Metatarsal head resection in the rheumatoid foot: 5-year follow-up with and without resection of the first metatarsal head

Impact of Foot Surgery and Pharmacological Treatments on Functionality and Pain in Rheumatoid Arthritis: A Five-Year Longitudinal Study

BACKGROUND

Rheumatoid arthritis (RA) frequently leads to foot deformities, significantly impacting pain, mobility, and quality of life. Surgical and pharmacological treatments are prescribed to manage symptoms, but their long-term effects on foot function remain unclear. This study evaluates the impact of different treatment approaches, including surgery, methotrexate (MTX), and biological therapy (Bio), on foot functionality and pain progression over five years.

METHODS

A longitudinal cohort study was conducted with 103 RA patients classified into five groups: surgery, MTX < 10 years, MTX ≥ 10 years, Bio < 10 years, and Bio ≥ 10 years. Data from 2018 and 2023 were compared using the Visual Analog Scale (VAS), the Manchester Foot Pain and Disability Index (MFPDI), and the Foot Function Index (FFI). Statistical analyses included ANOVA, Kruskal-Wallis, and ROC curve analysis to assess differences between groups and identify key progression factors.

RESULTS

Patients with ≥10 years of disease duration and non-biological treatment (MTX ≥ 10 years) experienced the most severe deterioration in foot function, with a mean FFI increase of +11.89 points (p < 0.01). In contrast, MTX < 10 years was the only group to show an improvement in foot function (FFI: -5.29, p = 0.02). The surgery group exhibited moderate but highly variable functional changes, while patients on biological therapy showed less progression in pain and disability compared to their non-biologic counterparts. Hallux abductus valgus severity increased across all groups.

CONCLUSIONS

Patients with long-standing RA on non-biologic therapy exhibited the greatest decline in foot function, whereas early treatment with MTX (<10 years of disease duration) appeared to slow deterioration. Surgery did not consistently provide functional benefits, and biologics helped mitigate progression, though outcomes varied. These findings underscore the importance of early intervention and personalized treatment strategies for foot preservation in RA.

[Long-term clinical and radiological results of metatarsophalangeal resection arthroplasty in patients with large forefoot deformities]

INTRODUCTION

metatarsophalangeal resection arthroplasty is considered a salvage surgical procedure able to improve the quality of life of patients with major forefoot deformities.

MATERIAL AND METHODS

a retrospective observational study of 31 patients (36 feet) with major forefoot deformities operated at our institution was performed. Thirty two feet required additional surgery involving the first ray, most of them (72.2%) through MTP joint fusion. The mean follow-up period was 10.3 ± 4.6 years. Most patients were women (87.1%), the mean age was 74.2 ± 11.5 years.

RESULTS

at the final follow-up, mean AOFAS score was 77.9 ± 10.2 points and mean MOxFQ score was 18.3 ± 8.3 points. Visual analog scale (VAS) for pain improved significantly from 7.5 ± 1.2 points to 3.4 ± 2.1 points on average. Good clinical results were also reported on ability to put on shoes comfortably. The mean resection arthroplasty spaces at the end of the study were 1.3, 1.8, 2.5 and 4.4 mm, for second to fifth rays, respectively. The mean sizes of remodeling osteophytes at the end of the study were 1.6, 1.4, 1.1 and 0.7 mm, respectively. Significant improvement was also achieved in the hallux valgus angle (HVA) and intermetatarsal angle (IMA) at the end of the study.

CONCLUSION

in our experience, metatarsophalangeal resection arthroplasty continues to be a valid choice in patients with major forefoot deformities, with satisfactory long-term clinical and radiographic results.

Forefoot Deformities in Patients with Rheumatoid Arthritis: Mid- to Long-Term Result of Joint-Preserving Surgery in Comparison with Resection Arthroplasty

Background: Joint-preserving surgery for the forefoot has been increasingly performed for rheumatoid arthritis (RA). We compared joint-preserving surgeries with resection arthroplasty for RA in the forefoot. Methods: Forefoot surgeries were performed on 62 toes in 42 patients with RA (men: 2; women: 40) between 2002 and 2018. Three groups were compared: PP—31 toes treated with joint-preserving surgery involving the modified Mann method for the big toe and offset osteotomy for lesser toes, PR—15 toes treated with joint-preserving surgery for the big toe and resection arthroplasty for lesser toes, and RR—16 toes treated with resection arthroplasty for all the toes. Results: The PP group had significantly higher mean scores on a scale for RA in the foot and ankle at the latest follow-up than the RR group (86 vs. 75 points; p < 0.05). Hallux valgus (angle > 20°) of the big toe at the latest follow-up recurred in 10 (32%), 9 (60%), and 16 (100%) patients in the PP, PR, and RR groups, respectively. A revision surgery was performed in one patient each in the PP and PR groups. Conclusions: Joint-preserving surgery is superior to resection arthroplasty in preventing function loss and the recurrence of hallux valgus.

