• LecturehallRheumatoid Patient - Surgical Considerations
  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Schoenhaus: Our next speaker hails from Philadelphia, happens to be one of my partners, happens to be a gentleman that I assisted in training at Penn Presbyterian Medical Center where he did a four-year residency. He's done a fellowship. He's a major reconstructive surgeon in all aspects of foot and ankle trauma, ankle joint replacements, arthroscopy. He is what I consider the next generation that I can walk away and feel very comfortable that a lot of patients are in good hands. So I want you to welcome Dr. Andrew Peacock who's going to be talking on the rheumatoid foot.

    Andrew Peacock: Thank you, sir. Well, it's a heck of an introduction, and a tough act to follow with, you know, one of my senior partners, the chairman of the board here and a mentor of mine. But, you know, as you can see, he was discussing all the training that he had for me, and arguably over trained as we go through every step of the way here for me, with four years of training in a fellowship, but I'm here to talk about the rheumatoid patients and surgical considerations for it.

    So for those of you who don't know me, my name is Andrew Peacock. I practiced with Dr. Schoenhaus in Philadelphia, Pennsylvania. I'm attending at Penn Presbyterian Medical Center along with Dr. Schoenhaus and also the assistant residency director at the former Aria Residency Program which is now known as Jefferson Northeast Health System.

    So, unfortunately, I don't have any disclosures to disclose for you today. I will jump right in starting about the learning objectives. We'll go through a little bit of the historic procedures, we'll go through some of the board's type material for any of those – for your board certifications, or your recertification exams. And then we'll go into some of the, kind of, tried and true procedures as well as some of the shifts that have to do with rheumatoid arthritis. So when it comes to what we're looking at today, we'll start again with the pathology and the procedure selection for patients with rheumatoid arthritis.


    We'll move forward with some of the perioperative, preoperative, and postoperative considerations. And then we're going to some of the shifts in management. There's a lot of tried and true management with rheumatoid arthritis in surgical realm. And then there's also some advancements that have happened in the recent years, and kind of, some shifts in our way of thinking when it comes to looking at rheumatoid patients and their underlying protoplasm and, kind of, what procedures maybe better or worse for them in terms of maintaining motion and maintaining quality of life.

    So as far as the rheumatoid foot and ankle, 90% of rheumatoid patients are affected in their feet. It's a disease that affects the foot distally to proximally. So almost everyone's affected in the metatarsophalangeal joints, and we all think of the rheumatoid foot, you always think of those horribly deviated forefeet and, kind of, the classic procedures that go along with it, but you know, it's not to be discounted how much this affect the midfoot and the ankle and subtalar joint as well.

    So it kind of slowly progresses back, almost everyone's affecting the forefoot, the midfoot is a little bit less affected and about 30% to 60% in the ankle and subtalar joint. But it's one of the first areas to be affected, and something that, as a profession, we're often early to recognize this condition.

    And a lot of the rheumatologists we work with look at rheumatoid surgery as a failure on their part, because it wasn't identified earlier enough, they weren't put on the disease modifying medications early enough. So it is a, kind of, a dying breed of surgery and that it's not – it's not performed quite as often because the management from a medical standpoint, a prophylactic standpoint has so much improved from where it was before.

    So some of the classic findings with the rheumatoid patients, especially those who are, kind of, early on the process or not formerly diagnosed, is that post-static dyskinesia in the morning that – that's stiffer from an hour or more. Stiffening and swelling, the classic bunion, hammertoes, claw toes, and of course, that fibular deviation is really, kind of, the place you want to focus on.


    They often have prominent met heads plantarly, that's really one of the biggest complaints, their hammertoes, aren't necessarily the toes themselves that bother them, but it's just the agitation and the lack of that fat pad underneath which we'll go through a little bit more. As you go back in the foot, like we talked about earlier, the collapse in the arch in that peritalar subluxation and that significant PES planovalgus foot type can cause quite a discomfort for them.

    Joint-space narrowing, typically a little more uniform than other types of arthritis, and a pretty significant osteopenia, which has some interesting implications as we get into some other more current literature.

