Surgery of the rheumatoid forefoot with special reference to the plantar approach

The key to the understanding of rheumatoid forefoot deformities is the predominant joint involvement of the tibial side of the hindfoot, of the fibular tarsometatarsal joints, and the destruction especially of the metatarsal heads. Independent of these patterns, the predominant sources of pain and impaired function, and thus of surgical remedies, remains the metatarsophalangeal joints. The authors prefer forefoot arthroplasty consisting of a judicious resection of the metatarsal heads, plantar capsulorraphy, tenolysis and rerouting of the tendons, through a dorsomedial approach to the great toe basal joint, and through a transverse plantar approach with dermodesis (plastic resection of a plantar wedge of skin and subcutaneous tissue) for the lesser toes. This method yields excellent pain relief that does not deteriorate for at least 15 years. However, 1/2 of the nearly complete postoperative correction was lost again within 10 years, and barefoot walking again became more difficult. Reviewing the literature, one cannot detect a clearcut superiority of plantar versus dorsal approaches, nor of one surgical routine versus another.