Patient-Reported and Radiographic Outcomes of Joint-Preserving Surgery for Rheumatoid Forefoot Deformities: A Retrospective Case Series with Mean Follow-up of 6 Years

BACKGROUND

Rheumatoid arthritis (RA) is an autoimmune disorder and a chronic inflammatory disease that can damage joints throughout the body. As dramatic improvements in medical treatment have contributed to reduced progression of joint destruction, surgical methods for the treatment of RA-related forefoot deformities have gradually changed from joint-sacrificing to joint-preserving. The aim of this study was to assess the long-term outcomes, including patient-reported outcomes, of joint-preserving surgery for forefoot deformities associated with RA.

METHODS

This retrospective study included 105 feet in 89 patients with RA who were treated during the period of January 2012 to May 2015 and had a minimum of 5 years of follow-up (mean, 6.0 ± 0.9 years). The patient-reported outcome measure used was the Self-Administered Foot Evaluation Questionnaire (SAFE-Q), which was completed preoperatively and at the latest follow-up (n = 53 feet). The hallux valgus angle (HVA), the intermetatarsal angle (IMA), and the position of the medial sesamoid were measured preoperatively, at 3 months postoperatively, and at the latest follow-up. Cases of delayed wound-healing, hallux valgus recurrence, nonunion at the osteotomy sites, and reoperation were recorded. Kaplan-Meier survival curves were used to determine the estimated survivorship, with reoperation as the end point.

RESULTS

Scores of all 5 subscales of the SAFE-Q demonstrated significant improvement at the latest follow-up. The average HVA and IMA decreased significantly 3 months postoperatively, and these measurements remained significantly lower than the preoperative values (p < 0.01). The position of the medial sesamoid at the latest follow-up improved significantly (p < 0.01). Delayed wound-healing was found at the site of surgery in 21 (20.0%) of the 105 feet. Recurrence of hallux valgus was observed in 11 (10.5%) of the feet. There was no case of nonunion at any osteotomy site. Eleven (10.5%) of the feet required reoperation. The estimated survivorship of the studied joint-preserving surgery at 7 years, with reoperation as the end point, was 89.5%.

CONCLUSIONS

Satisfactory long-term patient-reported and radiographic outcomes after joint-preserving surgery for forefoot deformities associated with RA can be achieved.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical Management of Monoarticular Rheumatoid Arthritis of the Fifth Metatarsophalangeal Joint

OBJECTIVE

To investigate the clinical and radiological outcomes in patients with monoarticular rheumatoid arthritis of the fifth metatarsophalangeal joint after Weil osteotomy.

METHODS

From July 2011 to September 2015, 18 feet of 16 rheumatoid arthritis patients who underwent Weil osteotomy of the fifth metatarsal toe with a mean age at the time of surgery of 48.8 ± 7.4 years were reviewed retrospectively. The mean disease duration was 44.6 ± 6.8 months, and the follow-up period was 36 months. Clinical outcomes were evaluated according to the American Orthopaedic Foot and Ankle Society lesser metatarsophalangeal interphalangeal scale (AOFAS), 10-item SF-36 physical functioning and 2-item SF-36 bodily pain, Visual Analogue Scale (VAS), and satisfaction scores. In the radiologic evaluation, fifth metatarsophalangeal angle (MTP-5), lateral deviation angle (LDA), and longitudinal axes of the fifth metatarsal were measured on anterior-posterior (AP) weight-bearing radiographs preoperative and at the last follow-up.

