal interphalangeal joint hyperextension. • Rupture of flexor digitorum superficialis tendon can be caused by infiltrative synovitis, which can lead to decreased volar support of proximal interphalangeal joint and subsequent hyperextension deformity. • Lateral-band subluxation dorsal to axis of rotation of proximal interphalangeal joint preventing the normal flexion of PIP joint. Nalebuff, Feldon, and Millender swan-neck deformities • Type I deformities are flexible and require flexor tenodesis of the proximal interphalangeal joint, fusion of the distal interphalangeal joint, and reconstruction of the retinacular ligament. • Type II deformities are caused by intrinsic muscle tightness and require intrinsic release in addition to one or more of the aforementioned procedures. • Type III deformities are stiff and do not allow satisfactory flexion, but do not have significant joint destruction radiographically. These deformities require joint manipulation, mobilization of the lateral bands, and dorsal skin release. • Type IV deformities have radiographic evidence of destruction of the joint surface and stiff proximal interphalangeal joints, which usually can be best treated with arthrodesis of the proximal interphalangeal joint FINGER DEFORMITIES BOUTONNIERE DEFORMITY • Caused by underlying joint synovitis which produces an attenuation and lengthening of central slip of extensor digitorum communis tendon. • Lateral bands become lengthened as apart of extensor mechanism of PIP joint and are displaced volarwards. • Attempted extension at PIP leads to flexion. • With increased power n overpull of extensor slip at DIP occurs leading to hyperetension. • Thumb with fixed rheumatoid boutonnière deformity (type I). Metacarpophalangeal flexion and interphalangeal hyperextension. • In mild deformities, there is a flexion deformity at the proximal interphalangeal joint with lessened ability to flex the distal joint fully, but the joint is not fixed in hyperextension.. In these deformities, treatment may consist of releasing the lateral tendons near their insertion into the distal phalanx. • A moderate buttonhole deformity has an approximately 40-degree flexion contracture of the proximal interphalangeal joint, most of which is passively correctable. The distal joint is hyperextended, The lateral bands are fixed in their subluxated position volarward. To correct this deformity, there must be functional restoration of the central slip and correction of the subluxation of the lateral bands. Radiographs of these joints should show no severe joint destruction • A fixed buttonhole deformity usually has joint changes on radiographs and a passively uncorrectable flexion contracture of the proximal interphalangeal joint. Combined procedures on both joints, usually metacarpophalangeal joint arthroplasty or fusion with interphalangeal joint release or fusion, are necessary. • Central extensor tendon reconstruction for rheumatoid boutonnière deformities unpredictable and recommended arthrodesis for severe boutonnière deformities. RUPTURE OF TENDONS • Major cause of deformity and disability in the rheumatoid hand. • Rheumatoid tenosynovitis is the basic cause of such ruptures. • The long extensor tendons of the middle, ring, and little fingers seem to rupture as a group • Dorsal subluxation of the distal ulna contributes to rupture of these three tendons because the diseased end of the bone is rough, and the tendons usually glide between it and the tight, intact dorsal carpal ligament. • Rupture of extensor tendons at level of extensor retinaculum in rheumatoid arthritis. Most ruptures of common finger extensors occur at an abrasive point created by dorsally dislocated distal ulna. • A ruptured extensor tendon can be repaired by direct suture if found within a few days and if the remaining tendon is adequate. • If surgery must be delayed for several days, it is well to splint the wrist in extension to relieve the constant tension on the remaining intact tendons. • If the ruptured tendon is diagnosed after several weeks, a segmental tendon graft, transfer of a tendon to the distal segment of the ruptured tendon, or possibly a side-to-side suture of the proximal and distal segments of the ruptured tendon to an adjoining intact tendon are options for treatment • A synovectomy is always indicated in the region of the rupture and the repair. RUPTURE OF TENDONS Flexor Tendon Rupture • More difficult to treat surgically. • Not as common as extensor tendon rupture. • Rupture may occur within the digit as a result of infiltrative tenosynovitis or at wrist level because of bony erosion of the tendon, especially the flexor pollicis longus tendon. • Rupture of one sublimis slip can cause triggering of the finger. • TENDON SHEATH INVOLVEMENT Presents as carpal tunnel syndrome • RHEUMATOID NODULES interferes with hand function when they occur on pulp pads of digits or on the ulnar border of the forearm.They can be excised. But recurrance rates high due to infiltrative nature. THUMB • Rheumatoid thumb deformities frequently are complex and can involve the joints individually or in combination . THUMB • type I, the most