    So you got your Bouchard's and Heberden's nodules, a lot of these patients you can tell they're rheumatoid arthritis before you can open their chart, you walk in, you shake their hand, and you, kind of, know it right off the bat. So, you know, they're obviously pretty severe deformities as they get towards to the end stage and tough deformities to correct. There's a lot of small vascular structures to deal with in those areas.

    So I really like this schematic when we're talking about rheumatoid forefoot reconstructions because I think it really harps on the points that are important, and why the rheumatoid forefoot is a little bit different. You know, I find all my hammertoe patients complain in one of three places, the tip of the toe, the dorsal – the dorsal joint of the DIP or PIPJ, and then they also complain of submetatarsal pain.

    But we're going to step further with the rheumatoid patients is that subluxation of the fat padding anteriorly, and I think that's a big consideration that in your end stage rheumatoid forefoot reconstructions, you really need to take seriously and consider or you're not going to have happy patients because they're having so much pain underneath that, and that metatarsalgia type pain.

    So it's something to be considerate of. Ideally, you're getting to these people ahead of this, they manage to have it medically, the surgeries aren't getting that far. But when you get to this end stage patients who've had rheumatoid for years or was poorly managed for a long time, you can really get to see some pretty nasty deformities specifically at the MPJ level.

    So, again, that classic ulnar deviation and fibular deviation can't be stressed enough, you know, that's really where you see the deformities and they drift in those classic patterns.


    And then, kind of, some of the more subtle findings that you'll find, and the real important thing about these subtle findings is to look at the serial radiograph and continue to radiography these patients, and make sure that things aren't continuing to get worse as you treat the patients. So they often have – juxtaarticular osteoporosis for those marginal erosions around the edges of the joints, so often subtle but with the advent of digital radiograph, it's made a lot easier to see some of these subtleties because you're not often over underdeveloped like we were with some of the plain film radiographs.

    Additionally, with the uniform joint space narrowing, it's pretty classic. They often have cystic changes which can be a challenge in any part of the rheumatoid foot when it comes to reconstructive procedures. And pretty significant subluxations and dislocations that, again, become a challenge because you're not only dealing with that underlying pathology, but you're now looking at deformity correction at each level of foot.

    So the bony ankylosis, we'll talk about a little bit more with the perioperative considerations. So when we look at the American Academy of Rheumatologists, most up-to-date recommendations, you know, I like the rest of you probably lean on the rheumatologist for which medications you're going to hold and which ones you're going to move forward with but, you know, it's pretty simple when you really look at it.

    Pretty much everybody's continuing methotrexate and Plaquenil and aside from that, almost everything else is held until the wound is healed and the American Academy of Rheumatology deems the wound healed, once it's been healed with the sutures removed without any drainage which is pretty much our definition but not something I often define, it's just – you can kind of look at come, it's healed.

    So that classic board's question, you're looking at something – cervical radiographs, you're looking for the atlantoaxial dislocations. So it's just something to be considerate of. You may need C-spine X-rays for clearance depending on your hospital procedures and policies.


    So as far as the forefoot goes, you can really do anything that you're comfortable with and it's kind of dealer's choice but there some tried and trues.

    You can start with synovectomy, some met head resections, there's plenty of joint sparing procedures. You know, everybody does their forefoot a little bit different. And then there's obviously joint replacement and your fusion procedures to consider in this realm as well.

    So this is a patient of mine that I like to bring up for lectures like this because I think it's a good learning tool and it humbles me quite a bit with the outcomes that we had because it was such a success and such a roller coaster of a patient all at the same time.

    So you can kind of see that diffuse osteopenia, that significant deformity. And these patients come in and they're miserable. Their quality of life isn't there and they're unable to get a lot of propulsion, they're very low demand. It's not only their forefoot that bothers them so, you know, you're trying to preserve as much motion as possible and get them as much function in their foot to help decrease some of these pain.

    And when you see these deformities, they can be overwhelming at first and a lot of my residents said – I trained 25 residents, they all worry about the bone quality in these patients. And again, interestingly enough, and some of the literature we'll dive into, you know, it may not be – it's something to consider and something to be weary of and have your back up plans but it's also something that when you look at it, there may be some advantages to that we're looking at as well.

