Resection or Preservation of the Metatarsal Heads in Rheumatoid Forefoot Surgery? A Randomised Clinical Trial

SLR - November 2019 - Alexus G. Cox

Reference: Schrier JC, Keijsers NL, Matricali GA, Verheyen CCPM and Louwerens JWK. Resection or Preservation of the Metatarsal Heads in Rheumatoid Forefoot Surgery? A Randomised Clinical Trial. Foot Ankle Surgery Feb;25(1):37-46. doi: 10.1016/j.fas.2017.07.1126.

Scientific Literature Review

Reviewed By: Alexus G. Cox, DPM
Residency Program: Ascension – Milwaukee, WI

Podiatric Relevance: To compare the clinical and radiographic results of metatarsal head resection versus preservation in patients with rheumatoid arthritis.

Methods: Patients 18 to 85 years of age with rheumatoid arthritis associated with forefoot deformity including presence of erosive changes. The current study had a randomized control design and eligible patients were randomly assigned to undergo first metatarsal phalangeal joint arthrodesis with either resection or preservation of the lesser metatarsal phalangeal joints. Patients were then clinically and radiographically assessed at postoperative month three and one year.

Results: Twenty-three patients were analyzed in this study, 10 underwent the metatarsal head preservation and thirteen metatarsal head resection. Clinical assessment at one year follow up found a decrease of the VAS pain score and FFI subscales with an increase in SF-36 and AOFAS score for both groups. The postoperative complication rate was equivalent between the two groups. Radiographic evaluation with both groups showing overall adequate lesser metatarsal alignment, with the exception of one patient with lesser MTPJ dislocation noted post operative after metatarsal head preservation procedure. One patient with metatarsal head resection lead to a nonunion arthrodesis and one patient with metatarsal head preservation lead to malaligned fusion site.

Conclusions: There is debate and lack of clear, well developed literature on the comparison of joint preservation versus destruction in patients with rheumatoid arthritis undergoing forefoot elective surgery. Overall from this study it can be concluded that there is no clinical or radiographic difference in terms of pain control for these patients dependent on the procedure of choice. Both joint preservation and destruction are options for patients with rheumatoid arthritis undergoing forefoot reconstruction surgery.