Arthritis

of the Forefoot
 Rheumatoid Arthritis
• Epidemiology
– Autoimmune Disorder Affects 1 - 2% of
Population (2.1 Million Individuals)
– Female : Male = 3 : 1
– HLA-DRW4 Haplotype in 80% of affected
individuals
– Increased frequency in family & twin studies
– Common Virus or Bacterium Probably triggers
disease process
 Rheumatoid Arthritis:
Early Articular Disease
• History
– Morning stiffness lasting 1-2 Hours
– Tenderness & Soft tissue swelling of hands &
feet common (symetric)
– 85% of patients with RA have foot involvement
– Forefoot Involvement is initial complaint in
35% (MTP Most Common)
 Rheumatoid Arthritis:
Early Articular Disease
• Histology
– Synovial Hyperplasia & Hypertrophy
– Infiltration of Lymphocytes, Plasma Cells &
Macrophages
– Russell bodies, lymphoid Follicles & fibrinous
exudate
– Inflammatory Cytokines : TNF-alpha, IL-1, IL-
8, GM-CSF Rheumatoid Arthritis
 Rheumatoid Arthritis:
Chronic Articular Disease
• Chronic inflammation leads to destruction of
cartilage, bone & ligamentous restraints
• Loss of Motion, Muscle Wasting & Fibrosis of
Joints is common
• Medications contribute to osteopenia & wasting
of soft tissues
 Rheumatoid Arthritis:
Chronic Articular Disease
• Histology
– Pannus Formation
– Destruction of Cartilage
– Periarticular Erosion
– Bony & Fibrous Ankylosis
 Rheumatoid Arthritis:
Laboratory Diagnosis
• Rheumatoid Factor: 75% Positive
– Autoantibody to IgG
• Acute Phase Reactants Elevated
– ESR
– CRP
 Rheumatoid Arthritis:
Treatment
• Anti-Inflammatory Medications
– NSAID’s & Prednisone
• Disease Modifying Agents (Immunosuppressive)
– Methotrexate, Sulfasalazine, Cyclosporine
• Anti-Cytokine Agents (New)
– Anti-TNF Alpha agents
• Etanercept & Infliximib
– Anti- Interleukin Drugs
• Under development
 Rheumatoid Arthritis:
Disease of Forefoot
• Hallux
– Hallux Valgus – Most Common
– Hallux Rigidus
– Hallux Varus (Uncommon)
 Rheumatoid Arthritis:
Disease of Forefoot
• Lesser Toes
– Synovitis of the MTP’s Common (Early)
– Progresses to
• Dorsiflexion Contraction of MTP
• Hammering & Clawing of Toes
• Dorsal Migration of Fat Pads
Radiographic Findings with RA
Forefoot Deformity
 Rheumatoid Arthritis:
Disease of Forefoot
• Extra-articular Involvement
– Rheumatoid Nodules (Flexor or Extensor
Tendons)
– Ischemic ulceration with longstanding disease
– Felty’s Syndrome (RA, Splenomegally,
Leukopenia in longstanding disease)
• Ulcerative lesions of the legs & feet
 Rheumatoid Arthritis:
Disease of Forefoot
• Conservative Treatment Options
– Modification of medications
– Shoe Modification
• Extra-Depth, wide toe box
• Plastizote Orthotics with MT pad
• Rocker Bottom Shoe
• AFO to control hindfoot if necessary
 Rheumatoid Arthritis:
Disease of Forefoot
• Surgical Indications
– Pain & Deformity which cannot be controlled
with medication & shoe modifications
- Early disease may be treated by synovectomy
(Especially Lesser MTP’s)
- Excision of prominent/painful rheumatoid
nodules is indicated
Painful Rheumatoid Nodules
 Rheumatoid Arthritis:
Disease of Forefoot
• Surgical Treatment of the Hallux
– Arthrodesis – best choice for most patients
• Stability for Gait & Push Off
• Prevents Recurrence of Deformity
• Stabilizes Lesser Toes & Fat Pad
• Disadvantages:
– Fusion may be delayed with Medications
– Poor Bone stock may make fixation
difficult
Rheumatoid Forefoot
Reconstruction
Pre-Op Post-Op
 Rheumatoid Arthritis:
Disease of Forefoot
• Surgical Treatment of Hallux
– Resection Arthropolasty
• Sedentary & Low Demand Patients
• Problems
– Recurrence of deformity
– Development of other Deformity (Cock-
Up, Varus or Valgus)
– Implant Arthroplasty
• Problems : Loosening, Silicone Synovitis,
Difficult to salvage, high failure rates
 Failed Hallux MTP Implants
Failed Metal/Plastic Implant

Failed Silicone
 Rheumatoid Arthritis:
Disease of Forefoot
• Surgical Treatment of Lesser Toes
– Goals are reduction of subluxed/dislocated
MTP’s & Correction of IP contractures
– Resection of lesser MT heads often necessary
– Closed osteoclasis of IP deformity vs resection
arthroplasty to straighten toes
 Seronegative
Spondyloarthropathies
• Ankylosing Spondylitis
• Psoriatic Arthritis
• Reiter’s Syndrome
Treatment Similar to RA
 Ankylosing Spondylitis
• High incidence of HLA-B27 Genotype (95%)
– Typically young male at presentation
• Inflammation of Ligament, Tendon & Capsular Insertion
Points.
