CURRENT METHODS OF TREATMENT

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~ CURRENT METHODS OF TREATMENT Rheumatoid Deformity of the Foot* By LEONARD MARMOR T HE PATIENT with rheumatoid arthritis often develops severe, crippling deformities of his upper and lower limbs.

1 ~ CURRENT METHODS OF TREATMENT Rheumatoid Deformity of the Foot* By LEONARD MARMOR T HE PATIENT with rheumatoid arthritis often develops severe, crippling deformities of his upper and lower limbs. The medical profession has now adopted a more aggressive approach to the correction and prevention of these deformities, especially in the upper extremities. But the deformity of the foot can also be extremely disabling. The patient can not obtain suitable shoes which are comfortable to accommodate his deformed, painful joints. It is indeed a dilemma, since he also can not walk barefoot because of the pain. His problem is compounded in areas of the country where the winters are severe. He is a pathetic sight confined to a wheel chair because of bad feet or shufhing about with severe pain. Deformities of the feet from rheumatoid arthritis can be alleviated by surgical procedures to an extent that is often termed a miracle by the postoperative patient. It is time to take stock of this patient and to begin to approach his problems with hope and enthusiasm. Deformities The common foot deformities in rheumatoid arthritis are clawing of the toes, hallux valgus (bunion), and dislocation of the metatarsal phalangeal joints of all of the toes (fig. 1). These deformities tend to be combined in the severe, advanced case and to produce symptoms that are a consequence more of the mechanical deformity than of the arthritis itself. The dislocation of the toes with contracture of the extensor tendons produces a severe clawing of the toes and forces the metatarsal head down into the plantar surface so that the metatarsal arch is obliterated. The prominence of the metatarsal heads on the sole of the foot produces the severe calluses and pain on walking (Fig. 1B). Combined with the severe clawing and hallux valgus, this makes the fitting of a comfortable shoe almost impossible. TREATMENT In the severe case almost all conservative measures will meet with little success, although they should be attempted. Soft, pliable leather shoes with a metatarsal bar may be of value in relieving pressure on the metatarsal heads. Special shoes can be constructed from plaster molds of the patient s feet, and although large and bulky, they give the patient considerable relief. If nothing aids the patient, an operation to correct the deformities should be considered, since very good results have been obtained. In 1912, Hoffman1 advocated excision of the metatarsal heads for correction of multiple toe deformities. However, although relief was obtained in many Supported in part by a grant from the.arthritis G Rheumatism FouncEation. 749 ARTHRITIS AND RHEUMATISM, VOL. 6, No. 6 (DECEMBER), 1963

750 LEONARD MARMOR Fig. 1A.-This patient was severely disabled by her painful feet. She had an intractable ulcerated callus beneath the metatarsal heads and a severe hallux valgus with clawed toes.

2 750 LEONARD MARMOR Fig. 1A.-This patient was severely disabled by her painful feet. She had an intractable ulcerated callus beneath the metatarsal heads and a severe hallux valgus with clawed toes. Fig. 1B.-A patient with marked hallux valgus and clawed toes. Note how the clawing of the toes with dislocation of the metatarsal phalangeal joints has forced the metatarsal head down into the sole of the foot. cases, painful calluses eventually developed again, because the base of the phalanx was depressed by the pull of the contracted extensor tendons. Flint and Sweetnam2 in 1960 advised amputation of all of the toes for relief of pain. They had good results, but the cosmetic appearance of the foot was not acceptable and a filler for the shoes was required. Fowler excised the proximal half of the proximal phalanges and trimmed the underside of the metatarsal heads level and to an even line anteriorly. He also excised an ellipse of plantar skin to shift the weight-bearing skin back into the same relationship with the reconstituted metatarsal heads. We have utilized the approach of Clayt~n,~ who recommended removal of the proximal half of the proximal phalanges and the metatarsal heads through a transverse dorsal incision (fig. 2). The patient is allowed to bear weight in one week on the heels and gradually within the next week to walk on the entire foot. The toes are held in place by a pressure dressing and allowed to scar down in a corrected position. Later a metatarsal pad is prescribed for the shoe. In a less severe case with only a hallux valgus, we prefer the Keller operation (fig. 2B). It consists of removal of the medial exostosis of the first metatarsal head and excision of the proximal half of the proximal phalanx. Long term follow-up has shown very satisfactory results.