    So you can't talk about surgery without incisional placement, you know, it's the first thing you're doing – you're drawing out your incisions. You're going through and it really dealer's choice with these – some of its N equals one of where's the deformity, where are you trying to get, what exactly are you trying to achieve?

    I tend to favor one or two approaches. If they don't have that end stage sublux plantar fat pad, I like to do everything pretty dorsally because it's kind of that comfort zone that we all use for our hammertoes and our bunions and everything else. But when they had those end stage, I think it's really to get away without doing a big plantar ellipse because you need to really relocate that fat padding and I haven't found a way to do it from my dorsal approach.


    But there's a million different approaches described in the literature and it really becomes dealer's choice. You can use the straight incision, you can use multiple incisions per toe, you can use one per toe, there's the curvilinear incisions to kind of give yourself a little bit of exposure and then the dorsum plantar transverse incision which, again, proceed with some caution. You want to make sure you're not lacerating intervascular structures. But they can give you good access when you need them.

    So this is back to that same patient that I wanted to present and kind of show you a success story and then kind of the reason that you need to proceed with caution with these. It is obviously a fairly significant deformity that we're dealing with and you can see the large rheumatoid nodules and that significant painless deformity and a severely dislocated first metatarsal phalangeal joint. So, you know, I've favored, you know, doing kind of the standard from the top but on this one, there's no way you can't do a big elliptical incision.

    And you really have to be fairly aggressive with these. If you undercut that ellipse, you're not going to be able to relocate that plantar fat padding and you're not necessarily getting the fat padding to place where you need to be. So this was kind of our basic incisional approach. I don't have a drawn out with the skin marker on these but, you know, I think got close enough to where we were looking. And, again, just to pretty severe deformity to work with.

    So going back to the procedures, pan met head resections are an option. They were a classic option and there's something that, you know, we've perfected over the years by adding in other procedures. But, again, when you look at rheumatoid reconstructions, a lot of these people have rear foot and ankle rheumatoid arthritis in addition, probably have knees hip shoulders as well.

    But it's often start with the forefoot first. It's often the most debilitating deformities and it's the most longstanding deformity that they've had. And it's dissimilar to a lot of other pathologies where a lot of times we think of building a foundation from the rear foot, forward. So it's important to maintain your parabola.


    Resect them – the met heads more plantarly which we all do to help make sure there's less plantar pressure.

    And, you know, the problem with the historic procedures like a complete pan met head resection is the shift laterally and the cause – the recurrence of the hallux abducto valgus deformity. So, you know, we look into kind of what else can we do with the first ray? You have the Keller procedure, you have fusion procedures, there's your joint destructive options. So I tend to favor an arthrodesis. I think it gives you that increase medial columns stability. It alleviates your risk of recurrence as long as everything fuses. It's more or less a one and done, there's not a whole lot of problems, unless it's fused in a poor position or you have a nonunion or delayed union.

    It allows the first ray to really take its fair share of the weight. You know, biomechanically, I think of it taking most of the weight anyway but if you're taking away the met head, you're kind of relying on some of those lesser rays – take a little more than their fair share which can lead to their problems.

    And it really gives you a pretty solid, tried and true reconstructive procedure. So as far as long term fall for first MPJ fusions in rheumatoid patients, this study by Coughlin showed 96% satisfaction rate with 6-year follow up with – you know, most surgical studies are somewhere between 6 and 12 months. And, you know, everybody's pretty happy at that point but you know, are they really lasting? And at six years, if you have a 96% satisfaction rate, it seems to be kind of the procedure du jour as well as the procedure of choice for these.

    So, it can really – the important part of this is really that – what I harped on the last couple of slides is that maintenance of the alignment of the foot because if you just let everything loose and you let everything without that guidance in the first ray, you can really get a lot of recurrence with these deformities which can be very debilitating for these patients. And you really want to look for that functional outcome, as well as that decrease in pain.

    So as far as joint replacements versus fusions, I think they both have their place.


    I'm not a huge advocate of replacements for procedures like these because, again, I think they're not as long standing and they have their risks but they do have quicker recovery times, they're not waiting for the fusion.

