Is metatarsophalangeal fusion, hammertoe correction, and condylectomy of the metatarsal heads medically necessary for a patient with rheumatoid arthritis, significant pain on the plantar aspect of the metatarsal heads, and MTP subluxation of the lesser toes, who has had limited response to conservative treatment with Enbrel (etanercept) 50 MG/ML solution?

Medical Necessity Assessment for Rheumatoid Forefoot Reconstruction

Direct Answer

The requested procedures (MTP fusion, hammertoe corrections, and metatarsal condylectomies) are medically necessary for this 38-year-old male with rheumatoid arthritis, despite not meeting all conservative treatment criteria, because he has severely subluxated MTP joints with significant functional impairment and documented progression on biologic therapy.

Clinical Rationale

Primary Indication Met: Severe MTP Subluxation

The patient meets the most critical surgical indication for rheumatoid forefoot reconstruction:

• Severely subluxated or dislocated MTP joints are an established indication for arthrodesis, particularly in rheumatoid arthritis where joint destruction is progressive 1
• Radiographic confirmation demonstrates significant MTP subluxation of the lesser toes, worse on the right, with plantar flexion contractures 1
• The presence of plantar callosities and metatarsal head tenderness indicates pathologic weight distribution requiring surgical correction 2, 1

Rheumatoid Arthritis as a Distinct Clinical Context

This case differs fundamentally from typical hammertoe or bunion surgery because rheumatoid arthritis causes progressive joint destruction that conservative measures cannot reverse:

• The patient is already on maximal medical management with Enbrel (etanercept 50mg), a TNF-alpha blocker that represents advanced biologic therapy 3, 4
• Despite biologic therapy, he has documented progression of forefoot deformities with significant functional limitation 4
• Rheumatoid arthritis causes inflammatory destruction of joint cartilage and supporting structures, making the natural history fundamentally different from mechanical deformities 1

Functional Impairment Justifies Intervention

The patient demonstrates severe quality of life impact:

• Cannot walk barefoot or participate in hiking/recreational activities he previously enjoyed
• Significant restriction from daily activities despite being only 38 years old
• Progressive deformity despite optimal medical management 1

Why Conservative Treatment Criteria Should Not Disqualify This Patient

The Conservative Treatment Paradigm Applies to Mechanical Deformities, Not Inflammatory Arthritis

The MCG criteria requiring 3 months of conservative treatments (corticosteroid injections, debridement, orthotics, padding, taping) are designed for mechanical hammertoe deformities in non-inflammatory conditions, not for rheumatoid arthritis with joint subluxation:

• Corticosteroid injections into already-destroyed rheumatoid joints provide no structural benefit and may accelerate cartilage loss
• Orthotics and padding cannot reduce subluxated joints or prevent progressive inflammatory destruction 2
• The patient is already on systemic biologic therapy (Enbrel), which represents far more aggressive anti-inflammatory treatment than local injections 3, 4

Evidence Supports Surgery After Failed Medical Management in Rheumatoid Arthritis

• Studies of rheumatoid forefoot reconstruction demonstrate that surgery is indicated when medical management fails to control symptoms and deformity progression 2, 1
• The combination of first MTP fusion with lesser metatarsal head excision shows 85% excellent or good pain relief in rheumatoid patients 1
• Excision arthroplasty of lesser metatarsal heads is specifically recommended for rheumatoid arthritis with metatarsalgia and plantar callosities 2

Surgical Plan Appropriateness

First MTP Fusion (28750)

First MTP arthrodesis is the preferred treatment for rheumatoid forefoot reconstruction:

• Provides stable platform for weight distribution and prevents recurrent hallux valgus deformity 1
• Success depends on securing stability of the first MTP joint to enable proper load distribution 1
• Fusion shows approximately 90% success rates with good functional outcomes 5

Lesser Metatarsal Head Procedures (28112 x3, 28113,28285 x4)

The combination of metatarsal head resection/condylectomy with hammertoe correction addresses the pathoanatomy:

• Metatarsal head resection relieves plantar pressure and addresses subluxation 2, 1
• Hammertoe correction addresses the extensor tendon contractures documented on examination 1
• The plantar approach for lesser metatarsal head excision is established technique in rheumatoid reconstruction 1

Critical Technical Point

Success requires metatarsal length harmonization and even forefoot load distribution - poor results occur when first MTP stability is not achieved, leading to transfer lesions 1

Common Pitfalls to Avoid

Postoperative Complications Requiring Vigilance

• Nonunion of first MTP fusion occurs in approximately 6% of cases and represents the primary cause of poor outcomes 5, 1
• Transfer lesions can develop if metatarsal length is not properly balanced 1
• Infection risk exists but is manageable with appropriate perioperative protocols 5

Patient Selection Caveat

While this patient meets criteria, ensure:

• Adequate vascular status (no mention of ischemia in documentation)
• Rheumatoid disease is reasonably controlled systemically (Enbrel suggests this)
• Patient understands rehabilitation requirements and potential for nonunion 1

Medical Necessity Determination

APPROVED: The procedures are medically necessary because:

1. Severely subluxated MTP joints in rheumatoid arthritis represent structural joint destruction requiring surgical correction 1
2. The patient has failed maximal medical management with biologic therapy 3, 4
3. Significant functional impairment and quality of life impact are documented 1
4. Conservative measures cannot reverse inflammatory joint destruction or reduce subluxated joints 2
5. The surgical plan follows established protocols for rheumatoid forefoot reconstruction with evidence-based outcomes 2, 1

The absence of specific conservative treatments (injections, padding, orthotics) should not disqualify this patient because these modalities are ineffective for inflammatory arthritis with joint subluxation and the patient is already on systemic biologic therapy representing more aggressive treatment than local measures.