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Rheumatoid Forefoot

Tim Williams, 2006

90% of RA pts have forefoot involved. ( = Hand incidence!)
15% of RA pts initially present with forefoot pain.

Pathology

MTPJ Synovitis & Pannus destruction
IPJ's usually Spared

Deformities

  • 2nd-5th MTPJ Synovitis ? Capsular laxity ? P1 Dorsal subluxation / dislocation ? Prominent MT Heads as fat pad drawn distally ? METATARSALGIA & PLANTAR KERATOSES
  • Subsequent Intrinsic / extrinsic muscle imbalance ? CLAW TOE & DORSAL CORNS

  • 1st MTPJ Synovitis combined with loss of lateral support from lesser toes ? HALLUX VALGUS & BUNION

Larsen Staging (Acta Orthop 1977)

Stage I: No bony deformity. Discomfort and synovitis without significant joint space narrowing.
Stage II: Early involvement without fixed deformity. Minimal erosive changes.
Stage III: Soft tissue deformity. No significant joint erosive changes.
Stage IV: Articular destruction. Severe hallux valgus, dislocation of the lesser MTP joints with fixed hammer toe or claw toe deformities, pes planovalgus (flatfoot), and hindfoot arthroses.


TREATMENT OPTIONS

Multidisciplinary Approach

Non - Operative

  • Medical Optimisation (Rheumatologists & G.P.)
    • NSAIDS, Steroids, DMD's, anti-TNF etc..
  • Orthotics
    • Large Toe Box Shoes
    • Metatarsal Pads / Bars
    • Total Contact Insoles
    • Rocker Bottom Shoes
  • Physiotherapy - Try to maintain movement

Operative

  1. Lesser MTPJ Surgery - Decompress the Joint to allow relocation
  • Synovectomy
  • Hoffman Procedure (1911) - Excision of

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