    So for those of you who favor the replacements that do think they're good ideas, it's just when the complications happen, they can be a little bit harder to deal with. Which is why, I tend to favor a little bit more definitive procedure in some of these advanced deformities.

    So as far 1st MTPJ fusions, this is some of that literature. I wanted to reference this in article by Hyer. This was published a couple years back with a 155 1st MTPJ Fusions, 116 were for osteoarthritis and 39 for rheumatoid arthritis.

    But interestingly enough kind of counterintuitively, the rheumatoid fusions tend to diffuse a little bit faster. And some of that was credited to the softer bone in the first – in the osteoarthritis there was a lot more sclerosis. So there was just a slower healing rate versus you're kind of dealing with that soft bone that – you know, they're not the healthiest patients with the rheumatoid but, you know, what they saw was a little bit more of rapid fusion which made it again more of a positive procedure selection for these patients.

    So again, they – like a lot of studies, they only saw – they only saw delayed wound healing with the rheumatoid patients and I think that's something to discuss as well when we get into perioperative considerations is these patients aren't to be taken lightly. They're higher risk than your average patient.

    You know, a lot of people avoid operating on anybody that smokes and anybody with poor protoplasm and they avoid elective procedures in diabetics and rheumatoid patients and things like that. But there's a lot of these people that you can really help, but just kind of making sure that your patient understands it and that they're as optimized as possible prior the procedures.

    So this is a – this is a patient that came to us who'd had a previous work done years prior – and again, no fault to the previous surgeon. I think they did everything they could and again, it's one of the reasons in the more end-stage procedures to be a little more definitive because you can have recurrence but, you know, this patient got about 20 years out of the first couple procedures, so there was no urgency to do anything different.


    But when she came to us, she was having recurrence to the bunion. That was our main problem and so we were able to get everything corrected with adding that 1st MTPJ fusion and with the pan met head resection and getting a pretty good result that the patient was fairly happy with.

    So another case example that we have here, an implant gone wrong. So this was one that I did during my fellowship and we had this patient come in who had significant shortening from the implant that had kind of gone wrong here. So we harvested the calc to be able to fuse the first ray and kind of get that stability back, but it didn't really feel like a pan met head resection was the appropriate procedure because we didn't want to destroy all these joints.

    So we went ahead with multiple Weils, which – I'm not a huge fan of doing this many Weils at once, but it really decompress the joints and did a lot of good to kind of rebalance the parabola given we couldn't the length back quite to where we wanted it with the 1st MTPJ Fusion.

    And you can see it is fairly dislocated inside the joint here – our prosthetic joint here. And just a much better access of gait as well as the graft that we took from the heel that we moved upfront. So it's just a much better Meary's angle and alignment of the hallux.

    So back to that procedure that was a little bit of a rollercoaster for me early on on my career is – this is a – this is that same rheumatoid patient. You can see that diffused osteopenia which again may fuse faster but, you know, makes screws not bite so well. So it's something to be considerate of. And the reason I like to bring this patient up is because we did that standard Hoffman-Clayton procedure, brought her – the wires were a little long but we like the way they bit, left them in. She was now weight bearing for that timeframe. And once she healed up – you know, she had a beautiful before and after.

    You know, this is her right foot versus her left foot. This is a before and after of the same feet. And she was one of those people who is asking me if she can stand by my side at lectures like this because she was so pleased with the procedure and didn't know that something like this could be done for.


    But as we go a little more into the lecture, we'll talk about why, you know, these procedures aren't always as glorious as this one and they don't always go quite as well because – it's a good thing the first one went as well as it did because there was a little bit of trouble on side number two. But as you can see, excellent correction, really nice and straight. Everything was going to where we wanted, so we'll catch up with the second foot in a few minutes here after we go through so many other rear foot and midfoot considerations.

    So as far as the midfoot goes for rheumatoid arthritis, you know, I kind of think of it as just significant flat feet. They never really get that true rocker bottom foot the way that your Charcot patients do. But they start to break down a lot of significant transverse and sagittal plane deformities. And there's not a lot of rocket science when it comes to the midfoot. Again, this can be tough procedures with the midfoot and rear foot. But there's not a lot new and different, the fusions are kind of a tried and true reconstructive procedure when you have a significant amount of deformity.

