Foot and Ankle Surgery 1996 2: 83–89

Surgical correction of the rheumatoid forefoot by

the Lelièvre procedure
M. PFAHLER, M. KRÜGER-FRANKE∗ AND
F. W. H A G E N A
Orthopädische Klinik, Klinikum Grosshadern, Ludwig-Maximilians-Universität, and
∗Staatliche Orthopädische Klinik, Munich, Germany

Summary
From January 1986 to December 1990 we treated 57 patients with
deformed forefeet due to rheumatoid arthritis. In 70 cases (13
patients on both sides) surgical correction according to the Lelièvre
procedure was carried out. The outcome of this operation has been
analysed in an attempt to find reasons for poor results and the
relatively high recurrence rate of hallux valgus. Thirty-one patients
were reviewed, i.e. a total of 44 operations at a median follow-up of
5 years and 3 months. The investigation included a subjective,
objective and radiological assessment of the outcome of this kind of
surgical management. The results showed that 77% of the operated
feet by the Lelièvre procedure were painfree or had dramatically
reduced pain. Patients with persisting complaints had a recurrence
of plantar callosities and a distinct fibular shift of toes.
Radiologically the failures showed inadequately resected metatarsal
heads. We have emphasized a critical evaluation of the metatarsal
index. The plus-minus index was associated with a good result,
whereas the plus index always went along with a poor result. The
Lelièvre procedure performed precisely and with a plus-minus
metatarsal index can produce very good results and can be
recommended for the surgical management of the deformed forefoot
due to rheumatoid arthritis.

Keywords: foot, surgery, rheumatoid arthritis

Introduction type’ of chronic rheumatoid arthritis predominates.

In 16% of patients rheumatoid arthritis starts in
the feet [1]. Metatarsophalangeal (MTP) joint
involvement during the course of the disease is
reported in 80–92% of all cases [2–4]. In the affected
MTP joints, Clayton and Charley’s [5] so-called ‘loose
Correspondence: Dr M. Pfahler, Orthopädische Klinik, Klinikum
Grosshadern, Ludwig-Maximilians-Universität, München, Mar-
chioninistrasse 15, D-81377 München, Germany.
Pathogenetically soft tissue and bursal involvement
cause secondary joint deformity with gradual
destruction and instability.
In 1912 Hoffmann [6] was the first to recommend
metatarsal head resection for ‘infectious arthritis’ of
the forefoot. Numerous surgical procedures followed.
The Hoffmann operation was modified by Kates,
Kessel and Kay [7] in 1967. In 1961 Lelièvre [8]
reported on a similar surgical technique of metatarsal
head resection in rheumatoid arthritis of the foot.

 1996 Arnette Blackwell SA 83

84 M. PFAHLER, M. KRÜGER-FRANKE & F. W. HAGENA

At the Orthopaedic Department of the Ludwig-

Maximilians-University in Munich the Lelièvre
procedure for surgical correction of the rheumatoid
arthritic deformed forefoot has been used routinely
for many years. We analysed the outcome of this
operation to find reasons for an unsatisfactory result.

Materials and methods

From January 1986 to December 1990 a total of 57
patients had surgery for correction of a deformed
forefoot due to rheumatoid arthritis. In 13 patients
both feet were operated upon (70 surgical cases). Only
31 patients with 44 treated feet could be examined
retrospectively with a median follow-up of 5 years
and 3 months after surgery. Their median age was
58 years (range 31–74); 26 (84%) were female with a
median age of 59 years, and five (16%) were male
with a median age of 52 years.
The surgical technique was a slight modification
of the Lelièvre procedure as described in 1961 [8].
Like Tillmann [9] we used a plantar approach with a
plastic elliptical skin excision and removal of plantar
callosities. Through this transverse plantar skin
incision for toes 2–5 and a separate longitudinal
dorso-medial incision for the first toe the metatarsal
heads were thoroughly prepared and finally resected
at the subcapital level. Attention was paid to a plus-
minus metatarsal index (1=2>3>4>5) as described
by Lelièvre [8] and Viladot [10]. The operation was
completed by plastic closure of the capsule,
mobilization of the sesamoids and rebalancing of
the flexor tendons. Post-operatively, a bulky wound
dressing is applied for 3–5 days followed by a special
dynamic splint for 6 weeks (Figure 1). Walking is
primarily allowed by heel contact. Full weight-
bearing is achieved at the end of the fourth week.
Finally an orthosis was made for the foot. Twenty-
four closed mobilizations of PIP joints were
undertaken to improve claw toe deformities.
Each patient answered a questionnaire on
satisfaction, pain, cosmesis, function and whether
walking aids were used or not. The clinical
examination consisted of assessment of local pain,
callosities, hallux valgus and recurrence of claw toes,
Figure 1
foot shape, toe index and function. A dorso-plantar Dynamic splint for immobilization after surgery (a, b)
and oblique radiograph of all feet were analysed
for resection planes, bony fragments and metatarsal
index.

