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Kim SJ, Gil YW, Sung IH. Preoperative patient's expectations and clinical outcomes after rheumatoid forefoot deformity reconstruction by joint sacrificing surgery. JOURNAL OF RHEUMATIC DISEASES 2024; 31:33-40. [PMID: 38130962 PMCID: PMC10730808 DOI: 10.4078/jrd.2023.0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/12/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
Objective To study the clinical and radiologic factors related with overall patient satisfaction of joint scarifying reconstruction on severe rheumatoid forefoot deformity (RFD). Methods Forty cases of RFD were retrospectively enrolled. A questionnaire on the factors for patient's expectations and satisfactions of the greater and lesser toes was administered, including repression of relapse in deformity (D), pain reduction (P), improvement in shoe wearing (S), barefoot activity (B), and appearance (A). Overall satisfaction were assessed using the 5-digit-scale. Hallux valgus angle, 1, 2 intermetatarsal angle, and other radiologic parameters were measured. Pearson's correlation and multiple linear regression analyses were used to evaluate the relationships between these factors and overall satisfaction. Results Overall satisfaction was 4.0±0.82. Postoperative radiologic parameters were corrected in adequate range. Visual analog scale (VAS) was reduced from 7.2±2.1 to 2.2±1.8. For the greater toe, patient's expectations (D, P, S, B, and A) were 4.2, 4.1, 3.0, 2.5, 2.7 and satisfactions were 4.2, 4.0, 3.4, 3.5, 3.3, respectively. For the lesser toes, patient's expectations (D, P, S, B, and A) were 3.9, 4.1, 3.4, 3.0, 2.8, and satisfactions were 3.4, 4.0, 3.4, 3.6, 2.9, respectively. Satisfactions with P and B, and reduction amounts of VAS were significantly correlated with overall satisfaction. Conclusion Although forefoot reconstruction with a joint sacrificing procedure is non-physiological, it could be a good surgical option for severe RFD. Each patient's expectations and satisfactions with this procedure could vary. Thus, it seems important to inform patients preoperatively that expectation could be fulfilled well or less.
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Affiliation(s)
- Sung-Jae Kim
- Department of Orthopedic Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Young-Woon Gil
- Department of Orthopedic Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Il-Hoon Sung
- Department of Orthopedic Surgery, Hanyang University College of Medicine, Seoul, Korea
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Hassel K. Unterschiede in der Therapie entzündlich rheumatischer und
degenerativer Füße. Die Vorfußchirurgie. AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1814-4096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungDer Unterschied zwischen rheumatischen und degenerativen Veränderungen am
Fuß liegt in der fortschreitenden Destruktion der Gelenke bei
persistierender Synovialitis der rheumatoiden Arthritis (RA). Unter der heute
wirksameren immunsuppressiven Therapie und eines frühen und aggressiven
Beginns zeigen sich mildere Verlaufsformen. So können zunehmend auch
gelenkerhaltende Verfahren der Vorfußchirurgie Anwendung finden.
Entscheidend ist hier jedoch die Remission mit sicherer Krankheitskontrolle
für den gelenkerhaltenden Eingriff. Dennoch ist das Rezidiv- und
Fehlstellungsrisiko aufgrund wiederkehrender arthritischer Phasen höher.
Rheumaorthopädische Standardverfahren, wie die Arthrodese des
Großzehengrundgelenkes mit Resektion der Metatarsaleköpfchen
haben aber Ihren Stellenwert beim Vollbild des erosiven rheumatischen
Vorfußes nicht verloren. Ein standardisiertes Vorgehen fehlt. Umso
wichtiger ist es, mit jedem Patienten individuell die richtigen
Maßnahmen zu festzulegen.
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Affiliation(s)
- Kathryn Hassel
- Orthopädische Rheumatologie, Vitos Orthopadische Klinik Kassel
gGmbH, Kassel, Germany
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Takakubo Y, Wanezaki Y, Oki H, Naganuma Y, Shibuya J, Honma R, Suzuki A, Satake H, Takagi M. Forefoot Deformities in Patients with Rheumatoid Arthritis: Mid- to Long-Term Result of Joint-Preserving Surgery in Comparison with Resection Arthroplasty. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111257. [PMID: 34769775 PMCID: PMC8583379 DOI: 10.3390/ijerph182111257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 11/30/2022]
Abstract
Background: Joint-preserving surgery for the forefoot has been increasingly performed for rheumatoid arthritis (RA). We compared joint-preserving surgeries with resection arthroplasty for RA in the forefoot. Methods: Forefoot surgeries were performed on 62 toes in 42 patients with RA (men: 2; women: 40) between 2002 and 2018. Three groups were compared: PP—31 toes treated with joint-preserving surgery involving the modified Mann method for the big toe and offset osteotomy for lesser toes, PR—15 toes treated with joint-preserving surgery for the big toe and resection arthroplasty for lesser toes, and RR—16 toes treated with resection arthroplasty for all the toes. Results: The PP group had significantly higher mean scores on a scale for RA in the foot and ankle at the latest follow-up than the RR group (86 vs. 75 points; p < 0.05). Hallux valgus (angle > 20°) of the big toe at the latest follow-up recurred in 10 (32%), 9 (60%), and 16 (100%) patients in the PP, PR, and RR groups, respectively. A revision surgery was performed in one patient each in the PP and PR groups. Conclusions: Joint-preserving surgery is superior to resection arthroplasty in preventing function loss and the recurrence of hallux valgus.
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Affiliation(s)
- Yuya Takakubo
- Department of Orthopaedic Surgery, Faculty of Medicine, Yamagata University, Yamagata 990-9585, Japan; (Y.W.); (H.O.); (Y.N.); (J.S.); (R.H.); (A.S.); (H.S.); (M.T.)
- Department of Rehabilitation, Faculty of Medicine, Yamagata University, Yamagata 990-9585, Japan
- Correspondence:
| | - Yoshihiro Wanezaki
- Department of Orthopaedic Surgery, Faculty of Medicine, Yamagata University, Yamagata 990-9585, Japan; (Y.W.); (H.O.); (Y.N.); (J.S.); (R.H.); (A.S.); (H.S.); (M.T.)
| | - Hiroharu Oki
- Department of Orthopaedic Surgery, Faculty of Medicine, Yamagata University, Yamagata 990-9585, Japan; (Y.W.); (H.O.); (Y.N.); (J.S.); (R.H.); (A.S.); (H.S.); (M.T.)
- Faculty of Orthopaedic Surgery, Yamagata Saisei Hospital, Yamagata 990-9585, Japan
| | - Yasushi Naganuma
- Department of Orthopaedic Surgery, Faculty of Medicine, Yamagata University, Yamagata 990-9585, Japan; (Y.W.); (H.O.); (Y.N.); (J.S.); (R.H.); (A.S.); (H.S.); (M.T.)
- Faculty of Orthopaedic Surgery, Yamagata Prefectural Central Hospital, Yamagata 990-2292, Japan
| | - Junichiro Shibuya
- Department of Orthopaedic Surgery, Faculty of Medicine, Yamagata University, Yamagata 990-9585, Japan; (Y.W.); (H.O.); (Y.N.); (J.S.); (R.H.); (A.S.); (H.S.); (M.T.)
- Department of Orthopaedic Surgery, Izumi Orthopaedic Hospital, Sendai-shi 981-3121, Japan
| | - Ryusuke Honma
- Department of Orthopaedic Surgery, Faculty of Medicine, Yamagata University, Yamagata 990-9585, Japan; (Y.W.); (H.O.); (Y.N.); (J.S.); (R.H.); (A.S.); (H.S.); (M.T.)
