Download rheumatiod arthritis

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
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•
•
•
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
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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
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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
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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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