3 RHEUMATOID DEFORMITY OF THE FOOT 751 Resected area Fig. 2A.-A drawing of a severely deformed foot showing the surgical incision and the amount of bone removed in the correction of this deformity. Fig. 2B.-Diagram showing the Keller operation for a hallux valgus without clawing of the toes. Fig. 2C.-Diagram of a claw toe deformity showing the method of arthsodesis of the proximal interphalangeal joint. A simple claw or hammer toe, without dislocation of the metatarsal phalangeal joint, can be arthrodesed at the proximal interphalangeal joint with a permanent correction of the deformity (fig. 2C). DLSCUSSION It is our feeling that in the severe crippling deformity of the foot (fig. 3A), the operation of radical excision of the proximal half of the proximal phalanx and the metatarsal heads is the best procedure. The cosmetic and functional improvement is marked and the results gratifymg (fig. 3B). In the less severe deformities such as a hallux valgus, the Keller operation will give excellent long term results. An operation can be tolerated very well by the patient with rheumatoid arthritis under good medical management. If the rheumatologist and surgeon work together as a team, greater improvement in the care of the arthritic can be expected.

752 DISCUSSION Fig. 3A.-Patient with severe preoperative rheumatoid deformity of the foot with a hallux valgus, clawing, and subluxation of the toes.

4 752 DISCUSSION Fig. 3A.-Patient with severe preoperative rheumatoid deformity of the foot with a hallux valgus, clawing, and subluxation of the toes. She was disabled from the painful foot and unable to wear shoes. Fig. 3B.-Marked postoperative improvement, both functional and cosmetic. Pain has been relieved and patient is wearing shoes. REFERENCES 1. Hoffman, P.: An operation for severe 3. Fowler, A. W.: A method of forefoot grades of contracted or clawed toes. reconstruction. J. Bone and Joint Surg. Am. J. Orth. Surg. 9:441, B:507, Flint, M., and Sweetnam, R:. Amputation of all toes. J. B~~~ and Joint surge 4. Clayton, M.: Personal communication. 42-B:90, Denver, Colorado, Discussion THE ESSAYIST has confirmed the well established principle that surgical decompression of a severely damaged joint is one means for the relief of pain stemming from that joint. This is the case in the foot as it is in other joints and in rheumatoid arthritis as it is in other joint afflictions. The modification of the Hoffman procedure that is mentioned, stemmed from a technical fault in that removal of the metatarsal head is only the partial excision of a joint. Hence, the additional removal of the base of the first phalanx in addition to the metatarsal head provides a circumstance better suited to pseudarthrosis. Removal of the base of the phalanx also provides further decompression of the painful joint. Experience has taught that if and when surgery is indicated for the painful foot, it is better that all the metatarso-phalangeal joints, with the exception of the first, be excised as part of the same operation to allow more even distribution of weight at the new metatarsal level. It is timely to mention that surgery can be applied beneficially to the foot in early rheumatoid arthritis before there is deformity. Protracted involvement of the subastragalar joint, if allowed to go on can lead to peroneal spasm and fixed valgus which is preventable by early subtalar fusion. Additionally early operation saves flexibility in the remainder of the foot. Mid tarsal involvement, if localized, and treated early by single or multiple specific joint fusions, will

DISCUSSION 753 likewise relieve pain and prevent delayed antalgic deformities, It is worthy of mention that early and persistent exercise for the intrinsic muscles of the foot can at times prevent