    So, you know, as we all know from Hanson's essential and nonessential joints, the midfoot's pretty much all nonessential joints. So in significant deformity, they were all pretty quick to fuse them. Maybe a little bit careful around the navicular cuneiform joints because they tend to be a little bit of a nonunion maker but there are areas where you want to be concerned about – just kind of taking your time, making sure you're prepping the joints.

    You know, we spend the most time prepping the joints of anything when we do our fusion procedures and I can't harp that enough. It doesn't matter – it doesn't matter how good the position looks. If it never fuses, your patient's probably going to be fairly symptomatic and painful and that makes it tougher for the results and nobody wants to have to go into revision if you don't have to.

    So mistakenly put subtalar and ankle arthritis together here, I think they're very different animals when it comes to rheumatoid arthritis. Subtalar joint arthritis is that debilitating subtalar joint arthritis like anybody else.


    And again, when it starts to get towards that advance stage, fusions, subtalar, isolated subtalar joint fusions, or triple arthrodesis or as the trends have set it, leaning towards those double arthrodesis whether you go medially or two incisional approach tend to be really good option for these rheumatoid patients, but it's very few and far between you get these isolated rheumatoid patients with isolated subtalar joints. So, you know, there's often more to consider which is why we included the ankle in this section.

    So as far as ankle rheumatoid arthritis, for a long time it was fuse, fuse, fuse and the more we – the more we've looked at it, the more we think that – you know, it's again, back to that N equals one, not all patients are the same. You have to really look at their needs and the patients who need – who need the fusions are those severely end stage patients but these fusions can take a while, they're sick patients, the soft tissue envelopes not always all that great. So you got to be careful with it versus the replacement is still a good option as well. But, again, you know, a lot of us don't like to push the envelope too much in terms of deformity.

    So it's finding, are you doing a lot of deformity correction? Is fusion your better route? Do you have a more straightforward arthritic ankle that they just have bone on bone arthritis because the rheumatoid kind of taken over and destroyed the cartilage and preserving that motion for these rheumatoid patients is really key to a quality of life.

    So as far post-operative complications, it's not far off from a lot of the other procedures that we all do. But there's an increased risk with these patients. They're sick people. They're almost all in chronic steroids, they're on their DMARDs. So you have to be careful about your planning. You have to be careful about over underusing biologics. They often have delayed wound healings, so I treat them very similar with my diabetics and that stitches really can't stand too long. There's no urgency to pull the sutures. If the skin is not healed, the skin is not healed, then – and give it time.

    So they often have soft tissue damage that's underlying from the vasculitis and the underlying rheumatoid arthritis. So it's something that you want to be considerate of. And they're at a higher risk of nonunions and malunions even though they have – because they have that soft bone, it doesn't mean it's always going to fuse like Hyer's article did.


    So they're often recurrent deformities especially if they're undertreated or not treated aggressively enough. And, you know, they're at a high risk of DVTs. They may need to be immobilized longer. They're pretty low demand patients at baseline.

    So to kind of wrap things up, I'll go back to my patient of again a result I was very proud of on the first side and, you know, as they say, God protects fools and surgeons. So this is one of those where, you know, thank God, I went right on the first side the first time that my patient had faith in us to kind of get through this. But when we went to do our second foot, we had a pretty rough result. I think we're a little aggressive with the plantar resection of that plantar ellipse and it put a little bit of tension along the medial aspect of our first ray.

    So I'll go into a little – there's a little bit more tomorrow on some of my trauma topics. But, you know, we've kind of adopted some of the same techniques from our plastics colleagues down in Philadelphia. And seeing something like this doesn't immediately jump to amputation. It doesn't – you know, there's no true infection at this point. You have necrosis. You have exposed hardware underneath that eschar when we peeled it off. But we really just kind of took this one patiently, kept our own antibiotics and did everything we could to get that joint fused before we really worried about what to do with the exposed hardware.

    And once I was comfortable that there was a fusion around 12 or 14 weeks, we took the hardware out, debrided down the bone and this is what we're left with. So, you know, you're looking at this. A lot of people are looking at an amputation for a quick fix, but you really don't want to lose your hallux and, you know, we're willing to try whatever we could for us. So the key to managing these really devastating soft tissue losses is really kind of sticking with your principles. We rely pretty heavily on some of the biologics for something like this because you just need some coverage and you can't get granular tissue directly over bone especially when it's stripped to the periosteum in this situation.