- Department of Rehabilitation, Faculty of Medicine, Yamagata University, Yamagata 990-9585, Japan
| | - Akemi Suzuki
- Department of Orthopaedic Surgery, Faculty of Medicine, Yamagata University, Yamagata 990-9585, Japan; (Y.W.); (H.O.); (Y.N.); (J.S.); (R.H.); (A.S.); (H.S.); (M.T.)
| | - Hiroshi Satake
- Department of Orthopaedic Surgery, Faculty of Medicine, Yamagata University, Yamagata 990-9585, Japan; (Y.W.); (H.O.); (Y.N.); (J.S.); (R.H.); (A.S.); (H.S.); (M.T.)
| | - Michiaki Takagi
- Department of Orthopaedic Surgery, Faculty of Medicine, Yamagata University, Yamagata 990-9585, Japan; (Y.W.); (H.O.); (Y.N.); (J.S.); (R.H.); (A.S.); (H.S.); (M.T.)
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Outcomes of Scarf and Akin Osteotomy with Intra-Articular Stepwise Lateral Soft Tissue Release for Correcting Hallux Valgus Deformity in Rheumatoid Arthritis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182010667. [PMID: 34682415 PMCID: PMC8535323 DOI: 10.3390/ijerph182010667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/04/2021] [Accepted: 10/09/2021] [Indexed: 02/08/2023]
Abstract
Background. The effectiveness of scarf and Akin osteotomy with intra-articular lateral soft tissue release for the correction of hallux valgus (HV) in patients with rheumatoid arthritis (RA) has not been elucidated. Methods. A total of 36 feet in 28 patients with RA who had scarf and Akin osteotomy with intra-articular stepwise lateral soft tissue release between 2015 and 2020 at a single institute were investigated retrospectively, with a mean follow-up period of 32.0 ± 16.9 months. Radiographic evaluations including the HV angle, intermetatarsal angle, and sesamoid position were performed preoperatively and postoperatively. Clinical outcomes were assessed using the Japanese Society of Surgery of the Foot (JSSF) hallux scale and self-administered foot evaluation questionnaire (SAFE-Q). Results. The procedure resulted in significant HV correction, with a recurrence rate of 13.9%. The JSSF scale and all five SAFE-Q subscale scores significantly improved (p < 0.05), with no major complications. More than 90% of cases achieved adequate lateral soft tissue release without sacrificing the adductor tendon of the hallux. Conclusions. Intra-articular stepwise lateral soft tissue release in combination with scarf and Akin osteotomy provided satisfactory radiographic and patient-reported outcomes for the correction of HV in patients with RA with minimum lateral soft tissue release.
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Combination of Modified Scarf Osteotomy and Metatarsal Shortening Offset Osteotomy for Rheumatoid Forefoot Deformity. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910473. [PMID: 34639772 PMCID: PMC8508223 DOI: 10.3390/ijerph181910473] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 09/27/2021] [Accepted: 10/02/2021] [Indexed: 11/17/2022]
Abstract
With the progress of medical treatment for rheumatoid arthritis (RA), several joint-preserving forefoot surgical procedures have been established and performed. In this situation, we have been choosing the combined surgery: modified scarf osteotomy for the great toe and metatarsal shortening offset osteotomy for the lesser toes in RA cases. A retrospective observational study of 53 RA patients (mean follow-up period: 4.6 years) who underwent the surgery was completed. RA foot ankle scores were assessed, using the Japanese Society for Surgery of the Foot (JSSF) standard rating system, and a self-administered foot evaluation questionnaire (SAFE-Q) was also checked to evaluate clinical outcomes. For radiological evaluations, deformity parameters were measured using radiographs of the feet with weight-bearing. JSSF hallux and lesser toes scores and the SAFE-Q score showed significant improvement in all indices. HVA, M1-M2A, M1-M5A, M2-M5A, and sesamoid position were significantly improved after surgery. At the final follow-up, the hallux valgus deformity had recurred in 4 feet (7.5%), and hallux varus deformity had developed in 8 feet (15.1%). No case of recurrent hallux valgus deformity required revision surgery. Recurrence of dorsal dislocation/subluxation of the lesser toe MTP joint was seen in 6 feet (11.3%) after surgery. A combination of modified scarf osteotomy for the great toe and modified metatarsal shortening offset osteotomy for the lesser toes is one of the novel surgical procedures for rheumatoid forefoot deformity. Preoperative disease activity of RA negatively affected the clinical score of the hallux. The spread of M2-M5A was a risk factor for resubluxation of the lesser toe MTP joint.
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Joint-Preserving Surgery for Forefoot Deformities in Patients with Rheumatoid Arthritis: A Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18084093. [PMID: 33924481 PMCID: PMC8068870 DOI: 10.3390/ijerph18084093] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/23/2021] [Accepted: 04/08/2021] [Indexed: 11/17/2022]
Abstract
The combination of first metatarsophalangeal joint arthrodesis and resection arthroplasty of all lesser metatarsal heads has been historically considered the golden standard treatment for rheumatoid forefoot deformities. However, as recent improved management of rheumatoid arthritis have reduced progression of joint destruction, the surgical treatments for rheumatoid forefoot deformities have gradually changed from joint-sacrificing surgery, such as arthrodesis and resection arthroplasty, to joint-preserving surgery. The aim of this literature review was to provide current evidence for joint-preserving surgery for rheumatoid forefoot deformities. We focused on the indications, specific outcomes, and postsurgical complications of joint-preserving surgery in this review.
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Yano K, Ikari K, Tobimatsu H, Okazaki K. Patient-Reported and Radiographic Outcomes of Joint-Preserving Surgery for Rheumatoid Forefoot Deformities: A Retrospective Case Series with Mean Follow-up of 6 Years. J Bone Joint Surg Am 2021; 103:506-516. [PMID: 33475311 DOI: 10.2106/jbjs.20.01144] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Rheumatoid arthritis (RA) is an autoimmune disorder and a chronic inflammatory disease that can damage joints throughout the body. As dramatic improvements in medical treatment have contributed to reduced progression of joint destruction, surgical methods for the treatment of RA-related forefoot deformities have gradually changed from joint-sacrificing to joint-preserving. The aim of this study was to assess the long-term outcomes, including patient-reported outcomes, of joint-preserving surgery for forefoot deformities associated with RA. METHODS This retrospective study included 105 feet in 89 patients with RA who were treated during the period of January 2012 to May 2015 and had a minimum of 5 years of follow-up (mean, 6.0 ± 0.9 years). The patient-reported outcome measure used was the Self-Administered Foot Evaluation Questionnaire (SAFE-Q), which was completed preoperatively and at the latest follow-up (n = 53 feet). The hallux valgus angle (HVA), the intermetatarsal angle (IMA), and the position of the medial sesamoid were measured preoperatively, at 3 months postoperatively, and at the latest follow-up. Cases of delayed wound-healing, hallux valgus recurrence, nonunion at the osteotomy sites, and reoperation were recorded. Kaplan-Meier survival curves were used to determine the estimated survivorship, with reoperation as the end point. RESULTS Scores of all 5 subscales of the SAFE-Q demonstrated significant improvement at the latest follow-up. The average HVA and IMA decreased significantly 3 months postoperatively, and these measurements remained significantly lower than the preoperative values (p < 0.01). The position of the medial sesamoid at the latest follow-up improved significantly (p < 0.01). Delayed wound-healing was found at the site of surgery in 21 (20.0%) of the 105 feet. Recurrence of hallux valgus was observed in 11 (10.5%) of the feet. There was no case of nonunion at any osteotomy site. Eleven (10.5%) of the feet required reoperation. The estimated survivorship of the studied joint-preserving surgery at 7 years, with reoperation as the end point, was 89.5%. CONCLUSIONS Satisfactory long-term patient-reported and radiographic outcomes after joint-preserving surgery for forefoot deformities associated with RA can be achieved. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Koichiro Yano