common, is a boutonnière deformity; • type II, which is rare, includes metacarpophalangeal joint flexion, interphalangeal joint hyperextension, and trapeziometacarpal joint subluxation or dislocation; • type III, the second most common, is a swan-neck deformity; and • type IV, which is unusual, results from ulnar collateral ligament laxity and includes abduction of the proximal phalanx with metacarpal adduction. THUMB • Treatment of type I thumb deformities depends on the passive correctability of the joints and the extent of joint destruction. If the metacarpophalangeal subluxation and interphalangeal joint hyperextension are correctable, and radiographically the joints are normal, metacarpophalangeal synovectomy and extensor reconstruction may suffice • If destruction is radiographically significant, metacarpophalangeal arthrodesis provides a satisfactory thumb. THUMB • Type II thumb deformities include metacarpophalangeal joint flexion, interphalangeal joint hyperextension, and dislocation or subluxation of the trapeziometacarpal joint. Using combinations of interphalangeal fusion and metacarpophalangeal and trapeziometacarpal arthroplasty, type II deformities can be treated similar to type I and type III deformities . THUMB • The treatment of type III deformities depends on the extent of metacarpophalangeal joint destruction, pain, the passive correctability of the metacarpophalangeal joint deformity and trapeziometacarpal subluxation, metacarpal adduction contractures, and metacarpophalangeal joint hyperextension. • Trapeziometacarpal hemiarthroplasty • metacarpophalangeal joint fusion with trapeziometacarpal hemiarthroplasty or resection arthroplasty THUMB • Type IV (gamekeeper) thumb deformity includes a thumb proximal phalanx abduction deformity and an adducted metacarpal caused by stretching of the ulnar collateral ligament and attenuation of the capsuloligamentous structures by chronic rheumatoid synovitis. • Metacarpophalangeal synovectomy, ligament reconstruction, and adductor release may be sufficient for milder deformities. • For more advanced deformities, metacarpophalangeal arthroplasty or arthrodesis may be required to stabilize the joint. • Main en lorgnette” (opera glass hand). Late changes in progressive rheumatoid arthritis. • 89% have symptomatic arthritis of the feet of varying severity. • Approximately 17% of patients with rheumatoid arthritis present initially with symptoms affecting the joints of the feet. FOREFOOT • Most rheumatoid foot surgery involves the forefoot • Of patients with rheumatoid arthritis, 89% have forefoot involvement, and patients often present with this involvement within 1 year of diagnosis. • Hallux valgus and dislocation of the metatarsophalangeal joints associated with clawing of the toes and painful plantar callosities over protruding metatarsal heads are the most common symptomatic deformities. • Hammer toes complicated by painful callosities or even ulceration over the proximal interphalangeal joints, intermetatarsal and forefoot pad bursae, and interdigital neuromas also commonly require surgical correction. • Rheumatoid foot. Note multiple deformities of rheumatoid arthritis of forefoot with hallux valgus, subluxed and dislocated metatarsophalangeal joints, claw toes, hammer toes, and bursal formation. • Multiple deformities of rheumatoid arthritis. MIDFOOT • The cuboid-metatarsal, cuneiformmetatarsal, and naviculocuneiform articulations may be involved with the destructive rheumatoid process, but symptoms at these joints do not commonly require surgical treatment unless marked collapse of the medial longitudinal arch severely impairs ambulation or causes skin ulceration. • Naviculocuneiform joint is the most common offender in midfoot collapse with weight bearing, which results in loss of the longitudinal arch and flattening and pronation of the foot. • Collapse of midfoot at talonavicular joint in patient with rheumatoid arthritis. HINDFOOT • The rheumatoid hindfoot deformity usually is a pronounced valgus posture of the heel secondary to erosive synovitis of the subtalar or talonavicular joint or both. • With loss of support by the talocalcaneal interosseous ligament, the bifurcate ligaments, and the talonavicular ligaments and capsule, weight bearing forces the heel into valgus and the forefoot into pronation with loss of the longitudinal arch • Heel valgus and foot pronation secondary to rheumatoid arthritis. With time, forefoot deformity may become fixed. If subtalar and midtarsal joints are reduced surgically, forefoot is actually in pronounced supination relative to hindfoot. This may make it difficult to plantar flex first ray enough to produce plantigrade foot on weight bearing. B, Multiple dislocations of metatarsophalangeal joints. TIBIALIS POSTERIOR INVOLVEMENT • This complex hindfoot-midfoot collapse pattern can be initiated or exacerbated by rupture or insufficiency of the posterior tibial muscle-tendon unit • Chronic tenosynovitis of the posterior tibial tendon renders it incompetent because of reduced excursion or loss of continuity and loss of its support for the longitudinal arch. • The function of this muscle-tendon