A 65-year-old woman with rheumatoid arthritis presents with severe forefoot pain and difficulty walking. Examination shows hallux valgus with dislocation of the 2nd, 3rd, 4th MTP joints and 'cock-up' toe deformities. The most appropriate surgical intervention for the forefoot is:

• A Silastic MTP joint arthroplasty of the hallux alone
• B Bilateral corrective osteotomies with hallux valgus correction
• C Excision arthroplasty of all metatarsal heads (Fowler procedure) with hallux fusion ✓
• D Custom-molded orthotic insole as definitive treatment

Explanation

In rheumatoid forefoot with multiple MTP dislocations and hallux valgus, the Fowler procedure (excision arthroplasty of all lesser metatarsal heads combined with fusion of the first MTP joint) is the standard reconstructive operation. Hallux valgus in RA should be treated with MTP fusion rather than osteotomy because RA bone is soft and deforming forces persist. Excision of the lesser MTP heads relieves metatarsalgia from dislocated joints. Custom orthotics provide temporary relief but do not correct structural deformity in advanced RA forefoot.

Reference: Maheshwari Essential Orthopaedics, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.