- Department of Orthopedic Surgery (K.Y., K.I., H.T., and K.O.) and Institute of Rheumatology (K.Y., K.I., and H.T.), Tokyo Women's Medical University, Tokyo, Japan
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8
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Zaid HHG, Di W, Yang R, Wu D, Yang M. Surgical Management of Monoarticular Rheumatoid Arthritis of the Fifth Metatarsophalangeal Joint. Orthop Surg 2020; 12:1597-1604. [PMID: 32776484 PMCID: PMC7767787 DOI: 10.1111/os.12725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To investigate the clinical and radiological outcomes in patients with monoarticular rheumatoid arthritis of the fifth metatarsophalangeal joint after Weil osteotomy. METHODS From July 2011 to September 2015, 18 feet of 16 rheumatoid arthritis patients who underwent Weil osteotomy of the fifth metatarsal toe with a mean age at the time of surgery of 48.8 ± 7.4 years were reviewed retrospectively. The mean disease duration was 44.6 ± 6.8 months, and the follow-up period was 36 months. Clinical outcomes were evaluated according to the American Orthopaedic Foot and Ankle Society lesser metatarsophalangeal interphalangeal scale (AOFAS), 10-item SF-36 physical functioning and 2-item SF-36 bodily pain, Visual Analogue Scale (VAS), and satisfaction scores. In the radiologic evaluation, fifth metatarsophalangeal angle (MTP-5), lateral deviation angle (LDA), and longitudinal axes of the fifth metatarsal were measured on anterior-posterior (AP) weight-bearing radiographs preoperative and at the last follow-up. RESULTS Clinical assessment showed that the total average of AOFAS was significantly increased from preoperative 53.6 ± 9.0 to 98.7 ± 2.0 points, and the VAS score was significantly decreased from preoperative 4.1 ± 1.5 to 1.1 ± 0.8 points at the last follow-up (P < 0.001). The total averages of SF-36 physical functioning and SF-36 bodily pain were significantly increased from preoperative 48.9 ± 9.0 to 99. ± 2.1 and from 61.4 ± 12.1 to 99.4 ± 2.4 points, respectively, at the last follow-up (P < 0.001). Subjectively, the excellent outcome of the surgery results were rated by 13 patients (81.3%) that underwent surgery and three patients (18.7%) were rated as good. Regarding radiographic parameters, the mean MTP-5 significantly decreased from 21.5° ± 1.2° preoperatively to 10.2° ± 1.2°, the mean LDA significantly decreased from 7.1° ± 1.2° preoperatively to -2.4° ± 1.0°, and the mean length of the fifth metatarsal was significantly shortened from 71.5 ± 1.4 preoperatively to 67.8 ± 1.5 mm at the final follow-up visit (P < 0.001). No malunion, nonunion, necrosis, pseudoarthrosis, or fracture of the fifth metatarsal was found. No exuberant bone growth, perforation of the screw, subluxation, or dislocation was observed. No indications of modification, revision or repeat surgery, or delayed wound healing were observed during follow-up period. CONCLUSION Surgical management of the monoarticular rheumatoid arthritis of the fifth metatarsophalangeal joint can achieve good clinical and radiological outcomes, with pain relief and dislocation reduction, as well as high satisfaction and improvement without recurrence or progression during the follow-up period.
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Affiliation(s)
- Hamood H G Zaid
- Department of Orthopedics, The First Hospital of China Medical University, Shenyang, China
| | - Wu Di
- Department of Orthopedics, The First Hospital of China Medical University, Shenyang, China
| | - Rufei Yang
- Department of Rehabilitation Medicine, The First Hospital of China Medical University, Shenyang, China
| | - Di Wu
- Department of Orthopedics, The First Hospital of China Medical University, Shenyang, China
| | - Maowei Yang
- Department of Orthopedics, The First Hospital of China Medical University, Shenyang, China
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9
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Abstract
Weil osteotomy (WO) is the most common technique worldwide for the treatment of mechanical metatarsalgia. The main indication for WO is propulsive/third rocker metatarsalgia that is in relation with an abnormal length of a certain metatarsal with respect to the neighboring metatarsals in the frontal plane. Most clinical studies have showed good to excellent results after WO. However, complications such as floating toes led to evolution of WO and the development of the triple-cut WO that allows for shortening coaxial to the shaft without plantar translation of metatarsal head. Other variations of WO may treat other forefoot disorders.
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Affiliation(s)
- Manuel Monteagudo
- Orthopaedic Foot and Ankle Unit, Orthopaedic and Trauma Department, Hospital Universitario Quirónsalud Madrid, Faculty Medicine UEM Madrid, Madrid, Spain.
| | - Ernesto Maceira
- Orthopaedica Foot and Ankle Unit, Complejo Hospitalario La Mancha Centro, Av de la Constitución 3, 13600, Alcázar de San Juan, Ciudad Real, Spain
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Dmytriiev D, Lysak Y, Glazov Y, Geranin S, Zaletska O. Mini-invasive methods of treatment of diabetic foot pain. PAIN MEDICINE 2019. [DOI: 10.31636/pmjua.v4i3.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Neuropathic pain occurs with diabetic polyneuropathy more often than with all polyneuropathies of another etiology. Because the cause of pain can rarely be cured, treatment is usually symptomatic. Neuropathic pain is usually poorly controlled by analgesics. Management of neuropathic pain is started with conservative pharmacotherapy before invasive pain management is applied. Although there are many drugs that can be used in patients with diabetic pain syndrome, pain syndrome can not be surely stoped with monotherapy. In addition, the patient may not tolerate the full therapeutic dose of the drug.
All this dictates the need for combination therapy. It is believed that regional anesthesia as an independent type of analgesia or a component of combined anesthesia is the method of choice for the elderly and senile patients. The main reasons for this choice, when comparing regional anesthesia with narcosis, are less stressful response of the organism, absence of depression of the central nervous system, stable reliable analgesia with complete blockade of nociceptive reflexes with the provision of adequate muscle relaxation, prevention of neurovegetative reactions, which ultimately helps to reduce the incidence of postoperative complications and mortality. Clinicians have accumulated considerable experience demonstrating the need for regional analgesia in the management of diabetic foot pain.
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11
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Kasai T, Nakamura T, Iwasawa M, Nagase Y, Juji T, Tanaka S, Matsumoto T. Factors affecting bone union after distal shortening oblique osteotomy of the lesser metatarsals. Mod Rheumatol 2019; 30:502-508. [PMID: 31154882 DOI: 10.1080/14397595.2019.1626972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives: There have been few reports on factors affecting bone union after metatarsal osteotomies. The purpose of this study was to clarify the factors affecting bone union after distal shortening oblique osteotomy of the lesser metatarsals.Methods: Patients who underwent distal shortening oblique osteotomy of the lesser metatarsals were retrospectively investigated. Failure to achieve bone union at 6 months after surgery was defined as delayed union. Background characteristics and radiographic measurements were compared between patients with and those without delayed union, and factors affecting bone union were assessed using multivariate analysis.Results: Among 204 toes in 58 patients evaluated in this study, delayed union occurred in 28%. In multivariate analysis, corticosteroid use (odds ratio (OR), 3.68; 95% confidence interval (CI), 1.65-8.16; p< .01), larger preoperative overlap between the metatarsal and the proximal phalanx (OR, 1.11 (per 1 mm increase); 95% CI, 1.02-1.21; p= .02), and larger gap at the osteotomy site (OR, 3.02 (per 1 mm increase); 95% CI, 1.76-5.16; p< .01) were identified as independent risk factors of delayed union.Conclusion: The identified risk factors of delayed union after distal shortening metatarsal osteotomies were corticosteroid use, preoperative overlap between the metatarsal and the proximal phalanx, and a gap at the osteotomy site.