RESULTS

Clinical assessment showed that the total average of AOFAS was significantly increased from preoperative 53.6 ± 9.0 to 98.7 ± 2.0 points, and the VAS score was significantly decreased from preoperative 4.1 ± 1.5 to 1.1 ± 0.8 points at the last follow-up (P < 0.001). The total averages of SF-36 physical functioning and SF-36 bodily pain were significantly increased from preoperative 48.9 ± 9.0 to 99. ± 2.1 and from 61.4 ± 12.1 to 99.4 ± 2.4 points, respectively, at the last follow-up (P < 0.001). Subjectively, the excellent outcome of the surgery results were rated by 13 patients (81.3%) that underwent surgery and three patients (18.7%) were rated as good. Regarding radiographic parameters, the mean MTP-5 significantly decreased from 21.5° ± 1.2° preoperatively to 10.2° ± 1.2°, the mean LDA significantly decreased from 7.1° ± 1.2° preoperatively to -2.4° ± 1.0°, and the mean length of the fifth metatarsal was significantly shortened from 71.5 ± 1.4 preoperatively to 67.8 ± 1.5 mm at the final follow-up visit (P < 0.001). No malunion, nonunion, necrosis, pseudoarthrosis, or fracture of the fifth metatarsal was found. No exuberant bone growth, perforation of the screw, subluxation, or dislocation was observed. No indications of modification, revision or repeat surgery, or delayed wound healing were observed during follow-up period.

CONCLUSION

Surgical management of the monoarticular rheumatoid arthritis of the fifth metatarsophalangeal joint can achieve good clinical and radiological outcomes, with pain relief and dislocation reduction, as well as high satisfaction and improvement without recurrence or progression during the follow-up period.

Preoperative radiographic and clinical factors associated with postoperative floating of the lesser toes after resection arthroplasty for rheumatoid forefoot deformity

Background

This study aimed to clarify the characteristics associated with postoperative floating of the lesser toes, especially focusing on the medial and lateral lessor toes, after arthrodesis of the first metatarsophalangeal joint and resection arthroplasty of the lessor toes in rheumatoid forefoot deformity.

Methods

Fourty-seven feet of 43 people who underwent resection arthroplasty of the metatarsal head of the lesser toes for rheumatoid arthritis of the metatarsophalangeal joints were included. We retrospectively evaluated the preoperative radiographic findings and clinical characteristics of the patients, and the occurrence of postoperative floating of the lesser toes. The mean duration of follow-up was 36.5 (range 12 to 114) months.

Results

Preoperative dislocation grades of the second and third toes that demonstrated postoperative floating were significantly higher than those of toes that did not experience postoperative floating. The hallux valgus deformity before surgery was significantly more severe in toes with postoperative floating of the second and third lessor toes than those with no floating (p < 0.05). In addition, the Japanese Society for Surgery of the Foot (JSSF) hallux scale scores before surgery in toes with postoperative floating of the fourth and fifth lessor toes were significantly worse than those in non-dislocating toes (p < 0.05).

Conclusions

The preoperative condition of the first metatarsophalangeal joint, including hallux valgus deformity, pain, range of motion, activity of daily living, and function is significantly different between postoperative floating of the lesser toes and non-floating of them after resection arthroplasty for rheumatoid forefoot deformity.

Outcomes of Resection and Joint-Preserving Arthroplasty for Forefoot Deformities for Rheumatoid Arthritis

BACKGROUND

We investigated the clinical outcomes of resection and joint-preserving arthroplasty for forefoot deformities in patients with rheumatoid arthritis.

METHODS

Sixteen feet of 14 women (average age, 67.1 years; range, 53-82) underwent resection arthroplasty of the metatarsal head (resection group), and 18 feet of 15 women (average age, 61.3 years; range, 40-73) underwent a metatarsophalangeal joint-preserving procedure with shortening oblique metatarsal osteotomies of the lesser toes (joint preservation group). The mean disease duration in the resection and joint preservation groups was 23.6 and 19.1 years, and the average follow-up period was 37.3 and 33.5 months, respectively. The classification of Larsen was used to assess the severity of destruction of the metatarsophalangeal (MTP) joint. Preoperative and postoperative clinical evaluation included Japanese Society for Surgery of the Foot (JSSF) score and postoperative complications.

RESULTS

The number of preoperative radiographic destruction of the MTP joints (Larsen grade II, III, IV, and V) was 0, 29, 39, and 12 joints in the resection group and 13, 67, 9, and 1 joints in the joint preservation group. The mean JSSF score improved significantly from 61.3 to 83.9 points in the resection group ( P < .001) and from 62.2 to 90.8 points in the joint preservation group ( P < .001). In the resection group, recurrence of callosities and claw toe deformity was observed in 6 and 3 feet, respectively. In the joint-preserving group, recurrence of callosities and hammer toe deformity was observed in 1 foot each.