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 SURGICAL CORRECTION OF THE RHEUMATOID FOREFOOT 85

Figure 2
Clinical example of a very good cosmetic and functional result. a, b The pre-operative state of a 54-year-old female with rheumatoid
arthritis for 16 years. c, d, The post-operative result 8 years after metatarsal head resection.

Results supports in 86%, whereas 40% were supplied with

In 29 (66%) cases there was no pain at all after
operation. In the remaining 15 (34%) pain occurred
only while weight bearing and the pain was
subjectively classified as minor in four (9%), moderate
in seven (16%) and severe in four (9%) cases. Surgery
reduced pain in 34 (77%) feet; six (14%) feet were
unchanged and four (9%) were worse.
The cosmetic aspect was satisfactory in 21 (48%)
feet; 10 (23%) were uncertain and 13 (29%)
unsatisfactory (Figure 2). Shoe size decreased in 29
(66%) cases; 26 one size smaller, 3 two sizes smaller.
Sixty per cent could wear ordinary shoes with
orthopaedic shoes. The functional result was
regarded as improved in 23%, unchanged in 52%
and worse in 25%. The overall satisfaction rate was
77% and correlated with pain reduction.
There was a predominance of the Egyptian toe
index in 29 (66%) feet; the squared index was seen
in 15 (34%) feet. There was no Greek foot. Local
pain occurred in four first metatarsophalangeal joints.
Plantar callosities could be observed in eight (18%)
feet; the remaining 36 (82%) feet had soft plantar
skin without any callosities.
The clinical functional assessment showed an