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Affiliation(s)
- Taro Kasai
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Rheumatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Takeomi Nakamura
- Department of Orthopaedic Surgery, National Hospital Organization, Sagamihara Hospital, Sagamihara, Japan
| | - Mitsuyasu Iwasawa
- Department of Orthopaedic Surgery, National Hospital Organization, Sagamihara Hospital, Sagamihara, Japan
| | - Yuichi Nagase
- Department of Rheumatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Takuo Juji
- Department of Rheumatology, JCHO Yugawara Hospital, Kanagawa, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takumi Matsumoto
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Rheumatology, JCHO Yugawara Hospital, Kanagawa, Japan
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Schrier JC, Keijsers NL, Matricali GA, Verheyen CCPM, Louwerens JWK. Resection or preservation of the metatarsal heads in rheumatoid forefoot surgery? A randomised clinical trial. Foot Ankle Surg 2019; 25:37-46. [PMID: 29409260 DOI: 10.1016/j.fas.2017.07.1126] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 03/28/2017] [Accepted: 07/28/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Despite impressive results of the pharmacological management of rheumatoid arthritis, still certain patients suffer from rheumatoid forefoot problems. Surgical treatment of these forefoot deformities can be an option. In literature no high-quality studies on this topic can be found. The goal of present study is to compare the results of a metatarsal head (MTH) resecting technique with a MTH preserving technique in the operative treatment of severe rheumatoid forefoot deformity. METHODS Patients suffering from well-defined rheumatoid forefoot deformity were prospectively enrolled in three institutions. This non-blinded study had a randomised clinical design and eligible patients were randomly assigned to undergo either resection of preservation of the MTH. The primary outcome measure consisted of the AOFAS score. Secondary outcome measures were: the FFI, the VAS for pain and the SF-36. RESULTS Twenty-three patients (10 in MTH preservation group) were included and analysed. After one year follow-up no significant differences in AOFAS score and additional outcome factors were found. A total of 10 complications in 23 patients were reported. CONCLUSIONS This randomised clinical study did not show significant clinical difference between a MTH resecting and a preserving procedure in patients suffering from rheumatoid forefoot deformity. Both procedures resulted in considerable improvement of pain and activity scores.
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Affiliation(s)
- Joost C Schrier
- Dept Orthopaedic Surgery, Medinova Clinics Breda, The Netherlands; Dept Orthopaedic Surgery, Sint Maartenskliniek Nijmegen, The Netherlands.
| | - Noel L Keijsers
- Dept Orthopaedic Surgery, Sint Maartenskliniek Nijmegen, The Netherlands
| | | | - Cees C P M Verheyen
- Dept Orthopaedic Surgery and Traumatology, Isala Hospital Zwolle, The Netherlands
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13
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Aronow MS. Joint Preservation in the Rheumatoid Forefoot: Commentary on an article by Junichi Kushioka, MD, et al.: "Modified Scarf Osteotomy with Medial Capsule Interposition for Hallux Valgus in Rheumatoid Arthritis. A Study of Cases Including Severe First Metatarsophalangeal Joint Destruction". J Bone Joint Surg Am 2018; 100:e64. [PMID: 29715237 DOI: 10.2106/jbjs.17.01646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Kushioka J, Hirao M, Tsuboi H, Ebina K, Noguchi T, Nampei A, Tsuji S, Akita S, Hashimoto J, Yoshikawa H. Modified Scarf Osteotomy with Medial Capsule Interposition for Hallux Valgus in Rheumatoid Arthritis: A Study of Cases Including Severe First Metatarsophalangeal Joint Destruction. J Bone Joint Surg Am 2018; 100:765-776. [PMID: 29715225 DOI: 10.2106/jbjs.17.00436] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Arthrodesis of the first metatarsophalangeal (MTP) joint has been recommended for severe hallux valgus deformity in patients with rheumatoid arthritis (RA). However, with the progress of medical treatment of RA, joint preservation surgery has recently been performed. The aim of this study was to investigate the clinical and radiographic outcomes of modified Scarf osteotomy with medial capsule interposition for RA cases including severe destruction of the first MTP joint and to evaluate risk factors for recurrence. METHODS A retrospective observational study of 76 cases (60 patients) followed for a mean of 35.3 months (range, 24 to 56 months) after a modified Scarf osteotomy was performed. Scores on the Japanese Society for Surgery of the Foot (JSSF) RA foot and ankle scale, the JSSF hallux scale, and a self-administered foot evaluation questionnaire (SAFE-Q) were determined along with preoperative and postoperative radiographic parameters. RESULTS There was a significant improvement, from preoperatively to final follow-up, in the mean JSSF RA foot and ankle score (from 52.2 to 76.9 points) and the mean JSSF hallux score (from 38.2 to 74.5 points). There was a recurrence (hallux valgus angle [HVA] of >20°) in 12 feet (16%). The preoperative DAS28-CRP score (disease activity score [based on 28 joints in the body]-C-reactive protein score) and intermetatarsal angles between the first and second metatarsals (M1M2A) and between the first and fifth metatarsals (M1M5A) were significantly greater in the recurrence group, as were the HVA, M1M2A, M1M5A, and Hardy grade at 3 months after surgery. There was a significant negative correlation between the preoperative DAS28-CRP score and the JSSF RA foot and ankle score at final follow-up (β = -0.39, p = 0.02) and a significant positive correlation between the preoperative DAS28-CRP score and the HVA at final follow-up (β = 0.44, p = 0.001). CONCLUSIONS The modified Scarf osteotomy with medial capsule interposition for hallux valgus deformity improved clinical and radiographic outcomes in RA cases with severe destruction of the first MTP joint. Increased preoperative M1M2A and M1M5A; incomplete reduction of the sesamoid bone; and the HVA, M1M2A, and M1M5A at 3 months after surgery should be evaluated as they are associated with recurrence of the deformity. The preoperative DAS28-CRP score was associated with the clinical and radiographic outcomes after surgery. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Junichi Kushioka
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Makoto Hirao
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hideki Tsuboi
- Department of Orthopaedics, Osaka Rosai Hospital, Sakai, Japan
| | - Kosuke Ebina
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takaaki Noguchi
- Department of Orthopaedics/Rheumatology, National Hospital Organization, Osaka Minami Medical Center, Kawachinagano City, Osaka, Japan
| | - Akihide Nampei
- Department of Orthopaedics/Rheumatology, National Hospital Organization, Osaka Minami Medical Center, Kawachinagano City, Osaka, Japan
| | - Shigeyoshi Tsuji
- Department of Orthopaedics/Rheumatology, National Hospital Organization, Osaka Minami Medical Center, Kawachinagano City, Osaka, Japan
| | - Shosuke Akita
- Department of Orthopaedics/Rheumatology, National Hospital Organization, Osaka Minami Medical Center, Kawachinagano City, Osaka, Japan
| | - Jun Hashimoto
- Department of Orthopaedics/Rheumatology, National Hospital Organization, Osaka Minami Medical Center, Kawachinagano City, Osaka, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Japan
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Jo YH, Park KC, Song YS, Sung IH. Comparison of outcomes according to fixation technique following the modified Ludloff osteotomy for hallux valgus in patients with rheumatoid arthritis. BMC Musculoskelet Disord 2017; 18:371. [PMID: 28841865 PMCID: PMC5574211 DOI: 10.1186/s12891-017-1729-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 08/16/2017] [Indexed: 12/04/2022] Open
Abstract
Background Clinical and radiological outcomes including fixation stability of osteotomy site were compared in rheumatoid arthritis (RA) patients who underwent modified Ludloff osteotomy to correct hallux valgus with osteotomy site fixation using two screws versus those who underwent additional fixation using a plate. Methods The fixation technique performed with two screws was used to fix the osteotomy sites following modified Ludloff osteotomy in 15 patients (15 feet, Group S), while the augmented plate fixation technique was used in 14 patients (16 feet, Group P). Surgical outcomes were analysed using the American Orthopedic Foot and Ankle Society (AOFAS) scores, and radiologic parameters measured before surgery and during follow-up examinations. To evaluate the stability of each osteotomy site fixation technique, the 1–2 inter-metatarsal angle (IMA) and angle of the altered margin of the lateral cortex (AMLC) were measured immediately and 6 weeks after surgery, and variations in the angles were compared. In addition, bone mineral density (BMD) values were compared between patients with correction loss at the osteotomy site and those with no loss of correction. Results No significant differences between groups were found for total AOFAS scores before surgery and at the final follow-up. However, significant differences were observed in the 1–2 IMA, beginning at 6 weeks postoperatively and continuing through the final follow-up. The 1–2 IMA and angle of AMLC measured immediately after and 6 weeks after surgery showed significantly greater variation in Group S than in Group P. In Group S, patients with correction loss (5 feet) at osteotomy site showed significantly lower BMD values than those with no loss of correction (10 feet). Despite the lower BMD values of patients in Group P than in Group S, a loss of correction did not occur in these patients. Conclusions Correction loss occurred at the osteotomy site within 6 weeks postoperatively in patients who underwent fixation using only the two-screw fixation technique following modified Ludloff osteotomy; such loss could be reduced using the augmented plate fixation technique even in patients with osteoporosis.