5 DISCUSSION 753 likewise relieve pain and prevent delayed antalgic deformities, It is worthy of mention that early and persistent exercise for the intrinsic muscles of the foot can at times prevent the clawing and subsequent permanent subluxations, since a part of the joint destruction stems from dysfunction. Whereas I agree with the author that metatarso-phalangeal joint resections, combined with a Keller operation for the great toe, will relieve pain and thus a certain amount of crippling, no one should gain the notion that operation is the cure-all for painful feet in rheumatoid arthritis. The greatest chance for improvement will be in the case where the foot itself is the major stumbling block to locomotion. If knee and hip pains are present, operations on the foot will relieve only the foot and must be indicated on that basis and the price paid for the relief of pain will be the sacrifice of a spring step gait. IN RHEUMATOID CARROLL B. LARSON arthritis, as in other chronic diseases, participation in life s important activities is essential for the general welfare of the patient. Let us consider the housewife as an example. If she becomes unable to do her own housework, she reaches a milestone of physical and psychological regression. Something as apparently trivial as painful feet may be her sole disabling factor. In that event, appropriate therapeutic measures for her are demanded without delay. As Dr. Marmor has indicated, the metatarso-phalangeal joints are the chief site of disabling rheumatoid arthritis of the feet. However, his discussion does not cover the acute phase of the disease when the deformities of the toes are labile. It would seem that this phase is a most important one to consider because during it the deformities can be corrected by conservative means. In acute arthritis, the synovial spaces of the metatarso-phalangeal joints are distended and the toes are drawn up so as to rest in a more comfortable position-setting the stage for later permanent contractures. Any motion of, or pressure on, the joints is extremely painful. Since the whole body weight is carried directly on the metatarsophalangeal joints of a foot during each walking step, ambulation becomes very difficult. Redistribution of the weight borne by the foot may be accomplished by use of a metatarsal bar on the sole of the shoe, but the placement of this bar should not be left to the shoe repairman. The physician must prescribe its exact location, just behind the metatarsal heads, by marking on the shoe itself. A more effective method of supporting painful feet is by use of leather-and-spongerubber foot pads, worn in soft-toed ample shoes. Such a pad should be made by an experienced orthotist from a tracing which the physician supplies. This tracing1 comprises an outline of the weight-bearing foot, with the metatarsal heads dubbed in from a roentgenogram, so that areas for support can be localized precisely. The housewife with acute arthritis of the metatarso-phalangeal joints probably needs more than just foot supports. Hot soaks for her feet will help. Since she has a systemic disease, she may require extra rest periods, salicylates. Under the appropriate combination of local and systemic therapy, the painful swelling and deformity of her feet soon subside. She can again do her housework and care for her children. She is not the invalid that she had dreaded becoming. Furthermore, if she continues on a proper regimen, her feet may never become chronically involved. Unfortunately, however, we do encounter the housewife of middle age whose rheumatoid arthritis has entirely burned out but who, also, is becoming incapacitated from her painful feet. Here, as Dr. Marmor has well described, the problem is purely mechanical and arises from the residual fixed contractures of the toes. Use of metatarsal bars, foot pads and special shoes may still aid symptomatically-by taking pressure off the painful calluses beneath the metatarsal heads and by giving the stiff toes more room -but at this stage of the disease, as Dr. Marmor points out, surgery is far more efficacious. The operation of multiple joint resection which Dr. Marmor illustrates is also in my