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86 M. PFAHLER, M. KRÜGER-FRANKE & F. W. HAGENA
Table 1 Post-operative functional result. Mobility of the
arthroplastic resected MTP-joint
MTP Free mobility Reduced mobility
I 14 28
II 7 37
III 7 36
IV 5 39
V 17 27
expected preponderance of reduced mobility of the
MTP joints. But usually the patient was not impaired
by this functional loss. In two cases with fibrous
ankylosis the patients were not satisfied (Table 1).
The median pre-operative hallux valgus angle of
51° (range 20–85°) was improved to a median post-
operative angle of 23° (range 8–55°). By limiting
the physiological hallux valgus angle to 20° the
recurrence or persistence of hallux valgus was seen
in 34 (77%) feet but was not associated with a poor
result. This observation was unexpectedly high and
comparable with the persisting rate of fibular shift
of the lesser toes (Table 2).
The radiographic analysis showed smooth
resection planes in 36 (82%) cases; spurs in eight
(18%). Bony fragments and calcification in the
resected joint area could be seen in four (9%) feet.
Three patients (7%) had bony impingement because
of insufficient resection of the metatarsal head; they
were not satisfied with the surgical result. A plus-
minus metatarsal index was achieved in 34 (77%)
feet; a plus index in eight (18%) and a minus index
in two (5%) (Figure 3).
Complications
There were four (9%) complications. Two cases with
secondary wound healing and two wound infections
were easily managed. There was no deep vein
Table 2 Post-operative recurrence of fibular shift of toes
Toe (n=44)
I 34
II 27
III 28
IV 22
V 0
thrombosis, no pulmonary embolism and no flare up
of the rheumatoid disease.
Ankylosis
2
Discussion and conclusions
0
Metatarsal head resection for the management of
1
0 the rheumatoid arthritic deformed forefoot is well
0 established. Our retrospective analysis of 44 operated
feet shows good results in almost 80%, with pain
reduction. This is comparable with other authors
[2, 7, 8, 11–21] and reflects the success of this surgical
technique. Patients with persistent pain had a
recurrence of plantar callosities and a distinct fibular
shift of all toes. We are convinced that Tillmann’s
technique of plastic ovoid excision of plantar
callosities and subsequent dermodesis [9] can reduce
this problem.
We now prefer the transverse plantar approach for
the lesser toes. However, this approach is still not
fully accepted. Van Loon [18] found, in a retrospective
comparative study of plantar versus dorsal resection,
a higher rate of wound infections with the dorsal
incision and an increased recurrence of metatarsalgia
with the plantar one. However, there was no
statistical significance and the results were similar
and independent of the approach. On the other hand,
Gschwend [2] reported on a higher incidence of
wound infections with plantar resection. The senior
author of this paper found in an earlier study [15] a
better outcome after use of the plantar approach and
no longer uses the dorsal approach.
The rate of fibular shift of all toes except the little
toe was 50% for the lesser toes and 77% for the
hallux. This undesirable clinical appearance did not
coincide with the good and satisfying results. Similar
observations were made by Tillmann [9,20], who saw
a post-operative fibular shift in up to 50% and by
Stockley [19] in 73% of all cases. An explanation of
this phenomenon may lie in the morphology of the
rheumatic foot and its pathogenesis [22].
The hallux itself seems to play a dominant role in
the surgical technique and functional result. Three
patients were dissatisfied, because of inadequate
resection of the first metatarsal and subsequent bony
impingement and poor function. Van der Heijden et
al. [17] reported on the problem of the incomplete
reduction of hallux valgus deformity after metatarsal
head resection in rheumatoid patients and poor
post-operative function. Hughes et al. [16] published
 1996 Arnette Blackwell SA, Foot and Ankle Surgery, 2, 83–89
 SURGICAL CORRECTION OF THE RHEUMATOID FOREFOOT
Figure 3
Radiological example of a pain-free satisfied 59-year-old female with rheumatoid arthritis for 9 years. a, Pre-operative state. b, Post-
operative result demonstrates a desirable plus-minus metatarsal index.
a comparative study of metatarsal head resection
alone and in combination with an arthrodesis of MTP
I and found a slightly better outcome with the MTP
I arthrodesis. Perhaps the good results of Äström et
al. [23] with a proximal osteotomy of the first
metatarsal can improve the clinical and functional
outcome of the first ray. This should also be
considered with a primary metatarsus varus. The
correlation of a pathological hallux valgus and a
primary metatarsus varus was reported by Hoffmann
[24]. He saw a significantly higher incidence of
pathological hallux valgus deformity with a varus
metatarsal angle of more than 15 degrees.
Review of radiographs showed three patients with
bony impingement and an unsatisfactory result. This
contradicts the statement that the radiological result
 1996 Arnette Blackwell SA, Foot and Ankle Surgery, 2, 83–89
87
does not influence the clinical and subjective result
[12, 25, 26]. In addition, the analysis of the metatarsal
indices showed that in accordance with other
important studies [7, 8, 10, 14, 27], the plus-minus
index is the key for a good result.
The appearance of the foot did not have an
important influence on the assessment of the
operation. There was a decrease in foot size in two-
thirds of all cases. Forty per cent of the operated feet
had to be supplied with orthopaedic shoes, as in a
study by Grob and Gschwend [13].
When planning the treatment of rheumatoid
forefoot deformities the influence of mid and hindfoot
deformities play a specific role of importance [28]
and must be considered in the complex treatment
plan of rheumatoid foot surgery [29].
88 M. PFAHLER, M. KRÜGER-FRANKE & F. W. HAGENA
Conclusions
Metatarsal head resection by the technique of Lelièvre
[8] modified by Tillmann’s approach [9] is very
effective for the surgical management of the
deformed forefoot due to rheumatoid arthritis and
can reduce pain in almost 80% of the cases. The best
results are achieved by an exact operative technique
and by ensuring a plus-minus metatarsal index. The
patient must be informed that the operated foot
will become smaller and that usually supports or
orthopaedic shoes will be necessary after surgery.
The functional result and cosmesis are secondary to
the benefit of pain relief.
Zusammenfassung
Von Januar 1986 bis Dezember 1990 wurden 57
Patienten wegen einer cP-bedingten Destruktion
des Vorfußes operativ versorgt. In 70 Fällen
(13 doppelseitige Versorgungen) wurde eine
Arthroplastik in der Technik nach Lelièvre
durchgeführt. Das Ziel der vorliegenden Arbeit
war es, die Operationsergebnisse zu analysieren,
Ursachen für ein unbefriedigendes Resultat
herauszufinden und die hohe Rate an Hallux valgus
Rezidiven zu diskutieren. Wir konnten retrospektiv
31 Patienten mit insgesamt 44 operierten Füßen
bei einer mittleren postoperativen Nachunter-
suchungszeit von 5 Jahren und 3 Monaten auswerten.
Die Nachuntersuchung umfaßte eine subjektive,
klinische und röntgenologische Analyse und
Bewertung des Operationserfolgs. Die Auswertung
zeigte, daß in 77% der Fälle durch die
Operationsmethode nach Lelièvre Schmerzfreiheit
oder deutliche Schmerzreduktion erzielt werden
konnte. Patienten mit persistierenden Beschwerden
zeigten ein Rezidiv einer plantaren Schwielenbildung
und einen deutlichen fibularen Shift der Zehen.
Röntgenologisch bestanden bei den unbefriedigen-
den Fällen unzureichende Resektionen der Meta-
tarsaleköpfchen. Zusätzlich bewerteten wir kritisch
den Metatarsalindex. Dabei war der plus-minus
Index regelhaft mit einem guten Operationsergebnis
verknüpft, während der plus Index immer ein
schlechtes und unbefriedigendes Resultat mit sich
brachte. Die Operation nach Lelièvre erfordert ein
exaktes intraoperatives Vorgehen; dabei sollte
ein plus-minus Metatarsalindex angestrebt werden.
Unter Berücksichtigung dieser Kautelen können sehr
gute Resultate erreicht werden. Die Metatarsal-
köpfchenresektion nach Lelièvre kann demnach zur
operativen Korrektur des cP-bedingten destruierten
Vorfußes empfohlen werden.
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