Adjust Prednisone and Methotrexate dosing in conjunction with patient's rheumatologist pre-operatively. IV antibiotics with Cefazolin. Continuous popliteal catheter infusion. IV sedation. Keller resection 1st MPJ or Swanson total implant 1st MPJ with Trinity orthobiologic stem cell bone graft. Additionally,  I would perform a Met head resection 2-5 with insertion of submetatarsal Graft Jacket for fat pad atrophy. Arthroplasty/arthrodesis/tenotomy/percutaneous pinning as needed, digits 2-5. Admit for 23 hour observation for pain control, PT/OT, walker training, and 2 more doses Cefazolin. Post operatively, PWB as tolerated in CAM walker

—Dan Pero, DPM

This is a patient with RA, DM, and HTN. Patient has difficulty with ambulation and has failed conservative treatment. I would suggest surgical treatment. But, before we want to have a medical clearance and studies to document good blood flow to the foot, this is to avoid healing complications and favor the surgical outcome. After that, I would suggest you perform a 1st MPJ fusion, and lesser met head resections (2-5).

—Jorge Matuk, DPM

The general appearance of the foot is concerning for PVD.  If there is question, Iwould consider vascular workup first.  If exam is consistent with palpable pulses, good cap refill, and a warm foot then i would consider surgery. I would measure the ankle joint dorsiflexion and consider a gastroc recession at minimum (dependant on healing potential of foot from vascular standpoint).  I would address the foot pathology with first MPJ fusion and pan met head resection. For the perioperative period I would ask for rheumatology recommendations but would likely consider complete d/c of methotrexate during immediate perioperative period.

—Kenneth Lopez, DPM

1st MPJ fusion, MT head resection 2-5, check for equinus, and possible TAL or gastroc recession.

—David Smith, DPM

After consulting with her internist for management of her RA meds, I would perform met head resections 2,3,4,5 with PIPJ arthrodesis digits 2,3,and 4. I would most likely perform a 1st MPJ arthrodesis for the hallux valgus correction.

—Timothy Sorensen, DPM

I would fuse the first MTPJ and resect the lesser metatarsal heads as well as fuse the digital PIPJ’s, running K-wires through the digits into the corresponding metatarsals.

—Sandra Martin, DPM

This is a classic rheumatoid foot type deemed for surgical intervention. However, due to weakly palpable pulses and varicosities, highly recommend venous and arterial lower extremity Doppler studies and vascular consultation prior for surgical intervention

—Carlos Sepulveda-Figueroa, DPM

Consultation with the patient's primary care physician is indicated.  A plan should be presented to him which includes a Vascular Surgical Consultation with arterial doppler studies (and further invasive studies with corrective procedures if indicated) prior to introduction of podiatric surgical intervention with the patient.  Assuming this has been done, the primary care and / or rheumatologist may be requested to limit the patient's corticosteroids and methotrexate in the pre and post-operative course to allow for some restoration of immune response and healing ability.  Peri-operative antibiotic therapy would be indicated, proceeding with a surgical resection of the metatarsal heads 2-5, lesser digital "osteoclases" and a Keller procedure with K-Wire Fixation (0.062 for the Keller and 0.045 for the lesser digits works fine).  There is an important tip / trick to removing the lesser metatarsal heads which is VERY simple to teach and permits resection in less than one minute (each head) after the osteotomy is made.  Assuming a benign post-operative course ensues, sutures out by two weeks and k-wires out by four, her long-term comfort should be obtained (which is paramount here) but at the small cost of loss of some function and a propulsive gait (which is sacrificed). Patient's return to regular shoe gear by five to six weeks and report mild pain during the post-operative period, often less than pre-operatively where they have the bursitis and pain from the calluses,  IPK's and mal-aligned pedal deformities.

—Henry Stark, DPM

I would fuse the first MTPJ, possibly use Trinity, resect the rest of the met heads, fuse digits 2-4 with K-wire fixation and arthroplasty of the fifth toe if needed.  I would consider incision placement as patient has risk factors for wound complications and a bone stimulator as the patient has significant risk factors for non-union.  I would consult with PCP or rheumatologist in regards to the prednisone usage, giving a stress dose at the time of surgery then tapering down.  If non-union occurs consider a Keller.

—Michele N. Kurlanski, DPM

1. 1st MTPJ Arthrodesis with Locking plate
2. Lesser Met osteotomies 2-5(weil) with t&c and flexor plate releases
3. Digital Peg-in-hole arthrodesis for toes 2 and 3 with .035 k-wire and End to end fusion for toes 4 & 5 with .035 kwire
4. Plantar transverse elliptical excision to excise 3 Rheum. Nodules and thickened synovium

—Amit Luhadiya, DPM

In our management of this patient, there were a number concerns that we faced pre-operatively.  Due to the weakly palpable pulses, varicosities, and significantly atrophic appearing skin, we were concerned about the patient’s vascular status and her ability to heal any intervention.  Prior to surgery the patient was referred to the vascular surgery service for noninvasive vascular testing.  The patient was determined to have patent posterior tibial and dorsalis pedis flow with proximal popliteal stenosis, and TcPO2 values were obtained from the foot that were consistent with healing (3).

Additionally, there was concern that due to the patient’s long history of steroid and DMRAD usage for the maintenance of her rheumatoid arthritis.  Prior to surgery medical clearance was obtained via the patient’s primary care physician in conjunction with the patient’s rheumatologist, who was consulted to determine which drugs should be held and which should be maintained in the perioperative setting HPA-suppression was a concern, and the patient was given a loading dose of steroid prior to surgery, and then several supplemental doses post-operatively as instructed by the patient’s rheumatologist.  Additionally, the patient was given Ancef 1 gm IV approximately 30 minutes prior to surgery.

