RHEUMATOID FOREFOOT RECONSTRUCTION
The repair of the great toe and lesser toes in a patient with rheumatoid arthritis has two components, fusion of the MP joint and lesser toe correction.
Fusion of the hallux MTP joint
What is it?
This operation is designed to glue (fuse) the big toe joint together. It is also called an arthrodesis of the big toe or metatarsophalangeal joint (MTP). This is a very commonly performed operation for arthritis and deformity of the big toe (severe bunions) joint and sometimes in conjunction with other toe deformity corrections.
Arthritis of the MTP joint implies that there is no cartilage left and bone on bone grinding is occurring causing swelling, pain and deformity which is not salvageable and the body is in the process of fusing this joint which may take months to years.
Surgical fusion speeds up this process and the toe is positioned according to the need to roll off the big toe, exercise or the desire to wear different types of shoes including high heel shoes.
Once fused, the big toe does not move except at the end joint.
Once fusion is successful, you will be able to wear most shoes, including a high heel if desired of about 3 cm.
There are no limits to exercise activities after the fusion, including all sports and running.
Resection? Osteotomies of the lesser metatarsal heads
What is it?
This operation is designed to eliminate the pain under the bottom of your forefoot which may present as thickened skin at the front of the foot and a sensation of walking on a stone.
Depending on the age of the patient and degree of joint destruction I will either cut the bones and shift them (shortening Weil or MACEIRA osteotomy) or remove them completely (excision arthroplasty) and place surrounding soft tissue in between the toe and the metatarsal as a pseudo joint through an incision on the top of the foot.
If there are fixed deformities of the lesser toes keyhole fusions of the various interphalangeal joints may need to be performed.
You will usually have wires that exit out of your toes 2,3,4 and 5.
These will be removed in the office at 6 weeks.
There is no pain involved in removing the pins.
General Recovery Facts
- You are able to walk on the heel of the foot 7 days after surgery to pain and swelling.
- You must wear your surgical shoe at all times until the joint is fused.
- You may not walk on the bare foot at all even in the house without this shoe.
- You may drive as soon as comfortable, usually after about 14 days, however this is not advised unless driving is absolutely necessary and no traffic is anticipated.
- The surgical shoe is worn for 6-8 weeks.
- Limited exercise that does not involve any bending of the big toe joint is allowed at about 6 weeks after surgery and once all wires have been removed.
Before & After Pics
Specific post-operative recovery
- Foot wrapped in bulky bandage and surgical shoe.
- Do not remove surgical shoe – even at night.
- Start walking on heel and outside of the foot if needed and for bare necessities such as hygiene, mobilising onto and off the bed and or couch.
- Ice, elevate, take pain medication as prescribed.
- Expect numbness in foot 12-24 hours then pain.
- Blood drainage through bandage is expected, do not panic unless continuous bleeding occurs.
- Do not change bandage under any circumstances, contact my rooms before any such thoughts cross your mind.
- First follow-up in the office, X-rays taken if any incidents have occurred (falls, pain out of proportion, recurrence).
- Wound inspection with dressing Sister.
- Most of the time absorbable sutures are used and these do not need to be removed and will dissolve with time.
- Dressing changed.
- Bunion sleeve/strapping supplied for the next 4-6 weeks.
- Wound therapy commences with micropore and Bactroban dressings for the next 4-6 weeks.
- Second follow up at 6 weeks.
- K-wires are removed.
- Weight-bearing control x-ray at 6 weeks.
- Continued use of flat post operative shoe.
- Physiotherapy commences once wires are removed as this is helpful in decreasing the swelling of the foot and improving range of motion for the next 1-2 months.
- Expect swelling in the foot for about 6 to 9 months.
- Massage of the scar on the top of the foot is important 3 times a day for 10 minutes at a time in order to prevent contracture of the scar which may lift the toes or cause sensitivity of the scar.
- This massage should continue for about 1 month.
- Physical therapy may be useful for about 1 month.
- Third followup in rooms at 12 weeks with weight-bearing control x-ray.
- Light nonimpact exercise may commence to pain and swelling after initial 6 weeks.
- Sneakers with a straight medial border and supportive sole.
- Discontinuation of toe strapping.
- Continued range of motion exercises.
- Sometimes it may be necessary for a computer gait analysis of the foot to be performed, and possibility of orthotics discussed at this point.
- Six-month followup in consultation with weight-bearing control x-ray.
- Pictures taken for comparison to preoperative state.
- Functional outcome score taken.
- 1 year followup in consultation rooms with weight-bearing control x-ray.
- Pictures and video taken for comparison to preoperative state.
- Functional outcome score taken.