CONCLUSION

The resection arthroplasty and joint-preserving procedure showed satisfactory clinical outcomes. However, whether both procedures can maintain the good clinical results without the recurrence of forefoot deformity will require longer follow-up.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Fusion of the First Metatarsophalangeal Joint and Second to Fifth Metatarsal Head Resection for Rheumatoid Forefoot Deformity

The goals of the present study were to evaluate the mid-term results of first metatarsophalangeal joint fusion combined with second to fifth metatarsal head resection in rheumatoid forefoot deformity and identify the prognostic factors. The inclusion criteria were 2010 American College of Rheumatology and/or European League Against Rheumatism criteria for rheumatoid arthritis; symptomatic forefoot deformity; first metatarsophalangeal joint fusion and second to fifth metatarsal head resection; and a minimum of 4 years of follow-up data available. The patients were evaluated using the Disease Activity Score 28 for rheumatoid arthritis, Health Assessment Questionnaire for Rheumatoid Arthritis, Foot Function Index, forefoot American Orthopaedic Foot and Ankle Society scale, and weightbearing radiographs. Different pre-, intra-, and postoperative variables were investigated to identify the prognostic factors. Sixty-two patients (89 feet) with a mean age of 60.8°± 9.4 years and 85.5°± 22.4 months of follow-up data were included. The preoperative American Orthopaedic Foot and Ankle Society scale score was 33.4 ± 16 points and improved significantly (p < .001) after surgery (mean 82.9 ± 11.7 points). The mean Foot Function Index improved significantly (p < .001) from 131.6 ± 37.4 to 77.4 ± 46.3 points at the last follow-up visit. Only the revision surgery variable was significantly (p = .02) related to poor outcomes. Revision was necessary in 8 feet (9%). This procedure produced satisfactory results. Poor outcomes were significantly related to the necessity for revision surgery for nonunion, malunion, inadequate metatarsal resection, and painful hardware.

[Rheumatic forefoot deformities]

The frequency and extent of rheumatic forefoot deformities have been greatly reduced since the introduction of disease-modifying antirheumatic drugs (DMARD). The accompanying reduction in arthritic destruction of joints opens up new treatment options whereby priority is given to joint preservation. This is true for the first middle foot ray as well as for the small toe rays. Whereas resection arthroplasty of the metatarsophalangeal joints II-V was previously considered the gold standard treatment, joint-preserving operative procedures (e.g. metatarsal osteotomy and periarticular soft tissue interventions) are now being increasingly more propagated. Resection arthroplasty of the first midfoot ray has major biomechanical disadvantages so that it is not surprising that reconstructive procedures are given priority. In patients with severe arthritic destruction of the first metatarsophalangeal joint, arthrodesis has substantial biomechanical advantages compared to resection arthroplasty. Nevertheless, it has not yet been confirmed that fusion leads to superior clinical results.

The Influence of the Length of the First Metatarsal on the Risk of Reulceration in the Feet of Patients With Diabetes

Our aim was to identify the optimal diagnostic cutoff point on the scale of protrusion measurements of the first metatarsal (M1) to predict the probability of reulceration after metatarsal head resection in patients with diabetes mellitus. We conducted a prospective study of patients with diabetes who underwent resection of at least 1 metatarsal head in our department. After surgery, we measured the difference in length (protrusion) between the M1 and the longest of the 4 lesser metatarsals by radiographic view. The patients were divided into those in whom the M1 was the longest of the 5 metatarsals (group 1) and patients in whom at least one of the lesser metatarsals was longer than the M1 (group 2). They were followed-up for 12 months and were assessed for reulceration. Ninety-one patients were included in the present study: 43 (47%) in group 1 and 48 (53%) in group 2. In group 1, the longer the protrusion of M1 was, the higher the probability for reulceration ( P < .001, 95% confidence interval = 0.813-0.997). In group 2, the shorter the protrusion of M1, the higher the probability for reulceration ( P = .002, 95% confidence interval = 0.628-0.905). The optimal cutoff point for group 1 was 11 mm (sensitivity = 84.6%, specificity = 86.7%) for the probability of reulceration. In group 2, it was −7 mm (sensitivity = 81.8%, specificity = 65.4%). These results suggest that M1 protrusion is an optimum prognostic indicator for reulceration and could be recommended for detecting patients at risk of reulceration after surgery.

