Rheumatoid Forefoot Reconstruction. A Long-Term Follow-up Study* by MICHAEL J. COUGHLIN J Bone Joint Surg Am Volume 82(3):322-41 March 1, 2000 ©2000 by The Journal of Bone and Joint Surgery, Inc.

Fig. 1 Diagram demonstrating the hallux valgus angle, the first-second intermetatarsal angle, and the MTP-2 angle. Fig. 1 Diagram demonstrating the hallux valgus angle, the first-second intermetatarsal angle, and the MTP-2 angle. On the anteroposterior radiograph, reference points are placed at the midpoint of the proximal and distal aspects of the diaphyses of the proximal phalanges and the first and second metatarsals. The hallux valgus angle is subtended by the axes of the proximal phalanx and the first metatarsal. The MTP-2 angle is the angle subtended by the axes of the proximal phalanx and the metatarsal of the second toe. The first-second intermetatarsal angle is the angle subtended by the axes of the first and second metatarsals. MICHAEL J. COUGHLIN J Bone Joint Surg Am 2000;82:322-41 ©2000 by The Journal of Bone and Joint Surgery, Inc.

Fig. 2 Diagram demonstrating the dorsiflexion angle of fusion. Fig. 2 Diagram demonstrating the dorsiflexion angle of fusion. On the lateral postoperative radiograph, reference points are placed at the midpoint of the proximal and distal aspects of the diaphyses of the proximal phalanx and the first metatarsal. The angle subtended by these axes is the dorsiflexion angle of fusion55. MICHAEL J. COUGHLIN J Bone Joint Surg Am 2000;82:322-41 ©2000 by The Journal of Bone and Joint Surgery, Inc.

Fig. 3-A Diagram and radiograph demonstrating the medial-lateral position of the lesser metatarsophalangeal joints. Fig. 3-A Diagram and radiograph demonstrating the medial-lateral position of the lesser metatarsophalangeal joints. On the anteroposterior radiograph, points are placed at the midpoint of the proximal and distal aspects of the diaphysis of the proximal phalanx. If the axis of the proximal phalanx was centered within the diaphysis of the corresponding metatarsal, it was rated as aligned (Figs. 3-A and 3-B, second ray); if it was displaced by one diaphyseal width or less either medially or laterally, it was rated as subluxated (Figs. 3-A and 3-B, third ray); and if it was displaced by more than one diaphyseal width either medially or laterally, it was rated as dislocated (Figs. 3-A and 3-B, fourth ray). MICHAEL J. COUGHLIN J Bone Joint Surg Am 2000;82:322-41 ©2000 by The Journal of Bone and Joint Surgery, Inc.

Fig. 3-B Diagram and radiograph demonstrating the medial-lateral position of the lesser metatarsophalangeal joints. Fig. 3-B Diagram and radiograph demonstrating the medial-lateral position of the lesser metatarsophalangeal joints. On the anteroposterior radiograph, points are placed at the midpoint of the proximal and distal aspects of the diaphysis of the proximal phalanx. If the axis of the proximal phalanx was centered within the diaphysis of the corresponding metatarsal, it was rated as aligned (Figs. 3-A and 3-B, second ray); if it was displaced by one diaphyseal width or less either medially or laterally, it was rated as subluxated (Figs. 3-A and 3-B, third ray); and if it was displaced by more than one diaphyseal width either medially or laterally, it was rated as dislocated (Figs. 3-A and 3-B, fourth ray). MICHAEL J. COUGHLIN J Bone Joint Surg Am 2000;82:322-41 ©2000 by The Journal of Bone and Joint Surgery, Inc.

Fig. 4 Diagram demonstrating regular resection of the lesser metatarsals. Fig. 4 Diagram demonstrating regular resection of the lesser metatarsals. A transverse arc is drawn from the distalmost aspect of the second metatarsal to the distalmost aspect of the fifth metatarsal. If a metatarsal extended beyond this line, the resection was deemed irregular. MICHAEL J. COUGHLIN J Bone Joint Surg Am 2000;82:322-41 ©2000 by The Journal of Bone and Joint Surgery, Inc.

Fig. 5-A Preoperative radiograph demonstrating hallux valgus deformity and dislocation of the second, third, and fourth metatarsophalangeal joints. Fig. 5-A Preoperative radiograph demonstrating hallux valgus deformity and dislocation of the second, third, and fourth metatarsophalangeal joints. MICHAEL J. COUGHLIN J Bone Joint Surg Am 2000;82:322-41 ©2000 by The Journal of Bone and Joint Surgery, Inc.