unit must always be evaluated in any patient with rheumatoid arthritis of the foot, but especially if the hindfoot is symptomatically involved. FOREFOOT-MTP • Synovial proliferation distends the joint. • Stretches collateral ligaments. • Attenuation of supporting structures & dorsiflexion ground reaction force of ambulation leads to dorsal subluxation of digits. • Displacement of the digital flexors into the intermetatarsal space causes the tendons to pass dorsal to MTP jt axis. • The flexors now acts as functional extensors at MTP jt. FOREFOOT-MTP • Unopposed action of extrinsic extensors results in gradual and progressive dorsal phalangeal dislocation. • Forefoot dorsiflexion forces during ambulation contributes to the dislocation. • Intrinsic weakness results which prevents extension of interphalangeal joint leading to claw and hammer toe deformities. • With time deformities become fixed and result in fibrous ankylosis and soft tissue contractures. FOREFOOT-GREAT TOE • Hallux valgus Factors contributing to this deformity in rhematoid feet are • Presence of splay foot with metatarsus primus varus. • Loss of lateral stabilization • Pronation of I metatarsal and hallux secondary to hindfoot valgus FOREFOOT-GREAT TOE • Bowstringing of the EHL which adducts rather than extends the hallux. • Synovitis and articular destruction of the MTP joint with loss of ligamentous support. • The pathologic process involved in the joint destruction,instability and dislocation are familiar articular manifestations of RA. • Less commonly appreciated but potentially devastating is the non articular and non osseous involvement..involvement of nerve and vasculature. VASCULITIS • Obliterative endarteritis/inflammatory focal and segmental vasculitis. • Periungual haemorrhages • Infarctions/gangrene • Delay in wound healing NERVE INVOLVEMENT • Peripheral sensory neuropathy • Sensorimotor neuropathy • Entrapment neuropathy NON OPERATIVE MANAGEMENT • Appropriate footwear • An extra depth shoe that has a large toe box with enough room for the patient’s forefoot deformities. • The patient must understand that the disease process is progressive, and that surgical correction of deformity should be considered palliative, rather than definitive or curative. • Complications can be reduced to a minimum if the following recommendations are carefully considered: • Clean the skin meticulously, especially between the toes and around the nails, for 10 to 15 minutes before surgery, and apply a sterile wrap. • Use a prophylactic broad-spectrum antibiotic routinely, usually 30 minutes before the incision is made, intraoperatively, and 48 to 72 hours postoperatively. • Carefully inspect the skin of the foot and distal leg for any evidence of rheumatoid vasculitis, which manifests as macules and papules, usually over the anterolateral border of the distal tibia and dorsolateral surface of the foot. • If a patient is taking corticosteroids, consider removing the sutures at 3 weeks or longer instead of the customary 12 to 16 days. • Elevate the feet to the maximal level for 48 to 72 hours postoperatively. SURGICAL INTERVENTIONS • Arthrodesis of I MTP • Metatarsal head resection of lesser toes • Forefoot arthroplasties • Arthrodesis Talonavicular Subtalar arthrodesis Triple arthrodesis SURGICAL INTERVENTIONS INDICATIONS • CORRECTION OF DEFORMITY • PAIN RELIEF CONTRAINDICATIONS • CHRONIC INFECTION • SKIN BREAKDOWN • VASCULITIS • NEUROPATHY FOREFOOT SURGERIES • In 80% to 90% of the patients, a satisfactory result can be expected. • Inadequate relaxation of the soft tissues about the metatarsophalangeal joints from insufficient bony resection will compromise the result . • Unequal lengths of the metatarsal remnants or metatarsals that do not cascade in a gentle curve from metatarsals two through five will likely compromise the result. • Bony fragments remaining in the forefoot weightbearing pad after removal of the metatarsophalangeal joints may compromise an otherwise good outcome. • The location of the incision (plantar or dorsal) is not an important factor, but delicate care of the soft tissue during dissection and adequate hemostasis are mandatory. • Pain relief, walking endurance, and footwear variety should be improved enough to warrant the procedure. • A satisfactory result may deteriorate with time. • Arthrodesis of the first metatarsophalangeal joint combined with lesser metatarsophalangeal joint resections may reduce the complications of recurrence of deformity, painful callosities beneath the lesser metatarsal remnants, and deterioration of a satisfactory result with time • A.rheumatoid forefoot deformities. • B, dorsal subluxationdislocation of lesser toe metatarsophalangeal joints; right foot had similar deformities and is several months postoperative. • C, On plantar view, note scar from removal of metatarsal head-neck segments; surgery consisted of arthrodesis of first metatarsophalangeal joint, removal of both sesamoids, removal of head and neck of proximal phalanx of each lesser toe, and excision of distal lesser metatarsals. • D, After surgery on both feet. 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