6 754 DISCUSSION opinion much the best, except that I would do no more than the Keller procedure at the great toe. That is to say, I would not excise the head of the first metatarsal. So doing removes an important weight-bearing area of the forefoot. It is also entirely unnecessary, as judged from experience with a series of twenty-odd patients in the arthritis clinic at the Massachusetts General HOSpita1 during the early 1940's, and with similar cases since. However, complete resection of each of the lateral four metatarso-phalangeal joints is essential-excision both of metatarsal head and base of phalanx-regardless of whether a callus be present under each joint or not. The calluses themselves are not removed; they all disappear if resection of bone has been adequate and the remaining ends of the metatarsal necks all project evenly (as is not the case in Dr. Marmor's illustration). After this procedure the patient has functionless toes, but she does not mind because she is not going to be a sprinter. Her toes get in the way when she puts on her stockings, but this is better than having no toes at all. What matters most, her feet are no longer painful. Her morale rises and she is restored to her normal way of life. FREDERIC W. RHINELANDER "Rhinelander, F. W.: The effectiveness of splinting and bracing on rheumatoid arthritis. Arth. &i Rheumat. 2: , AM IN COMPLETE agreement with the principles outlined by Dr. Marmor. Just as an aggressive approach has been applied in om practice to the rheumatoid foot for the last ten years as to the rheumatoid hand. Chronic rheumatoid synovitis of the metatarsophalangeal joints plus weight bearing strain leads to inevitable deformity in progressive cases with pain on weight bearing, whether the disease is active or burned out. With the type of chronic deformity, if pain cannot be relieved by foot supports, surgery is indicated whether the disease is active or inactive, provided the patient's general condition is satisfactory. (Surgery in no way alters the general course of the disease). The fixed contracture of all soft tissues including the skin demands adequate bony resection for decompression of the forefoot, correcting the deformities, and realigning the weight bearing ends of the metatarsals. These must be properly aligned and beveled so that no undue pressure falls on any one metatarsal. Manipulation of the proximal interphalangeal joints of the smaller toes corrects the cock-up deformities. Resection of the bases of the proximal phalanges prevents unnecessary shortening of the metatarsals and helps prevent recurrence. The fifth toe is the least commonly dislocated and in many instances we resect only the fifth metatarsal head and manipulate the toe straight. This helps prevent lateral drift of the toes which may occur. Postoperatively the toes should be bandaged in the exact desired position. The surgical approach is optional; but the complete procedure is most easily performed through a single dorsal transverse incision where the exact bony area of resection can be tailored to fit the individual foot under complete vision. Steroids in clinical dosages do not interfere with wound healing and there has been no increase in the incidence of infection in steroid cases. I would agee that in simple cases with only hallux valgus and bunion deformity that the Keller procedure is the choice; the principle is the same, adequate bony resection. For a single cock-up toe, arthrodesis is an acceptable procedure, but we have found again that simple adequate bony resection of a portion of the proximal phalanx gives as satibfactory correction. In a chronic progressive disease for which we have no cure and in which patients are abnormally sensitive to pressure there will be some recurrent problems. I agree that all patients should wear simple metatarsal type supports and supports for the long arch if indicated. Even so, a few will need supplementary surgery to revise the abnormal weight bearing. Usually simply realigning a single metatarsal end is a minor procedure and corrects the problem. About 10 per cent of our patients have required this. An additional gain is that in many cases, with relief of pain in the forefoot, gait is so improved that there will he some relief

7 DISCXJSSION 755 of hip and knee pain. Because of this forefoot resection is usually the first procedure performed if a series of procedures for the lower extremities are necessary. Forefoot resection is the most satisfactory operative procedure available today for the rheumatoid lower extremity. The Committee on Arthritis of the American Academy of Orthopaedic Surgeons surveyed approximately 150 cases of forefoot surgery with 90 per cent good results. Over a one year follow-up of 44 feet was done at the University of Colorado in 1961 and revealed 39 good results and no patient was worse from the surgery. Adequate bony resection at the metatarsophalangeal level will give a weight tolerant foot in the chronic rheumatoid arthritic, and I agree that this operation deserves wider application; and with the increasing cooperation between the rheumatologists and orthopedists, I believe this will come to pass. MACK L. CLAYTON Leonurd Marwwr, M.D., DeplFrtmnt of Surgey, School of Medicine, University of California Medical Center, Los Angeles, Calif. Curroll B. Larson, M.D., University Hospitals, Department of Orthopedic Surgery, State University of Zowa, Iowa City, louu. Frederick W. Rhinelander, M.D., Professor of Orthopaedic Surge y, Western Reserve University School of Medicine, Clewland, Ohio; Chief, Orthopaedic Seruice, Cleveland Metropolitan General Hospital, Cbueland, Ohio. Mack L. Clayton, M.D., Am'stant Clinical Professor of Orthopedic Surgey and Consultant to the Arthritis Clinic, University of Colorado School of Medicine, Denver, Colo.

WHAT IS ARTHRITIS OF THE BIG TOE (HALLUX RIGIDUS)?

Mr Laurence James BSc MBBS MRCS(Eng) FRCS(Tr&Orth) Consultant Orthopaedic Surgeon Foot, Ankle and Sports Injuries WHAT IS ARTHRITIS OF THE BIG TOE (HALLUX RIGIDUS)? A common term for arthritis of the metatarsophalangeal