Surgery of the rheumatoid foot: preferable procedures.

Management of patients who have rheumatoid arthritis is best accomplished by a team approach utilizing the help of the family physician, the rheumatologist, the physical therapist and the orthopaedist. Such an approach insures careful screening and proper selection of those who can be helped by surgical procedures. Those who have painful feet welcome surgical intervention if nonoperative methods do not furnish relief. The forefoot is often involved and severe deformities of the metatarsophalangeal joints with painful plantar calluses are frequent. The deformities can be corrected and the calluses prevented or relieved by an operation that does not shorten the metatarsals. Such preserves and restores better function of the foot. After tenotomy of the extensor tendons and resection of the proximal portion of the proximal phalanges the plantar condyles of the metatarsals are excised and the remainder of the head is smoothed but not excised. The distance of the heel to metatarsal head strike during standing and walking is not shortened by this procedure. In some rheumatoid patients who have severe hallus valgus but minimal involvement of the interphalangeal joint the push off function of the great toe that is so important when walking can be preserved by arthrodesis in the correct position of the metatarsophalangeal joint. Arthrodesis of the talonavicular joint before fixed deformities develop in the hindfoot is a procedure that relieves pain and prevents progressive valgus deformity of the hindfoot. Other arthrodesing procedures are indicated occasionally. It must be remembered by the surgeon and thoroughly explained to the patient that activity of the rheumatoid process militates against the results from surgery and that corrected deformities and pain may recur if the disease progresses.