Once these concerns were addressed, the patient was brought to the operating room and a modified Hoffman-Clayton procedure was performed with proximal interphalangeal joint arthroplasty of the lesser digits. Visualization of the metatarsophalangeal joints for the lesser metatarsal head resections was obtained via three dorsal incisions (Fig.1).

Fig. 1: Three dorsal incisions were utilized for the procedure to allow for resection of the lesser metatarsal heads and to provide exposure to the 1st metatarsal phalangreal joint for the arthrodesis procedure.

To provide fixation at the 1st metatarsophalangeal joint, the INTEGRA Hallu-Fixâ plating system was utilized.  This system provides cannulated, concave and convex, cup-shaped reamers for both the proximal and distal sides of the joint to create a ball-and-socket articulation at the joint to allow for significant bone on bone contact to promote fusion.  Fixation was obtained utilizing the Hallu-Fix “C” plate (Fig. 2-6), which is pre-bent to closely approximate anatomic alignment.  In this case, due to the patient’s decreased bone density due to chronic steroid usage, we chose to reinforce the plate fixation with a trans-arthrodesis compression screw. Following proximal interphalangeal joint arthroplasty, the lesser digits of the left foot were then stabilized via percutaneous k-wire (Fig. 8).  C-arm was utilized to confirm placement of the 1st metatarsophalangeal joint arthrodesis fixation, as well as k-wire placement (fig. 9). 

Fig. 2: Placement of the guide-wire for the reaming system.

Fig. 3: The concave, cup-shaped reamer prepares the 1st metatarsal head.

Fig. 4: Preparation of the phalangeal base with the corresponding cannulated convex reamer.

Fig. 5: Temporary fixation of the Hallu-Fix "C" plate. Snap-off screws were utilized to provide fixation of the plate.

Fig. 6: Snap-off screw placement. A trans-arthrodesis compression screw was also placed to increase the stability of the construct.

Fig. 8: K-wire fixation of the lesser digits.

Fig. 10: Post-operative following a modified hoffman-clayton procedure with 1st metatarsal phalangeal joint arthrodesis.

Post-operatively the patient was placed into a modified jones-type compressive dressing with a posterior splint. The patient was instructed to remain non-weightbearing to the left lower extremity.  Considering the patient’s medical history, the patient was admitted for observation following surgery and was given two more supplemental doses of IV corticosteroid per the rheumatologist’s recommendation.

DISCUSSION:

Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints and affects approximately 1.3 million people in the United States (4). Characterized by multiple, symmetric joint presentation, RA often presents in flares of symptoms that are separated by periods of remission.  During flares, patients demonstrate significant inflammation in the soft tissues surrounding joints; persistent chronic inflammation can cause damage to body tissues, cartilage and bone, resulting in joint deformity, destruction, and loss of function.  In the lower extremity, these patients most commonly present with significant hallux abductovalgus deformities and dorsally dislocated lesser digits that often demonstrated fixed hammertoe contractures.

This case raises several interesting points regarding the management of patients with RA. Prior to surgery, it is vital to obtain rheumatology consult to maximize the medical management of patients with RA.  Oral corticosteroids, disease modifying rheumatoid arthritis drugs (DMARDS) such as methotrexate, and immune modulators such as tumor necrosis factor-alpha (TNF-alpha) inhibitors such as Adalimumab are all utilized to decrease systemic inflammation and therefore can reduce the pain and inflammation-associated tissue damage common in RA.  While these medications significantly improve patient’s quality of life while living with RA, they can have significant wound and bone healing complications and it is necessary to address with the rheumatologist which medications should be held prior to surgery.  Additionally, patients with RA demonstrate significant risk of Hypothalamus-Pituitary-Adrenal axis (HPA) suppression due to long exposure to exogenous corticosteroids.  In those patients who have taken greater than 7.5mg exogenous steroid daily, it is necessary to provide supplemental dosing of steroid at the time of surgery to reduce the risk of HPA axis suppression.

In addition to metabolic and endocrine concerns, patients with RA demonstrate increased risk of antlantoaxial subluxation.  This finding is common in as many as 32% of patients with RA (4)—that can increase risk of spinal injury during endotracheal tube placement during the induction of anesthesia and therefore C-spine films should be obtained prior to surgery.

CONCULSION:

Patients with RA demonstrate a significant medical and surgical challenge. These patients often present with significant osseous and soft tissue deformities that can be exquisitely painful and life altering, and these deformities often require surgical reconstruction when conservative therapies such as offload have failed to yield pain-free results.  As your responses indicate, forefoot reconstruction in patients with RA most commonly involves arthrodesis of the metatarsophalangeal joint of the great toe, resection arthroplasty of the metatarsal heads of the lesser toes with hammertoe correction (1). As with any other case, it is necessary to confirm the vascular status of the patient prior to any surgical intervention.  These patients may also demonstrate some degree of vasospasm following reconstruction as chronically contracted tissues are elongated during the reconstructive efforts.  It is important to monitor the patient’s lower extremity vascular status post-operatively to assure that transient vasospasm does not persist and lead to digital necrosis.  As previously discussed, it is encouraged to adopt a multidisciplinary approach in the management of patients with RA and to work closely with the patient’s rheumatologist to maximize the patient’s medical management perioperatively to reduce the risk of HPA axis suppression and wound healing complications.

I appreciate the many great responses we received from those of you who participated in this case presentation. As always I look forward to hearing from you, so please contact me if you have any comments, questions, or suggestions.