A 58-year-old woman with rheumatoid arthritis has fixed clawing of all four lesser toes with dislocation of the second through fifth metatarsophalangeal joints, plantar callosities under the metatarsal heads, and intractable forefoot pain despite wide shoes and custom insoles. Radiographs show preserved first ray alignment. The definitive surgical procedure is:

• A Midtarsal joint arthrodesis
• B Plantar fascia release with flexor-to-extensor tendon transfers
• C Excision of the second through fifth metatarsal heads with pinning of the toes (forefoot arthroplasty) ✓
• D Amputation of all four lesser toes at the proximal phalanx level

Explanation

Fixed dislocation of the lesser MTP joints with plantar keratoses unrelieved by conservative care is the classic indication for excisional arthroplasty of the metatarsal heads, described by Clayton and Hoffmann, often combined with correction of the hallux. Tendon transfers address flexible deformity only, so option B fails here. Midtarsal arthrodesis addresses hindfoot-midfoot collapse, not MTP dislocation. Toe amputation leaves prominent metatarsal heads that continue to bear weight and ulcerate.

Reference: Campbell's Operative Orthopaedics, 14th ed.

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Written and medically reviewed by the StethoPrep medical team.