• Axial Symptoms Predominate
– Bamboo Spine, SI ankylosis
• Extraskeletal Manifestations
– Cardiac conduction defects, Apical Pulmonary
Fibrosis, Unilateral Ocular Inflammation
 Ankylosing Spondylitis:
Foot & Ankle Disease
• Dactylitis – fusiform enlargement of single
digit (Sausage Digit)
• Metatarsalgia
• Perimalleolar Tenderness
• Plantar Fasciitis
 Psoriatic Arthritis
• Whites > Blacks, Males = Females
• Increased Frequency of HLA B27 & HLA B29
• 7% of Patients with Psoriasis develop arthritis
• Medications similar to RA management
 Psoriatic Arthritis:
Foot & Ankle Disease
• Psoriatic Lesions on dorsal skin of foot common
• Pitting of Nails
• “Pencil in cup” deformity seen at phalanges (arthritis
mutilans)
• “Ray Phenomena” somewhat unique to Psoriatic
Arthritis where MTP, PIP & DIP are involved in one
digit with relative sparing of the remaining digits.
Psoriatic Skin Lesions
Arthritis Mutilans -
“Pencil In Cup”
 Reiter’s Syndrome
• Reactive arthritis which follows subclinical
Genitourinary or Gastrointestinal infections
• GU form associated with Chlamydia trachomatis
• GI form associated with Shigella, Salmonella, Yersinia
or Campylobacter
• 96% with HLA-B27, 50% with Foot & Ankle involved
 Reiter’s Syndrome
• GU Reiter’s usually presents with the classic triad
“Urethritis, Uveitis, Oligoarthritis”
– Symptoms usually start about 1 month after
infection
– Culture of Urethra will make diagnosis
• Dysenteric Reitier’s affects Spine & SI joints
more frequently
 Reiter’s Syndrome:
Foot & Ankle Disease
• Plantar Fasciitis & Insertional achilles tendonitis
are common (“Lover’s Heel”)
– Fluffy Calcification at insertion of Achilles &
Origin of Plantar Fascia
• “Sausage Toe” – Dactylitis common
• Demineralization of DIP joints
Reiter’s Syndrome
Crystal Induced Arthropathy
• Gout – Monosodiumurate (MSU) Crystals
• Males > Females
– Females rarely present with gout before
menopause
• MSU is the end stage of purine metabolism
• MSU precipitates when concentration > 6.8mg%
 Gout
• Accumulation of MSU crystals occurs in:
– Overproducers
• Diet rich in purines (organ meats, cheese)
• Chemotherapy
• Alcohol
– Underexcreters (Diminished renal excretion)
• Renal failure
• Salilcylates
• Thiazide diuretics
• Cyclosporine
 Gout:
Acute Attack
• Symptomatic, abrupt monoarthritis
• MTP joint most common (Any joint can be affected)
• Clinically looks like septic joint
• DX: Aspirate Joint & Look for MSU Crystal
– Negatively birefringent (yellow) needle shaped crystal
• Hyperuricemia need not be present!
