Long-term outcome of joint-preserving surgery by combination metatarsal osteotomies for shortening for forefoot deformity in patients with rheumatoid arthritis

Objectives. We report the long-term outcome of joint-preserving surgery by combining metatarsal osteotomies for shortening for forefoot deformity in patients with rheumatoid arthritis (RA). Methods. Forty-three patients (57 feet) aged 41.7-70.8 years (mean, 57.7 years) underwent a combination of first tarsometatarsal fusion and distal realignment (modified Lapidus procedure), shortening oblique osteotomies of the bases of metatarsals 2-4, and fifth ray osteotomy (modified Coughlin procedure). Patients were followed up for 64-108 months (mean, 76.6 months). Results. Average postoperative Foot Function Index scores for pain, disability, and activity were 10.3, 19.9, and 16.2, respectively. Average Japanese Society for Surgery of the Foot RA foot and ankle score improved significantly from 52.1 points preoperatively to 90.3 points postoperatively. Postoperatively, 41% of patients reported some forefoot stiffness, but showed no disability. Residual deformity and callosity were absent in all patients. Average hallux valgus and intermetatarsal angles decreased postoperatively from 48.5 degrees to 8.6 degrees and from 15.2 degrees to 4.6 degrees, respectively. Nonunion in two metatarsals, hardware breakage in three, and mild infection in one were identified during follow-up. Conclusions. With good perioperative medical management of RA, surgical repositioning of the metatarsophalangeal joints by proximal metatarsal shortening and consequent relaxing of the surrounding soft tissue shows successful long-term results.