Outcome of Stainsby Forefoot Arthroplasty for Severe Rheumatoid Feet

Abstract

Category: Lesser Toes Introduction/Purpose: Treatment of the severely deformed rheumatoid forefoot generally involves resection arthroplasty of the lesser toe MTP joints. This can either involve resection of the metatarsal heads or, as described by Stainsby: resection of part of the proximal phalanx and extensor tendon interposition arthroplasty. The Stainsby procedure is a well accepted technique, however despite this there is little information on the outcome of this procedure especially long term results. We present, what we believe is, the largest series with longest follow up in literature apart from original authors’ work. Methods: Retrospective review of prospectively collected data was performed of 48 rheumatoid patients with 71 feet treated with the Stainsby procedure, between March 2006 and December 2013, by a single surgeon. American Orthopaedic Foot and Ankle Score (AOFAS) was recorded at both pre- and postoperative assessment alongwith a satisfaction survey at final follow-up. 5 patients had died at final follow up. The follow-up duration was 5.4 years (range 2.2-9.8). Results: 9/48 patients were on anti TNF therapy and 26/48 were treated with Methotraxate. 57 cases (80%) had 1st Metatarsophalangeal Joint (MTPJ) fusion (Group 1) alongwith Stainsby procedure for lesser toes. There was significant improvement in mean AOFAS from 32.5 to 67.4. The difference in improvement in mean AOFAS for Group 1 (29.4 to 72.0) as compared to Group 2 with Stainsby procedure alone (34.3 to 71.0) was statistically significant. 76% had no (50%) or painfree (26%) callosities at final follow up. Three patients had significant hallux valgus deformity (one for Group 1) at final follow up. There were four cases of superficial wound infection that resolved with oral antibiotics with no further consequences. Two patients had broken retained wires in metatarsal with no consequences and one patient had non-union of 1st MTPJ fusion not requiring revision. 77% were very happy (35%) or pleased (52%) with results of operation. 93% patients would recommend the operation – 78% definitely and 15% with reservation. Conclusion: Treatment of the rheumatoid forefoot involving resection of the metatarsal heads is an established procedure, with much published literature to support its use. Stainsby procedure in an effective procedure but unfortunately not as popular probably because of lack of long term results. This study highlights the long term benefits and very good satisfaction results with Stainsby procedure with even better results if combined with 1st MTPJ fusion.