A 58-year-old woman with long-standing rheumatoid arthritis has painful fixed clawing of all toes with dorsal subluxation of the metatarsophalangeal joints and callosities under the metatarsal heads. Conservative care has failed. The standard surgical procedure for the rheumatoid forefoot is:

• A First metatarsophalangeal fusion with lesser toe soft tissue correction only
• B Tarsometatarsal fusion with plantar fascia release
• C Total metatarsophalangeal joint replacement of all rays
• D Excisional arthroplasty of all metatarsophalangeal joints (Hoffmann/Clayton procedure) ✓

Explanation

The Hoffmann (Clayton) excisional arthroplasty removes the metatarsal heads of all rays through a plantar or dorsal approach, decompresses the forefoot, corrects claw toes, and relieves metatarsalgia. It remains the standard for the rheumatoid forefoot because implants fail in osteoporotic rheumatoid bone. Isolated first ray fusion alone leaves the lesser metatarsophalangeal dislocations unaddressed and does not relieve the transfer lesions.

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

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Written and medically reviewed by the StethoPrep medical team.