alexa Forefoot Surgery in Rheumatoid Arthritis: An Overview | Open Access Journals
ISSN: 2161-0533
Orthopedic & Muscular System: Current Research
Like us on:
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Forefoot Surgery in Rheumatoid Arthritis: An Overview

Nazera Dodia* and Anand Pillai

University Hospital of South Manchester, Southmoor Road, Manchester, United Kingdom

*Corresponding Author:
Nazera Dodia
University Hospital of South Manchester
Southmoor Road Manchester
M23 9LT, United Kingdom
Tel: +44-161-998-7070
Email: [email protected]

Received Date: February 04, 2015; Accepted Date: February 24, 2015; Published Date: March 05, 2015

Citation: Nazera D, Anand P (2015) Forefoot Surgery in Rheumatoid Arthritis, an Overview. Orthop Muscul Syst 4:e114. doi:10.4172/2161-0533.1000e114

Copyright: © 2015 Nazera D. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Orthopedic & Muscular System: Current Research

Editorial

Rheumatoid Arthritis (RA) is a chronic systemic progressive inflammatory arthropathy with the potential to cause destructive changes affecting synovial joints. The peak age of onset is between 35 and 55 years [1]. Whilst the exact causes and triggers for RA are unknown, it is likely that the aetiology is multifactorial including both genetic and environment factors. Autoantibodies are thought to be involved in an immunological cascade that results in the release of inflammatory cytokines and synovial inflammation. If synovitis is not adequately controlled, cartilage destruction and bone destruction ensues with dysfunction of surrounding structures such as tendons and muscles [2]. Damage to joints can lead to progressive disability and handicap. There is a significant health and cost burden related to RA with approximately 50% of patients unable to work after 10 years of the onset of disease [3].

Forefoot involvement often results in pain and disability in addition to having a significant impact on the quality of life in patients with RA. Metatarsophalangeal Joint (MTPJ) inflammation is frequently found in RA, leading to joint damage and deformities within the forefoot, with associated poor functioning of the supporting ligaments and capsular structures. This results in subluxation and ultimately dislocation of the involved joints. Plantar fat pads are distally displaced, predisposing to the formation of painful callosities. The hallux develops a valgus deformity, whilst the lateral four toes dislocate dorsally at the MTPJs. The imbalance created between the flexor and extensor tendons leads to the claw-toe deformities in the foot. This predisposes to the formation of the dorsal corns at the interphalangeal joints, which further aggravates pain and footwear problems. Ulcers and poor wound healing, sometimes secondary to medications, cause further disability.

Management of RA needs a multidisciplinary team approach involving an orthopaedic surgeon, rheumatologist, podiatrist, and physical therapist. Diseases Modifying Anti-rheumatic Drugs (DMARDs) form the mainstay in the management of disease by altering the disease progression and reducing pain and stiffness.

The National Institute for Health and Clinical Excellence (NICE) guidelines in the UK recommend a surgical opinion for patients with persistent arthralgia, worsening joint function, progressive deformity or persistent localised synovitis, despite optimal non-surgical management. The aims of surgery are pain relief, improvement of the function or prevention of further deterioration of joint function and prevention of deformity.

Hoffman et al. first described forefoot reconstruction in 1912 with excision of all five metatarsal heads using a distal transverse plantar incision. It was reported that this approach relaxed the soft tissues. The disadvantage of the Hoffman procedure is an increased risk of neurovascular damage. Recurrent hallux valgus and stiff metatarsophalangeal joints are usually the main concerns of unsatisfied patients following resection arthroplasty.

The Fowler procedure encompasses both a dorsal and plantar incision. The dorsal incision features five longitudinal extensions towards the metatarsals. This is used for the resection of the metatarsal heads and proximal portions of the phalanges. The plantar incision allows for the repositioning of the fat pad beneath the metatarsals.

Clayton et al. developed the Fowler procedure with the addition of extensor tendon transections and used only a dorsal transverse incision. A cohort review which followed up patients who underwent Clayton resection arthroplasties showed that postoperatively, 21% of patients struggled to stand on tiptoes [4]. Fibular drift of lateral toes and prominent metatarsal stumps were found on x-ray. However, these patients still felt an improvement in contrast with their postoperative state and would still recommend surgery. 6% of patients did not experience any improvement from the surgery and recurrent splay-foot deformity was observed. The authors put the unfavourable outcome in this group down to improper surgical technique and progression of the disease.

Metatarsal head excision can also be performed using an elliptical plantar incision, with K- wire to stabilise the first MTP joint. A dorsal approach has also been described.

The Stainsby procedure can be used to correct the claw toe. The aim of the Stainsby procedure is to correct the dorsally displaced plantar plate and reposition the metatarsal heads so they do not sink below the fat pad of the foot. Bony resection is performed on the lesser toes, the plantar plate freed, realigned underneath the metatarsal heads and intramedullary wire is then used to stabilise each toe.

Fusion of the first MTP joint is commonly used. The first MTP joint can be fused and rays 2-5 treated with a resection arthroplasty such as the Stainsby procedure. The disadvantage of arthrodesis is that joint mobility is lost. The aim of the procedure is pain management.

Current research in rheumatoid forefoot surgery focuses on joint sparing procedures. Scarf osteotomy for the first MTP joint combined with Weil osteotomy of the lesser metatarsal heads has been used with three in four patients describing the result as excellent at mean follow up 51 months [5]. A trial of 43 patients who underwent first tarsometatarsal fusion and distal realignment, shortening oblique osteotomies of the bases of metatarsals 2-4 and fifth ray osteotomy had significantly improved post-operative clinical outcome scores at a mean follow up of 77 months [6].

Most studies report favourable outcomes for the first few years post-operatively using scores such as the American Orthopaedic Foot and Ankle Society Score. Few studies report outcomes beyond the first five years postoperatively. This is an area for future research.

In conclusion, a range of procedures have been developed in the management of the rheumatoid forefoot. Studies into new techniques continue. It is thought that early intervention, early mobilisation and a multi-disciplinary team approach give the most favourable outcomes.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Article Usage

  • Total views: 11658
  • [From(publication date):
    February-2015 - Nov 19, 2017]
  • Breakdown by view type
  • HTML page views : 7891
  • PDF downloads : 3767
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri & Aquaculture Journals

Dr. Krish

[email protected]

1-702-714-7001Extn: 9040

Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001Extn: 9040

Clinical Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

Food & Nutrition Journals

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

General Science

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics & Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Materials Science Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Nursing & Health Care Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

Ann Jose

pharma[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001Extn: 9042

 
© 2008- 2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version
adwords