 Gout:
Acute Attack
• Treatment :
– Oral NSAID – diminishes cellular response & stops
acute attack within 24 hours
– Prednisone –Also very effective
– I.V. Colchicine – Microtubule inhibitor
• Previously popular for acute attack
• Diminished enthusiasm due to side effects
– Extravasation causes severe tissue necrosis
– Myopathy
– Bone marrow suppression
– Nausea, Vomiting
 Gout:
Chronic Disease
• Tophaceous Deposits – large collection of MSU
crystal which may erode into bones
• Periarticular Erosions visible on X-Ray
• Extra-articular effects:
– Renal : Interstitial nephritis can lead to renal
failure
– large staghorn calculi cause obstructive
uropathy
Chronic Tophaceous Gout
 Gout:
Chronic Disease - Treatment
• Medical Management
– Diet
• Avoidance of Alcohol
• Weight reduction
• Purine free diet
• Avoidance of Thiazides, Salicylates
• Medication
• Allopurinol – inhibits xanthine oxidase & lowers
MSU production
• Probenecid – Limits tubular resorbtion of MSU in
kidney
 Gout:
Chronic Disease - Treatment
• Large tophaceous gout without significant joint
destruction
– Debridement of tophus and irrigation of joint if
symptoms warrant
• Degenerative Arthritis of MTP
– 1st MTP Arthrodesis
– Resection Arthroplasty (Older, low demand)
 Pseudogout
• Calcium Pyrophosphate Crystal (CPP)
– Rhomboid, Positively birefringent (blue) crystals
• Similar presentation to acute gouty attack
• Knee more commonly affected than foot
– Radiographs with chondrocalcinosis
• Aspiration may abort attack
• Treat with NSAID
– (+/-) intraarticular steroid
 Hallux Rigidus:
Arthritis of 1st MTP
• Etiology
– Osteoarthritis (Most Common)
– Post-Trauma
– OCD
– Congenital Flat MT Head
 Hallux Rigidus:
• Physical Examination
– Prominent Dorsal Osteophyte
– Hallux Limitus (Pain with attempted Dorsal
Flexion)
• Conservative Treatments
– Orthotic with Morton’s Extension
– Stiff soled shoe with wide toe box
– Cortisone injection, NSAID
Hallux Rigidus
 Hallux Rigidus:
Surgical Management
• Dorsal Spurring with good joint space
– Dorsal Cheilectomy (Dorsal 1/3 of Head)
– Attain 90 deg dorsiflexion at surgery
– Early Post-Op Motion
– Combination with Moberg Osteotomy
(Proximal Phalangeal Dorsiflexion Osteotomy)
may provide excellent results
Cheilectomy/Moberg

8 Months PO Motion
 Hallux Rigidus:
Surgical Management
• Degenerative changes of entire joint
– 1st MTP Arthrodesis
• Fuse at 15 degrees Dorsiflexion to the floor
• 15 Deg Hallux Valgus Angle (Or to clear 2nd
toe)
• Neutral to slight suppination
Hallux Arthrodesis
 Hallux Rigidus:
Surgical Management
• 1st MTP Arthrodesis : Problems
– Malunion
• Too much Dorsiflexion
– Transfer Lesion to 2nd Metatarsal
– Can’t fit toe comfortably into shoe
• Too Plantarflexed
– IP Joint arthritis
• Pronation
– Uncomfortable weight-bearing on medial
border of hallux or nailbed
 Hallux Rigidus:
Surgical Management
• Resection Arthroplasty – better for low demand
and elderly patients
– Resect proximal 1/3 of proximal phalanx
– May interpose dorsal capsule & dorsal
periosteum into space to maintain length.
– Complications:
• Continued pain from inadequate resection
• Cock-up deformity
• 1st MTP Instability / loss of push off
 Lesser MTP Joint Synovitis
• Any MTP may be affected. Most commonly 2nd &
3rd MTP
• Etiology
– Shoewear (tight forefoot or inappropriate length)
– Tight Achilles
– Inflammatory Arthritis
Lesser MTP Joint Synovitis
• Clinical Findings
– Swollen, tender MTP
– Dorsal subluxation of MTP
– Positive Drawer Sign
– Easily confused with Morton’s Neuroma
• Conservative Therapy
– MT Pads (Hapads or Orthotics)
– Shoe with stiffened sole or forefoot
– Intraarticular Cortisone injection
– NSAID
 Lesser MTP Joint Synovitis
• Surgical Treatment
– Synovectomy
– Dorsal MTP release & relocation if necessary
– Reconstruction of collateral ligaments when
appropriate