Forefoot Surgery - Indications,Types, and Complications

Introduction:

The foot is divided into three regions: forefoot, midfoot, and hindfoot. The forefoot consists of three types of bone: metatarsals, phalanges, and sesamoids. A total of 21 bones constitute the forefoot. Joints in the feet are formed by the union of two or more bones. Joints of toes, except for big toes, include the metatarsophalangeal joint (MTP), proximal interphalangeal joint (PIP), and distal phalangeal joint (DP). Joints of the big toe include the metatarsophalangeal joint and interphalangeal joint.

What Is Forefoot Surgery?

Forefoot surgery is used in cases that are not resolved by conservative management. One of the most common causes of forefoot surgery is a deformity of bones and persistent pain in the forefoot. There are two types of forefoot surgery: joint-preserving surgery and joint-sacrificing surgery.

What Is a Forefoot Deformity?

Forefoot deformity is a condition that occurs due to misaligned bones of the front part of the foot. Shifting of one or more bones may lead to deformity, affecting normal foot functioning. Some forefoot deformities might be present from birth, while others may develop over time. As a result, the patient may experience pain or discomfort. As a result, they may need help to walk and perform day-to-day activities. But in some cases of forefoot deformity, patients are asymptomatic. This condition is also seen in cases of rheumatoid arthritis.

What Conditions Can be Treated By Forefoot Surgery?

There are different types of forefoot deformities seen in patients. Common forefoot deformities include:

• Bunion: It is one of the most common deformities of the forefoot. It occurs due to the enlarged bone and tissue outside the big toe joint (metatarsophalangeal or MTP joint). A bunion is hereditary in most cases. The affected area is inflamed, red, and swollen in symptomatic patients. Numbness may also be present in the affected area. This condition makes walking and wearing regular shoes difficult.

• Tailor’s Bunion: It is also known as a bunionette.This condition occurs due to the bony prominence present outside the small toe. It is caused due to hereditary factors and weak forefoot structure. Pain is the primary symptom of this condition. The person also finds it difficult to walk and wear shoes.

• Morton’s Neuroma or Interdigital Neuroma: A non-cancerous enlargement of the nerve segment due to the thickening of nerve tissue. It generally occurs between the third and fourth toes. This condition is more common in women than in men. Wearing high-heeled and tight footwear, arthritis, and injury are the causes of the neuroma. It leads to continuous radiating burning pain in the ball of the foot. Tingling or numbness may also be present. Patients may have a feeling of pebble-like mass below the forefoot.

• Hammer Toes and Mallet Toes: These conditions are caused due to joint, muscle, or tendon imbalance. This condition affects the second, third, and fourth toes. As a result, the middle portion of the joint curls upward, and the toe ends will bend downwards. The patient may have difficulty moving the toe due to pain. The affected area becomes hard due to callus or corn formation.

• Bone Spurs: It is a hard enlargement of the bone present on the terminal portion of the bone. It occurs due to injury, pressure, or stress due to the overuse of the tendon or ligament. Other causes of bone spur include osteoarthritis and rheumatoid arthritis.

• Stiff Big Toe: It is a form of osteoarthritis that causes pain and stiffness in the big toe joint. The patient may experience difficulty lifting the big toe and lying it flat inside the footwear.

What Are the Different Types of Forefoot Surgery?

Forefoot surgery is conducted in cases that cannot be cured with conservative management. Most of these surgical procedures are done under general anesthesia. The different forefoot surgery includes:

Foot Arthrodesis or Foot Fusion Surgery: This procedure involves the artificial fusion of separate bones in the joint. The joint becomes immobile after the surgery. Foot arthrodesis is done to reduce the deformity created by rheumatoid arthritis, osteoarthritis, poorly healed fractures, infections, and congenital disabilities. This procedure can be performed using two techniques which include:

1. Open Foot Arthrodesis- In this technique, long incisions are made to visualize the affected joint directly.

2. Arthroscopic Foot Arthrodesis- In this technique, a few small incisions are made in the skin, and the arthroscope (a thin, flexible tool with a fitted camera at one end) is inserted through one incision. This arthroscope is connected to the monitor to let the doctor view the area during the procedure. Other small instruments are passed through other incisions. The fusion of bone can be done with the help of screws, steel plates, steel bars, or bone grafts. Incisions are closed at the end of this procedure using stitches and bandages.

Resection Arthroplasty: In this procedure, a part of the joint is removed to reduce the pain. An incision is made over the joint to expose the affected joint, and the joint capsule is opened. Then the surgeon will remove joint surfaces and a small portion of bone to generate space. Tissues present over the area are sewn together to maintain the space. The surgeon will close the joint capsule using stitches in the final step. Later this space will be replaced with scar tissue. There are two types of arthroplasty procedures:

1. First Metatarsophalangeal (MTP) Joint Resection Arthroplasty: It is done to treat big toe arthritis.

2. Proximal Interphalangeal (PIP) Joint Arthroplasty: This surgical procedure is done to treat the hammer toe.

Joint-Preserving Surgery: This surgical procedure aims to preserve the function of the MTP (metatarsophalangeal) joint. This joint-preserving surgery is done in patients with rheumatoid arthritis who suffer from pain and deformity of the forefoot. This procedure is a combination of osteotomy and soft tissue reconstruction.

1. Osteotomy: This surgical procedure is used to correct the misaligned toe joint in patients with conditions like a bunion. In this procedure, the surgeon makes an incision over the affected area and trims off any extra bone on the bunion. Afterward, big toe bones are realigned with the help of screws and wires.

2. Soft Tissue Reconstruction: It is an important component of limb-sparing surgery. This can be done using a free flap.

What Are the Complications of Forefoot Surgery?

General complications of surgery apply to forefoot surgery as well. A few complications specific to forefoot surgery are the following:

• Recurrence of deformity.

• Improper healing of the toe joint.

• Delayed healing of the surgical wound.

• Infection at the surgical site.

• Nerve damage.

• Failure of fusion at the osteotomy site.

Conclusion:

Forefoot surgery aims to reduce pain and discomfort, correct any deformities, and restore normal foot function, to enable walking and wearing shoes. The ultimate goal of this procedure is to improve comfort and enhance the overall quality of life. The complications occurring after surgery can be avoided by taking proper rest and following the doctor’s advice.