Fig. 5-B Intraoperative photograph showing the dorsal longitudinal incisions and the dorsal plate used for internal fixation at the site of the arthrodesis of the first metatarsophalangeal joint. Fig. 5-B Intraoperative photograph showing the dorsal longitudinal incisions and the dorsal plate used for internal fixation at the site of the arthrodesis of the first metatarsophalangeal joint. MICHAEL J. COUGHLIN J Bone Joint Surg Am 2000;82:322-41 ©2000 by The Journal of Bone and Joint Surgery, Inc.

Fig. 5-C: Postoperative radiograph demonstrating arthrodesis of the first metatarsophalangeal joint, resection arthroplasty of the lesser metatarsophalangeal joints, hammer-toe repairs of the lesser toes, and intramedullary Kirschner-wire fixation. Fig. 5-C: Postoperative radiograph demonstrating arthrodesis of the first metatarsophalangeal joint, resection arthroplasty of the lesser metatarsophalangeal joints, hammer-toe repairs of the lesser toes, and intramedullary Kirschner-wire fixation. MICHAEL J. COUGHLIN J Bone Joint Surg Am 2000;82:322-41 ©2000 by The Journal of Bone and Joint Surgery, Inc.

Fig. 5-D: Radiograph, made at the time of the three-year follow-up, demonstrating anatomical alignment of the lesser metatarsophalangeal joints. Fig. 5-D: Radiograph, made at the time of the three-year follow-up, demonstrating anatomical alignment of the lesser metatarsophalangeal joints. MICHAEL J. COUGHLIN J Bone Joint Surg Am 2000;82:322-41 ©2000 by The Journal of Bone and Joint Surgery, Inc.

Fig. 5-E Lateral radiograph demonstrating fusion of the first metatarsophalangeal joint. MICHAEL J. COUGHLIN J Bone Joint Surg Am 2000;82:322-41 ©2000 by The Journal of Bone and Joint Surgery, Inc.

Fig. 6-A: Radiograph, made five years after an unsuccessful Keller resection arthroplasty, demonstrating fixed dislocation of the lesser metatarsophalangeal joints with hammer-toe deformities. Fig. 6-A: Radiograph, made five years after an unsuccessful Keller resection arthroplasty, demonstrating fixed dislocation of the lesser metatarsophalangeal joints with hammer-toe deformities. MICHAEL J. COUGHLIN J Bone Joint Surg Am 2000;82:322-41 ©2000 by The Journal of Bone and Joint Surgery, Inc.

Fig. 6-B: Radiograph, made five years and eight months after arthrodeses of the metatarsophalangeal joint and the interphalangeal joint, demonstrating alignment of the lesser metatarsophalangeal joints. Fig. 6-B: Radiograph, made five years and eight months after arthrodeses of the metatarsophalangeal joint and the interphalangeal joint, demonstrating alignment of the lesser metatarsophalangeal joints. A large exostosis (arrows) (more than three millimeters in size) of the second metatarsal was asymptomatic. MICHAEL J. COUGHLIN J Bone Joint Surg Am 2000;82:322-41 ©2000 by The Journal of Bone and Joint Surgery, Inc.

Fig. 7 Radiograph, made approximately eight years postoperatively, demonstrating successful arthrodesis of the first metatarsophalangeal joint and severe degenerative changes with joint destruction and subchondral cyst formation (grade-4 arthritis) of the i... Fig. 7 Radiograph, made approximately eight years postoperatively, demonstrating successful arthrodesis of the first metatarsophalangeal joint and severe degenerative changes with joint destruction and subchondral cyst formation (grade-4 arthritis) of the interphalangeal joint. MICHAEL J. COUGHLIN J Bone Joint Surg Am 2000;82:322-41 ©2000 by The Journal of Bone and Joint Surgery, Inc.

Fig. 8-A: Radiograph, made two years preoperatively, demonstrating severe hallux valgus with dislocation of the first and second metatarsophalangeal joints. Fig. 8-A: Radiograph, made two years preoperatively, demonstrating severe hallux valgus with dislocation of the first and second metatarsophalangeal joints. At the time of the operation, the third and fourth metatarsophalangeal joints had also dislocated. MICHAEL J. COUGHLIN J Bone Joint Surg Am 2000;82:322-41 ©2000 by The Journal of Bone and Joint Surgery, Inc.

Fig. 8-B: Following arthrodesis, the first metatarsophalangeal joint is realigned. MICHAEL J. COUGHLIN J Bone Joint Surg Am 2000;82:322-41 ©2000 by The Journal of Bone and Joint Surgery, Inc.