The rheumatoid forefoot

Rheumatoid arthritis (RA) manifests itself in a variety of ways, with its effect being seen in around 90 % of sufferers' feet. The foot has been found to be the most common reason for incapacity in patients with RA, with the forefoot the most common area. The foot is second, behind only the hand, as the most common place for manifestation of RA. Pain in the foot is commonly the most debilitating condition, which causes the patient to seek specialist help. As well as pain, foot deformities such as hallux valgus and claw toes are common complaints. These symptoms often arise as a result of continued walking on an unstable foot, leading to painful callosities and dislocation of the metatarsophalangeal joints. Other conditions, such as pannus formation and Morton's neuroma, can be related to RA. This review sets out what we believe to be a successful approach to the rheumatoid forefoot, which aims at the relief of pain and the preservation of ambulation. Key to a successful outcome is appropriate medical control with a multidisciplinary approach that enables close liaison between orthopaedic surgeons, orthotists, and rheumatologists. Combined clinics provide this multidisciplinary care. Those treating RA need to be aware of the high incidence of foot involvement and how early intervention may benefit the patient. The aim of this article is to present current evidence to enable people to develop a treatment algorithm for this condition.

Radiographic and clinical outcomes of joint-preserving procedures for hallux valgus in rheumatoid arthritis

BACKGROUND

The standard treatment for hallux valgus in rheumatoid arthritis has been arthrodesis of the first metatarsophalangeal (MTP) joint. There is limited literature regarding the results of hallux valgus procedures which preserve the first MTP joint in rheumatoid patients. We investigated the radiographic and clinical outcomes of joint-preserving surgery for hallux valgus in a series of rheumatoid patients to evaluate the result of nonarthrodesis reconstruction.

METHODS

Thirty-seven feet with hallux valgus in 27 patients with RA treated with a joint-preserving procedure of the first MTP joint were analyzed radiographically and clinically. Average follow-up was 42 (range, 12-111) months. Twenty feet had Ludloff osteotomies, 15 had scarf osteotomies, and 2 had chevron osteotomies. Radiographs were evaluated preoperatively and postoperatively for hallux valgus angle, 1-2 intermetatarsal angle, and degenerative narrowing of the first MTP joint based the Sharp score and the Larsen grade. Narrowing of the first interphalangeal (IP) joint was based on a modification of the classification of Hattrup and Johnson. Operative complications and required secondary surgeries were tabulated. Clinical outcomes were measured using preoperative and postoperative Short Form-36 (SF-36), AOFAS forefoot scale, and Visual Analogue Scale (VAS) pain questionnaires.

RESULTS

The average hallux valgus angle improved from 37 degrees preoperatively to 15 degrees postoperatively. The average 1-2 intermetatarsal angle improved from 14 degrees preoperatively to 5 degrees postoperatively. The average Sharp score of the first MTP joint was 0.9 preoperatively and 1.6 postoperatively. The average Larsen grade of the first MTP joint was 0.6 preoperatively and 1.4 postoperatively. Range of motion of the first MTP joint was essentially unchanged between preoperative and postoperative measurements. Seven of 37 feet had progression of first IP joint space narrowing, but none were symptomatic. The AOFAS score improved from 45.2 preoperatively to 82.6 at final follow-up (P value < .01). The VAS decreased from 4.8 preoperatively to 1.5 at final follow-up (P value < .02). The SF-36 physical component score decreased from 40.3 preoperatively to 37.4 at final follow-up, and the mental component score remained unchanged, and neither was statistically significant. There were 7 feet (19%) that required a return to surgery: 3 wound infections, 2 arthrodeses for progression of deformity, and 1 each for revision for recurrence and hardware removal.