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Affiliation(s)
- Young-Hoon Jo
- Department of Orthopaedic Surgery, Hanyang University College of Medicie, 222-1 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Ki-Chul Park
- Department of Orthopaedic Surgery, Hanyang University Guri Hospital, 153 Kyoungchun-ro, Guri-si, Gyeonggi-do, 11923, Republic of Korea
| | - Young-Sik Song
- Department of Orthopaedic Surgery, Hanyang University College of Medicie, 222-1 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Il-Hoon Sung
- Department of Orthopaedic Surgery, Hanyang University College of Medicie, 222-1 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea.
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Abstract
The causes of metatarsalgia are classified as primary, secondary, and iatrogenic. Anatomical and biomechanical considerations separate "static" from "propulsive" forms of metatarsalgia. The physical examination should be combined with an assessment of weight-bearing radiographs and, if needed, of ultrasound or magnetic resonance imaging scans. The first-line treatment is conservative (stretching exercises, footwear modification, insoles, and lesion debridement). Soft-tissue surgical procedures (gastrocnemius muscle recession, tendon transfer, and plantar plate repair) should also be considered. Among the various types of metatarsal osteotomy, the Weil procedure is reliable. Percutaneous methods are being developed but require evaluation. A treatment algorithm can be developed based on whether the hallux is normal or abnormal. Metatarsalgia due to inflammatory disease requires a specific treatment strategy.
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Affiliation(s)
- J-L Besse
- Université Lyon 1, IFSTTAR, LBMC UMR-T 9406, Laboratoire de Biomécanique et Mécanique des Chocs, 69675 Bron cedex, France; Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Service de Chirurgie Orthopédique et Traumatologique, 69495 Pierre-Bénite cedex, France.
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Triolo P, Rosso F, Rossi R, Cerlon R, Cottino U, Bonasia DE. Fusion of the First Metatarsophalangeal Joint and Second to Fifth Metatarsal Head Resection for Rheumatoid Forefoot Deformity. J Foot Ankle Surg 2017; 56:263-270. [PMID: 28073655 DOI: 10.1053/j.jfas.2016.11.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Indexed: 02/03/2023]
Abstract
The goals of the present study were to evaluate the mid-term results of first metatarsophalangeal joint fusion combined with second to fifth metatarsal head resection in rheumatoid forefoot deformity and identify the prognostic factors. The inclusion criteria were 2010 American College of Rheumatology and/or European League Against Rheumatism criteria for rheumatoid arthritis; symptomatic forefoot deformity; first metatarsophalangeal joint fusion and second to fifth metatarsal head resection; and a minimum of 4 years of follow-up data available. The patients were evaluated using the Disease Activity Score 28 for rheumatoid arthritis, Health Assessment Questionnaire for Rheumatoid Arthritis, Foot Function Index, forefoot American Orthopaedic Foot and Ankle Society scale, and weightbearing radiographs. Different pre-, intra-, and postoperative variables were investigated to identify the prognostic factors. Sixty-two patients (89 feet) with a mean age of 60.8°± 9.4 years and 85.5°± 22.4 months of follow-up data were included. The preoperative American Orthopaedic Foot and Ankle Society scale score was 33.4 ± 16 points and improved significantly (p < .001) after surgery (mean 82.9 ± 11.7 points). The mean Foot Function Index improved significantly (p < .001) from 131.6 ± 37.4 to 77.4 ± 46.3 points at the last follow-up visit. Only the revision surgery variable was significantly (p = .02) related to poor outcomes. Revision was necessary in 8 feet (9%). This procedure produced satisfactory results. Poor outcomes were significantly related to the necessity for revision surgery for nonunion, malunion, inadequate metatarsal resection, and painful hardware.
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Affiliation(s)
- Pierfranco Triolo
- Orthopedics Surgeon, First Department of Orthopaedics and Traumatology, University of Torino, CTO Hospital, Torino, Italy
| | - Federica Rosso
- Professor of Orthopedic Surgery, Department of Orthopaedics and Traumatology, University of Torino, AO Ordine Mauriziano Hospital, Torino, Italy
| | - Roberto Rossi
- Orthopedic Surgeon, Department of Orthopaedics and Traumatology, University of Torino, AO Ordine Mauriziano Hospital, Torino, Italy
| | - Raul Cerlon
- Orthopedics Surgeon, First Department of Orthopaedics and Traumatology, University of Torino, CTO Hospital, Torino, Italy
| | - Umberto Cottino
- Orthopedic Surgeon, Department of Orthopaedics and Traumatology, University of Torino, AO Ordine Mauriziano Hospital, Torino, Italy
| | - Davide Edoardo Bonasia
- Orthopedic Surgeon, Department of Orthopaedics and Traumatology, University of Torino, AO Ordine Mauriziano Hospital, Torino, Italy.
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Taniguchi D, Oda R, Ikoma K, Toyama S, Takatori R, Imai K, Hara Y, Sawada K, Tokunaga D, Fujiwara H, Kubo T. Recurrence of deformity after silicone implant and resection arthroplasty of the metatarsophalangeal joint for rheumatoid arthritis: long-term results. Mod Rheumatol 2016; 27:266-270. [PMID: 27539207 DOI: 10.1080/14397595.2016.1207286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To examine the recurrence of deformity after silicone implant arthroplasty combined with resection arthroplasty for severe forefoot deformity in patients with rheumatoid arthritis. METHODS We reviewed the long-term results of this procedure for 27 feet in 15 patients. Their average age and disease duration at the time of operation were 58.6 years and 17.5 years, respectively, and the average follow-up period was 10.3 years. RESULTS An improved hallux valgus angle (45.3° preoperatively, 23.6° 6 months after operation) was maintained. By contrast, deformity and dislocation of lesser toe had recurred at the final follow-up; the angle between the proximal phalanx and the metatarsal of the second toe improved 13.4° with recurrence of 22.5°, the angle between the proximal phalanx and ground surface improved 22.4° with recurrence of 34.5. Furthermore, claw toe deformity at the final follow-up was significantly worse in the group whose hallux valgus deformity was observed 6 months after operation. CONCLUSION This procedure could maintain the alignment of the first metatarsophalangeal joint, but the recurrence of claw toe deformity is a problem and the relation between the first toe and the lesser toe is an important consideration.
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Affiliation(s)
- Daigo Taniguchi
- a Department of Orthopaedics, Graduate School of Medical Science , Kyoto Prefectural University of Medicine , Kamigyo-Ku , Kyoto , Japan and
| | - Ryo Oda
- a Department of Orthopaedics, Graduate School of Medical Science , Kyoto Prefectural University of Medicine , Kamigyo-Ku , Kyoto , Japan and
| | - Kazuya Ikoma
- a Department of Orthopaedics, Graduate School of Medical Science , Kyoto Prefectural University of Medicine , Kamigyo-Ku , Kyoto , Japan and
| | - Shogo Toyama
- a Department of Orthopaedics, Graduate School of Medical Science , Kyoto Prefectural University of Medicine , Kamigyo-Ku , Kyoto , Japan and
| | - Ryota Takatori
- a Department of Orthopaedics, Graduate School of Medical Science , Kyoto Prefectural University of Medicine , Kamigyo-Ku , Kyoto , Japan and
| | - Kan Imai
- a Department of Orthopaedics, Graduate School of Medical Science , Kyoto Prefectural University of Medicine , Kamigyo-Ku , Kyoto , Japan and
| | - Yusuke Hara
- a Department of Orthopaedics, Graduate School of Medical Science , Kyoto Prefectural University of Medicine , Kamigyo-Ku , Kyoto , Japan and
| | - Koshiro Sawada
- b Department of Rehabilitation Medicine , Kyoto Prefectural University of Medicine , Kyoto , Japan
| | - Daisaku Tokunaga
- a Department of Orthopaedics, Graduate School of Medical Science , Kyoto Prefectural University of Medicine , Kamigyo-Ku , Kyoto , Japan and
| | - Hiroyoshi Fujiwara
- a Department of Orthopaedics, Graduate School of Medical Science , Kyoto Prefectural University of Medicine , Kamigyo-Ku , Kyoto , Japan and
| | - Toshikazu Kubo
- a Department of Orthopaedics, Graduate School of Medical Science , Kyoto Prefectural University of Medicine , Kamigyo-Ku , Kyoto , Japan and
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Abstract
UNLABELLED Wound dehiscence and infection may arise when the skin around the foot or ankle is closed under tension after a surgical incision or trauma. Two cases where a piecrusting technique, using small transdermal incisions made in the surrounding skin similar to the holes in a pie crust, are presented and a literature review of the technique has been performed. The multiple small stab incisions perpendicular to the line of tension have enabled skin closure without tension and have healed with minimal scarring. LEVELS OF EVIDENCE Level V: Expert opinion.
