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be a reliable treatment after failed, previous hallux valgus
correction surgery. Grimes et al showed that 73% of patients
had good to excellent outcomes along with significantly
improved pain scores at a mean of 8 years postoperatively.7
Some authors argue for primary arthrodesis in the setting of
severe hallux valgus deformity without prior attempts at
reconstruction.11
First MTP arthrodesis combined with lesser metatarsal
head resection, often referred to as a rheumatoid forefoot
reconstruction, has been an established treatment for
patients with forefoot pain and deformity caused by inflammatory arthritis or rheumatoid disease. Coughlin reviewed
47 RA feet with over 6 years of follow-up that had undergone rheumatoid forefoot reconstruction and demonstrated
that 49% of feet had excellent outcomes and 47% had good
results.2 Our data show that 80% of feet had a satisfaction
score at or above 9/10, which we subjectively classified as
excellent. Mann and Thompson also demonstrated that first
MTP arthrodesis and lesser metatarsal head excision can
relieve debilitating foot pain in patients with RA.14 We, too,
demonstrated significant improvements in patient pain
scores after surgery. Taken together, our cohort of patients
without rheumatoid disease reported similar outcomes in
satisfaction and pain after forefoot reconstruction compared
to patients with RA.
Based on our radiographic review, we found no cases of
nonunion. MTP joint alignment in the sagittal plane
improved significantly from preoperative to postoperative
assessment, with joint dislocation rates decreasing from
22% to 2%, respectively. Additionally, we showed significant improvements in the radiographic parameters of 1,2
IMA, MTP-2 angle, and HVA. Our findings are similar to
prior data from Coughlin that showed 100% union rate for
first MTP arthrodesis and decreased lesser toe dislocations
in the sagittal plane from 70% preoperatively to 7% postoperatively.2 This provides reassuring evidence that radiographic parameters following rheumatoid forefoot
reconstruction in the nonrheumatoid patient can be maintained at early-to-midterm follow-up. Although our study
does demonstrate an increase in lesser toe dislocations in
the axial plane postoperatively, it is of unclear clinical significance as the number of dislocated toes did not correlate
with patient-reported postoperative pain scores.
Only 1 prior study has examined rheumatoid forefoot
reconstruction in the non-rheumatoid patient.12 Mann and
Chou reported on 18 feet from 15 patients who underwent
first MTP fusion and lesser metatarsal head resection for
intractable forefoot pain at a mean follow-up of 5 years.12
This study reported 83% good to excellent results, with
87% of patients stating they would undergo the same procedure again. Only 1 first MTP arthrodesis developed a nonunion, and 1 patient required a second operation. Similar to
Mann and Chou's series, our patients were able to wear

Foot & Ankle International 38(6)
store-bought shoes, did not require chronic narcotic pain
medications, had low complication rates, and reported high
satisfaction.
Like Mann and Chou, we feel that proper patient selection
is critical to a successful outcome for rheumatoid forefoot
reconstruction in the nonrheumatoid patient. We do not routinely offer this surgery as a first-line intervention in patients
without a diagnosis of inflammatory or rheumatoid arthritis.
Instead, we typically reserve this procedure for lower-demand
patients whose previous surgeries have left them with multiple sites of deformity and pain in both the great and lesser
toes. We view this operation as a salvage procedure that aims
to provide patients with a definitive solution to their forefoot
deformity and pain. The data shown here support our hypothesis by showing low complication rates, high patient-reported
satisfaction, and decreased pain scores at follow-up.
Although first MTP arthrodesis with lesser metatarsal
head resection appears to be a viable option in selected
patients, our study has limitations inherent to retrospective
designs. Our inability to collect data from a validated outcome tool like the FAAM limits our full understanding of
the change in patient-reported disability following forefoot
reconstruction. We do not have a control population for
comparison. Additionally, we did not have patients report
to the clinic for in-person examination; therefore, selfreported measures over the phone may not fully capture
residual pain and disability following forefoot reconstruction. Lastly, the presence of neuropathy in a portion of our
study population (3 patients, 4 feet) could have altered the
postoperative pain response in those patients, and, by
extension, blunted their pain scores collected from the
phone survey.
In conclusion, first MTP arthrodesis coupled with lesser
metatarsal head resection was a viable option for patients
who failed prior attempts at forefoot reconstruction or had
chronic forefoot pain and deformity. Nonrheumatoid
patients reported high satisfaction and decreased pain following forefoot reconstruction. Future study in expanded
sample sizes that utilize outcome instruments specific to
foot and ankle patients should be considered.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.

Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.

References
1. Barouk P. Recurrent metatarsalgia. Foot Ankle Clin.
2014;19(3):407-424.

Table of Contents for the Digital Edition of Foot & Ankle International - June 2017