CONCLUSION

Rheumatoid arthritis patients who undergo a bunionectomy rather than arthrodesis to preserve the first MTP joint have satisfactory clinical and radiographic outcomes. This procedure appeared to be a reasonable alternative to first MTP arthrodesis in patients with relatively preserved joints.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Midterm results of resection arthroplasty for forefoot deformities in patients with rheumatoid arthritis and the risk factors associated with patient dissatisfaction

We investigated the midterm results of resection arthroplasty of all 5 metatarsal heads in patients with rheumatoid arthritis and forefoot deformity and analyzed the factors that affect patient satisfaction levels. Of 64 patients (1 male, 63 females), 107 feet were treated with resection arthroplasty for forefoot deformity at our hospital from January 1992 to December 2005. The mean follow-up period was 5.8 ± 3.1 years, with all patients having at least 1 year of follow-up. Of the 64 patients, 75% were satisfied with the surgery. The mean score for the postoperative Japanese Society for Surgery of the Foot lesser metatarsophalangeal-interphalangeal scale was 75.0 ± 15.8 points. Multivariate logistic regression analysis showed that patient-reported dissatisfaction was significantly associated with the recurrence of hammer toe deformity (odds ratio 2.66, 95% confidence interval 1.07 to 6.97), shortening of the resection arthroplasty space (odds ratio 0.85 for a 1-unit increase, 95% confidence interval 0.74 to 0.96), and the recurrence of hallux valgus (odds ratio 1.04 for a 1-unit increase, 95% confidence interval 1.00 to 1.09) during the postoperative period. From our results, interventions to prevent recurrence of hammer toe deformity, especially in toes with preoperative metatarsophalangeal joint dislocations, have been shown to be important in preventing complications and patient dissatisfaction after resection arthroplasty.

Rheumatoid forefoot deformity: pathophysiology, evaluation and operative treatment options

Despite recent advances in pharmacological management of rheumatoid arthritis, forefoot deformity, with its symptoms, remains a common problem, often requiring operative treatment. Typical deformities in these patients comprise hallux valgus and deformity of the lesser metatarsophalangeal (MTP) joints and toes. With regard to the lesser rays the standard operative procedure, advocated for the disabling forefoot pain in these patients, remains metatarsal head resection. It should be considered that with increasing success of pharmacological treatment the degree of forefoot deformity in these patients is becoming less and that resection of the lesser MTP joints is becoming more and more superfluous. This supports a trend towards metatarsal head-preserving surgery. The optimal treatment of the hallux deformity remains unclear. Fusion of the first MTP joint is, generally, recommended. This article will discuss the current surgical options in rheumatoid forefoot pathology.

Hammertoes/Clawtoes: metatarsophalangeal joint correction

Clawing of the lesser toes is not uncommon, can arise from a number of causes, and is often associated with other forefoot abnormalities. There is still some confusion in the nomenclature of lesser toe deformities affecting the MTPJ and PIPJ although the resulting deformities are probably part of the same pathologic process and thus treated in a similar manner. Many will be successfully treated with nonoperative methods, but if they fail a number of surgical options are available depending on the severity of the deformity and whether the deformity is fixed or flexible. Correction at the MTPJ can be achieved using a stepwise progression of soft-tissue procedures alone, bony procedures, or a combination of both.

Digital surgery: current trends and techniques

Digital deformities continue to be a common ailment among many patients who present to foot and ankle specialists. When conservative treatment fails to eliminate patient complaints, surgical correction remains a viable treatment option. Proximal interphalangeal joint arthrodesis remains the standard procedure among most foot and ankle surgeons. With continued advances in fixation technology and techniques, surgeons continue to have better options for the achievement of excellent digital surgery outcomes. This article reviews current trends in fixation of digital deformities while highlighting pertinent aspects of the physical examination, radiographic examination, and surgical technique.

Metatarsalgia

Metatarsalgia (ie, metatarsal pain) is one of the most common reports in patients with foot problems. This pain is confined to the area across the plantar forefoot, including the second through fourth metatarsal heads. However, it is frequently accompanied by deformity of the first and fifth rays as well as of the toes. There is great variability in possible causative factors, but all of them seem to be related to gait mechanics, foot anatomy, and foot and ankle deformity. An individualized treatment protocol is required. Nonsurgical management is usually sufficient to achieve satisfactory results. Surgical correction must be precise, and all pain-producing deformities must be corrected. Most patients present with abnormalities of the distal metatarsals. Metatarsal osteotomy, long a staple of treatment, always fails in the long term. Improved equipment and internal fixation methods may lead to better long-term outcomes.

Surgery of the lesser toes in rheumatoid arthritis: metatarsal head resection

This review article discusses the pathologic and anatomic basis of rheumatoid lesser toe deformities. It covers the history of lesser metatarsal head resection being used in its treatment and the theoretic basis behind differing techniques and their relative results and complications. The authors also present their preferred technique for lesser metatarsal head resection.