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Affiliation(s)
- Dishan Singh
- Foot and Ankle Unit, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Adam Lomax
- Foot and Ankle Unit, Royal National Orthopaedic Hospital, Stanmore, UK
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20
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Whitt KJ, Rincker SA, Hyer CF. Sustainability of Forefoot Reconstruction for the Rheumatoid Foot. J Foot Ankle Surg 2016; 55:583-5. [PMID: 26970909 DOI: 10.1053/j.jfas.2016.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Indexed: 02/03/2023]
Abstract
Ninety percent of patients with rheumatoid arthritis will display foot and ankle pathologic features, including hallux valgus, lesser metatarsophalangeal (MTP) joint subluxation/dislocation, and hammertoe deformity. Recently, a trend has ensued toward joint preservation with distal metatarsal osteotomies and various bunion corrective procedures. However, the reference standard remains first MTP joint fusion, lesser metatarsal head resection, and lesser proximal interphalangeal joint fusion. The present retrospective study followed the results of 4 different surgeons who had performed the reference standard rheumatoid forefoot reconstruction from August 2008 to August 2012 on patients with rheumatoid arthritis. Radiographic and statistical analysis of the data from 20 patients determined an overall first MTP joint fusion rate of 90%, often occurring by 108 (range 64 to 202) days postoperatively. Radiographic nonunion occurred in 2 of the 20 patients (10%), although both were asymptomatic, with no revision necessary. Lesser digit deformity revision occurred in 1 patient (5%), and mild to moderate infection developed in 4 patients (20%). The radiographic and clinical follow-up period was 12 months. Our study found that this technique provides exceptional radiographic improvement, an acceptable time to fusion, a low reoperation rate, and minimal complications. In addition, correction of the deformity was maintained at 1 year postoperatively. In conclusion, first MTP joint fusion with lesser metatarsal head resection should remain the reference standard for surgical intervention of the rheumatoid foot.
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Affiliation(s)
| | - Sarah A Rincker
- Foot and Ankle Surgeon, Eugene Foot and Ankle Health Center, Eugene, OR
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21
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Fukushi JI, Nakashima Y, Okazaki K, Yamada H, Mawatari T, Ohishi M, Oyamada A, Akasaki Y, Iwamoto Y. Outcome of Joint-Preserving Arthroplasty for Rheumatoid Forefoot Deformities. Foot Ankle Int 2016; 37:262-8. [PMID: 26449390 DOI: 10.1177/1071100715609981] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Along with the recent advances in the pharmacological management of rheumatoid arthritis, there is a trend toward the use of joint-preserving surgery in the treatment of rheumatoid forefoot deformities. However, the clinical outcomes of joint-preserving surgery for rheumatoid forefoot deformities have not been assessed in comparison to resection arthroplasty. METHODS We retrospectively evaluated 23 feet in 17 patients with rheumatoid forefoot deformities who underwent surgery between January 2010 and December 2013. The patients included 1 male (1 foot) and 16 females (22 feet), with a mean age of 62 years. The mean length of follow-up was 28 months. The patients were treated by 3 surgeons. One surgeon performed joint-preserving procedures (JP group) to the feet in which (1) no pain with motion existed, and (2) the range of motion in the first metatarsophalangeal (MTP) joint was greater than 30 degrees (n = 10); otherwise, resection arthroplasty with arthrodesis of the first MTP joint was performed (n = 3). The other surgeons performed resection arthroplasty in all cases (n = 10) (RA group, n = 13 in total). The clinical outcomes of the patients were evaluated using the Japanese Society for Surgery of the Foot (JSSF) hallux and lesser toe scales. RESULTS There were no significant differences in the preoperative total JSSF scores for either the hallux (54.5 and 61.4 points) or the lesser toe (45.2 and 57.4 points) between the RA and JP groups, respectively. Postoperatively, the total JSSF scores for both the hallux (79.4 and 88.2 points) and lesser toes (73.6 and 87.7 points) showed significant improvement in both the RA and JP groups, respectively; however, the JP group showed a greater postoperative improvement. The scores relating to the function category on the hallux scale and the alignment category on the lesser toe scale were significantly higher in the JP group. CONCLUSION With regard to the function of the hallux and the alignment of the lesser toes, the joint-preserving procedures for rheumatoid forefoot deformities resulted in better clinical outcomes than resection arthroplasty. LEVEL OF EVIDENCE Level III, comparative case series.
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Affiliation(s)
- Jun-ichi Fukushi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuharu Nakashima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken Okazaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hisakata Yamada
- Division of Host Defence, Medical Institute of Bioregulation, Kyushu University, Fukuoka, Japan
| | - Taro Mawatari
- Department of Orthopaedic Surgery, Hamanomachi Hospital, Fukuoka, Japan
| | - Masanobu Ohishi
- Department of Orthopaedic Surgery, Chihaya Hospital, Fukuoka, Japan
| | - Akiko Oyamada
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yukio Akasaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Yano K, Ikari K, Ishibashi M, Momohara S. Preventing delayed union after distal shortening oblique osteotomy of metatarsals in the rheumatoid forefoot. Mod Rheumatol 2015; 26:546-50. [PMID: 26457891 DOI: 10.3109/14397595.2015.1106638] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The aim of this study is to evaluate the surgical methods to prevent delayed union after the distal shortening oblique osteotomy of the lesser metatarsals in the rheumatoid forefoot. METHODS This retrospective observational study included 107 patients. The patients were classified into the following four groups, each of which represented the addition of a surgical technique to reduce postoperative delayed union: 1st group: original surgical method; 2nd group: a normal saline was dripped on the oscillating saw; 3rd group: the incised periosteum was sutured; 4th group: the osteotomy sites were ligated. The frequencies of delayed union were assessed. RESULTS Delayed union occurred in 21 of the 127 metatarsals (16.5%) in the 1st group, 13 of the 99 metatarsals (13.1%) in the 2nd group, 5 of the 94 metatarsals (5.3%) in the 3rd group, and 6 of the 136 metatarsals (4.4%) in the 4th group. The frequency of delayed union decreased significantly with improved surgical procedures (p = 0.0003). CONCLUSIONS A combination of techniques that included dripping normal saline on the oscillating saw, ligating the osteotomy sites, and suturing the periosteum at the osteotomy sites decreased the frequency of delayed union after the distal shortening oblique osteotomy of the metatarsals in rheumatoid arthritis patients.