    So the easiest way to go about it addressing a pretty devastating complication like this is to take and get back to healthy bone and healthy tissue like you do with any other damaged tissue. And so the way I managed this one was we took a bone borer and just bored back until we get bleeding bone. And the real key to those if you can avoid breaking into the medullary canal and you're able to get to bleeding cortical bone, these patients tend to do very, very well and they'll recover fairly well.

    When you break into the medullary canal of the bone, it makes it a little bit harder to get these recovered because you just start to lose your structural integrity. But everything was fused at the MPJ level. Sorry. I don't have the X-ray up here. And it was able to go on towards a pretty granular wound base and this was the day that we did the skin graft. And, again, apologies that I don't have the final skin grafts, but everything healed uneventfully and, you know, she's happy as a clam and thankfully it was the second foot that had the problems and not the first.

    So, you know, I think it's one of those things when we're looking at procedures, in conclusion, it's important to look at all of the realm of the patient and make sure that you're considering every bit of it. So, you know, there's patients like this patient, who was a really good patient, willing to go through the trenches with us together there. But there's a lot of patients who aren't necessarily the best surgical candidate for these. And, you know, in the wrong patient, this easily could have ended up in an amputation. It could have been a hallux amputation. It could have quickly turned into a transmetatarsal amputation.

    And when you're looking at these more aggressive procedures, it's one of the risks you take is you're putting a lot of torque and strain on these – on the forefoot, on the vascular statis and it's something that you want to be very careful about. When you go through that plantar ellipse incision, you're basically doing a transmetatarsal amputation but you're trying to spare their nerves and trying to spare the soft tissue and vascularity.

    So it's a very delicate procedure. You dissect out the rheumatoid nodules to get to the right place. And, you know, it wouldn't be a good lecture without a good complication, but, you know, as successful as we are with a lot of these, you have to be ready if you're going to do these procedures to be prepared to take over and get these taken care of.


    So as far as – I referenced this. I've got all my reference slides here if anybody needs anything. If you have any questions or concerns, my email address is here. That's my cellphone number. You can shoot me a text, give me a phone call. But I hope you learned something today and I'll turn it back over to Dr. Schoenhaus.

    Schoenhaus: That's an excellent job. I just want to ask one question of Dr. Peacock. In doing lesser metatarsal head resections, do you prefer going through the dorsum of the foot or plantar aspect?

    Andrew Peacock: So I think it's a good question because I think it's a little bit of a double-edged sword. So in procedures on patients like I had where we had the patient here and they have that significant deformity with the displaced fat pad, I think I tend to favor the plantar incision. It's a little riskier, but it's kind of necessary to bring that fat pad back underneath the metatarsal heads.

    In patients with less advanced disease but still kind of that end stage arthritis in more definitive procedures, I prefer to go through the top, but I found myself going through the plantar aspect more because we get a lot of these tertiary referrals where, you know, they've kind of let it go until they can't let it go anymore and you really need that plantar soft tissue to kind of bring that flap underneath. So I think the long answer and the short answer is it kind of depends on the patient.

    Schoenhaus: That's a good answer. I like going through the plantar as Andrew, as well.

    The metatarsal heads are right there. They're prominent. You feel them and you just make a nice transverse double incision and you need take out enough tissue. This is not just, "Let me make a little, small cut."


    This is the one you take out a wedge and run to the bathroom and change your shorts. This is like, you know, "Whoa, look at this sucker." But the heads of the metatarsals are right there. Your tendons are right there. Your plantar plate which is usually destroyed, everything is right there. And now, you're going to remove bone and then just close that whole flap back and now you're back into position. Toes come down very nicely and you have a fat pad that's there to protect the soft tissue and to protect the remaining bones.

    So I thank Andrew for his talk on rheumatoid foot. It's challenging obviously as you could see because it's an evolving disease. Just because you've done the surgery doesn't mean you've cured them. They still have problems.

    TAPE ENDS - [28:47]