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Affiliation(s)
- Koichiro Yano
- a Department of Orthopedic Surgery , Institute of Rheumatology, Tokyo Women's Medical University , Tokyo , Japan and
| | - Katsunori Ikari
- a Department of Orthopedic Surgery , Institute of Rheumatology, Tokyo Women's Medical University , Tokyo , Japan and.,b CREST, JST , Tokyo , Japan
| | - Mina Ishibashi
- a Department of Orthopedic Surgery , Institute of Rheumatology, Tokyo Women's Medical University , Tokyo , Japan and
| | - Shigeki Momohara
- a Department of Orthopedic Surgery , Institute of Rheumatology, Tokyo Women's Medical University , Tokyo , Japan and
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23
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Niki H, Hirano T, Akiyama Y, Mitsui H, Fujiya H. Long-term outcome of joint-preserving surgery by combination metatarsal osteotomies for shortening for forefoot deformity in patients with rheumatoid arthritis. Mod Rheumatol 2015; 25:683-8. [DOI: 10.3109/14397595.2015.1008672] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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24
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Nash WJ, Al-Nammari S, Khan WS, Pengas IP. Surgical management of the forefoot in patients with rheumatoid arthritis - a review article. Open Orthop J 2015; 9:78-83. [PMID: 25861409 PMCID: PMC4384227 DOI: 10.2174/1874325001509010078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 01/25/2015] [Accepted: 02/03/2015] [Indexed: 11/22/2022] Open
Abstract
Foot and ankle pathologies cause a significant disease burden on rheumatoid patients. Forefoot pathologies causes pain, callosities and possibly ulceration, and can cause problems with footwear. Forefoot correction in rheumatoid patients has historically comprised of excision of diseased joints. While satisfaction was high with this procedure, complications, changing expectations and improvement in medical therapy have raised expectation of patients, physicians and surgeons alike. This review assesses the role of joint preserving osteotomies and arthrodesis, as well as associated complications. It also describes the role of the multidisciplinary team in the management of these patients.
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Affiliation(s)
- W J Nash
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, UK
| | - S Al-Nammari
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, UK
| | - W S Khan
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, UK
| | - I P Pengas
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, UK
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25
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Sung IH, Sung YK, Huh DR, Kim SJ. A comparative study on the results of the modified Ludloff osteotomy for hallux valgus deformities with minimal erosion of the metatarsophalangeal joints in rheumatoid patients versus non-rheumatoid patients. Mod Rheumatol 2015; 25:694-700. [PMID: 25698372 DOI: 10.3109/14397595.2015.1008954] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES We aimed to compare the outcomes of joint-preserving surgery for hallux valgus deformities with minimal erosion of the metatarsophalangeal joint in rheumatoid patients with non-rheumatoid controls, and to determine the prognostic factors of recurrence in rheumatoid patients. METHODS A total of 18 rheumatoid patients (20 feet, Group I) and 35 non-rheumatoid patients (39 feet, Group II) were included. The mean follow-up was 29.6 months. Radiographic and clinical outcomes were compared. To identify the prognostic factors for recurrences in rheumatoid patients, subgroup analyses were done in Group I. RESULTS Most of the outcomes showed favorable results in both groups. However, Group II had better results in hallux valgus angle (HVA) (15.9° vs. 7.9°, p < 0.001), and in sesamoid position (p = 0.040) at final follow-up. Group I showed higher recurrence rate (50% vs. 0%). The final American Orthopaedic Foot and Ankle Society score was better in Group II (82.1 vs. 90.7, p = 0.014). The large preoperative HVA, non-performance of Akin osteotomy, and insufficient reduction of sesamoid position were related to recurrence in rheumatoid patients. CONCLUSIONS Joint-preserving surgery for hallux valgus deformities in rheumatoid forefoot deformity showed favorable results in mid-term follow-up; however, it should be warned of possible recurrent deformities.
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Affiliation(s)
- Il-Hoon Sung
- a Department of Orthopaedic Surgery , Hanyang University College of Medicine , Seoul , South Korea
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26
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Yamaguchi S, Tanaka Y, Shinohara Y, Taniguchi A, Sasho T, Takahashi K, Takakura Y. Anatomy of hallux valgus in rheumatoid arthritis: radiographic analysis using a two-dimensional coordinate system. Mod Rheumatol 2014. [DOI: 10.3109/s10165-012-0739-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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27
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Takakubo Y, Takagi M, Tamaki Y, Sasaki A, Nakano H, Orui H, Ogino T. Mid-term results of joint-preserving procedures by a modified Mann method for big toe deformities in rheumatoid patients undergoing forefoot surgeries. Mod Rheumatol 2014. [DOI: 10.3109/s10165-009-0253-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Rheumatoid arthritis (RA) manifests itself in a variety of ways, with its effect being seen in around 90 % of sufferers' feet. The foot has been found to be the most common reason for incapacity in patients with RA, with the forefoot the most common area. The foot is second, behind only the hand, as the most common place for manifestation of RA. Pain in the foot is commonly the most debilitating condition, which causes the patient to seek specialist help. As well as pain, foot deformities such as hallux valgus and claw toes are common complaints. These symptoms often arise as a result of continued walking on an unstable foot, leading to painful callosities and dislocation of the metatarsophalangeal joints. Other conditions, such as pannus formation and Morton's neuroma, can be related to RA. This review sets out what we believe to be a successful approach to the rheumatoid forefoot, which aims at the relief of pain and the preservation of ambulation. Key to a successful outcome is appropriate medical control with a multidisciplinary approach that enables close liaison between orthopaedic surgeons, orthotists, and rheumatologists. Combined clinics provide this multidisciplinary care. Those treating RA need to be aware of the high incidence of foot involvement and how early intervention may benefit the patient. The aim of this article is to present current evidence to enable people to develop a treatment algorithm for this condition.
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Chao JC, Charlick D, Tocci S, Brodsky JW. Radiographic and clinical outcomes of joint-preserving procedures for hallux valgus in rheumatoid arthritis. Foot Ankle Int 2013; 34:1638-44. [PMID: 23945521 DOI: 10.1177/1071100713500654] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The standard treatment for hallux valgus in rheumatoid arthritis has been arthrodesis of the first metatarsophalangeal (MTP) joint. There is limited literature regarding the results of hallux valgus procedures which preserve the first MTP joint in rheumatoid patients. We investigated the radiographic and clinical outcomes of joint-preserving surgery for hallux valgus in a series of rheumatoid patients to evaluate the result of nonarthrodesis reconstruction. METHODS Thirty-seven feet with hallux valgus in 27 patients with RA treated with a joint-preserving procedure of the first MTP joint were analyzed radiographically and clinically. Average follow-up was 42 (range, 12-111) months. Twenty feet had Ludloff osteotomies, 15 had scarf osteotomies, and 2 had chevron osteotomies. Radiographs were evaluated preoperatively and postoperatively for hallux valgus angle, 1-2 intermetatarsal angle, and degenerative narrowing of the first MTP joint based the Sharp score and the Larsen grade. Narrowing of the first interphalangeal (IP) joint was based on a modification of the classification of Hattrup and Johnson. Operative complications and required secondary surgeries were tabulated. Clinical outcomes were measured using preoperative and postoperative Short Form-36 (SF-36), AOFAS forefoot scale, and Visual Analogue Scale (VAS) pain questionnaires. RESULTS The average hallux valgus angle improved from 37 degrees preoperatively to 15 degrees postoperatively. The average 1-2 intermetatarsal angle improved from 14 degrees preoperatively to 5 degrees postoperatively. The average Sharp score of the first MTP joint was 0.9 preoperatively and 1.6 postoperatively. The average Larsen grade of the first MTP joint was 0.6 preoperatively and 1.4 postoperatively. Range of motion of the first MTP joint was essentially unchanged between preoperative and postoperative measurements. Seven of 37 feet had progression of first IP joint space narrowing, but none were symptomatic. The AOFAS score improved from 45.2 preoperatively to 82.6 at final follow-up (P value < .01). The VAS decreased from 4.8 preoperatively to 1.5 at final follow-up (P value < .02). The SF-36 physical component score decreased from 40.3 preoperatively to 37.4 at final follow-up, and the mental component score remained unchanged, and neither was statistically significant. There were 7 feet (19%) that required a return to surgery: 3 wound infections, 2 arthrodeses for progression of deformity, and 1 each for revision for recurrence and hardware removal. CONCLUSION Rheumatoid arthritis patients who undergo a bunionectomy rather than arthrodesis to preserve the first MTP joint have satisfactory clinical and radiographic outcomes. This procedure appeared to be a reasonable alternative to first MTP arthrodesis in patients with relatively preserved joints. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- John C Chao
- Baylor University Medical Center, Dallas, TX, USA
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Trieb K, Hofstaetter SG, Panotopoulos J, Wanivenhaus A. The Weil osteotomy for correction of the severe rheumatoid forefoot. INTERNATIONAL ORTHOPAEDICS 2013; 37:1795-8. [PMID: 23863996 PMCID: PMC3764294 DOI: 10.1007/s00264-013-2011-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 06/24/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE In rheumatoid arthritis the metatarsophalangeal (MTP) joints are predominantly affected with resultant metatarsalgia and dislocation. Therapy options include many different surgical procedures with results that are not always satisfying. We present the oblique Weil metatarsal osteotomy as a treatment option for the rheumatic forefoot. METHODS A total of 216 osteotomies in 63 consecutive patients (72 feet) with a mean age at the time of surgery of 59.3 years and long-standing rheumatoid arthritis were observed prospectively for an average of 57.4 months (minimum 36 months). All patients received a Weil osteotomy of the lesser metatarsals with at least one additional procedure of the forefoot. Patients were evaluated prospectively for clinical outcome by the American Orthopaedic Foot and Ankle Society (AOFAS) lesser MTP-interphalangeal scale and subjective satisfaction. In the radiological evaluation weight-bearing X-rays were analysed for alignment, shortening and union. RESULTS American Orthopaedic Foot and Ankle Society score increased significantly from 21.9 ± 6.7 to 63.3 ± 9.8 (p < 0.05). The increase was significant for all subgroups regarding pain, function and alignment. All joints were dorsally dislocated preoperatively; a subluxation was present in 13.6 % at follow-up. There was a significant decrease of callositas in 82 %, a decrease in need for orthopaedic shoes in 61 %, a decrease of MTP joint stiffness in 96 % and a relief of severe pain in 97 % of all patients. No metatarsal head dislocation or necrosis, pseudoarthrosis or screw perforation was observed. Of 63 patients, 55 (88 %) subjectively reported excellent or good results. CONCLUSIONS We conclude that the Weil procedure for lesser metatarsals is a satisfactory method for correcting the rheumatic forefoot and can be recommended as an approach for the future.
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Affiliation(s)
- Klemens Trieb
- Department of Orthopaedics, Klinikum Wels-Grieskirchen, Grieskirchnerstr. 42, 4600, Wels, Austria.
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Louwerens JWK, Schrier JCM. Rheumatoid forefoot deformity: pathophysiology, evaluation and operative treatment options. INTERNATIONAL ORTHOPAEDICS 2013; 37:1719-29. [PMID: 23892468 PMCID: PMC3764283 DOI: 10.1007/s00264-013-2014-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 06/25/2013] [Indexed: 10/26/2022]
Abstract
Despite recent advances in pharmacological management of rheumatoid arthritis, forefoot deformity, with its symptoms, remains a common problem, often requiring operative treatment. Typical deformities in these patients comprise hallux valgus and deformity of the lesser metatarsophalangeal (MTP) joints and toes. With regard to the lesser rays the standard operative procedure, advocated for the disabling forefoot pain in these patients, remains metatarsal head resection. It should be considered that with increasing success of pharmacological treatment the degree of forefoot deformity in these patients is becoming less and that resection of the lesser MTP joints is becoming more and more superfluous. This supports a trend towards metatarsal head-preserving surgery. The optimal treatment of the hallux deformity remains unclear. Fusion of the first MTP joint is, generally, recommended. This article will discuss the current surgical options in rheumatoid forefoot pathology.
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Affiliation(s)
- Jan Willem K Louwerens
- Department of Orthopaedic Surgery, Foot and Ankle Reconstruction Unit, St Maartenskliniek, Nijmegen, The Netherlands.
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Yano K, Ikari K, Iwamoto T, Saito A, Naito Y, Kawakami K, Suzuki T, Imamura H, Sakuma Y, Hiroshima R, Momohara S. Proximal rotational closing-wedge osteotomy of the first metatarsal in rheumatoid arthritis: clinical and radiographic evaluation of a continuous series of 35 cases. Mod Rheumatol 2012; 23:953-8. [PMID: 23070360 DOI: 10.1007/s10165-012-0776-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 09/20/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The introduction of powerful antirheumatic drugs has dramatically improved the treatment of rheumatoid arthritis (RA), leading clinicians to reconsider the benefits of joint preservation for rheumatoid forefoot deformities. We have employed joint-preserving forefoot surgeries, including rotational closing-wedge osteotomy of the first metatarsal. The aim of our study is to assess the short-term results of this procedure. METHODS From January 2011 through December 2011, 35 feet were treated with this procedure. Subjective, functional, and radiographic outcomes were surveyed. RESULTS The mean Japanese Society for Surgery of the Foot improved from a preoperative level of 52.6 to 68.7 postoperatively. The average hallux valgus and intermetatarsal angles improved from 47.3° preoperatively to 17.5° postoperatively, and from 16.7° preoperatively to 9.0° postoperatively, respectively. To assess the repositioning of pronation deformities of the first metatarsal, the position of the medial sesamoid was also surveyed according to the measurement system proposed by Hardy and Clapham. All feet except two were classified as grade V or higher preoperatively; 25 of these were grade IV or lower at the latest follow-up. CONCLUSIONS Rotational closing-wedge osteotomy of the first metatarsal was beneficial for correcting forefoot deformities in RA over the short term.
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Affiliation(s)
- Koichiro Yano
- Department of Orthopedic Surgery, Institute of Rheumatology, Tokyo Women's Medical University, 10-22 Kawada, Shinjuku, Tokyo, 162-0054, Japan
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Anatomy of hallux valgus in rheumatoid arthritis: radiographic analysis using a two-dimensional coordinate system. Mod Rheumatol 2012; 23:774-81. [PMID: 22930442 DOI: 10.1007/s10165-012-0739-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 08/01/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The purpose of this study is to compare the anatomy of rheumatoid hallux valgus with that of idiopathic hallux valgus from the standpoint of joint-preserving surgery. METHODS One hundred forty-eight feet of 81 rheumatoid patients were included. Feet with idiopathic hallux valgus and normal feet were compared as controls. Weight-bearing dorsoplantar radiographs of the feet were taken of each patient. A two-dimensional coordinate system was defined on the radiographic image, and 19 anatomic points of the forefoot were measured. RESULTS In rheumatoid hallux valgus, the first metatarsal head shifted medially as hallux valgus angle increased, which was similar to the deformity of idiopathic hallux valgus. Proximal deviation of the tips of the lesser toes, caused by clawing and dislocations of the metatarsophalangeal joints, occurred in rheumatoid hallux valgus. Specifically the tips of the second toes in rheumatoid hallux valgus were located more proximally than those in idiopathic hallux valgus irrespective of the severity of hallux valgus. CONCLUSIONS Corrective osteotomy of the first metatarsal is a reasonable procedure for rheumatoid hallux valgus. Additionally, correction of the second toe deformity to make a stable lateral support on the hallux may be another important factor for successful joint-preserving surgery.
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Bhavikatti M, Sewell MD, Al-Hadithy N, Awan S, Bawarish MA. Joint preserving surgery for rheumatoid forefoot deformities improves pain and corrects deformity at midterm follow-up. Foot (Edinb) 2012; 22:81-4. [PMID: 22280995 DOI: 10.1016/j.foot.2011.12.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Revised: 12/13/2011] [Accepted: 12/26/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rheumatoid arthritis is a chronic autoimmune disorder that commonly affects the metatarsophalangeal (MTP) joints. Conventional surgical treatment involves joint-sacrificing surgery to relieve pain and correct deformity. OBJECTIVES We retrospectively reviewed 49 patients with rheumatoid forefoot deformities who underwent 66 joint preserving procedures with Scarf osteotomy of the first metatarsal and Weil's shortening osteotomy of the lesser metatarsals. METHOD There were 5 males and 44 females with mean age 56.1 years and mean follow-up 51 months. All patients were evaluated clinically and radiologically with hallux valgus angle (HVA) and inter-metatarsal angle (IMA). RESULTS Mean AOFAS score improved from 39.8 preoperatively to 88.7 at final follow-up. Subjectively patients reported their outcome as excellent in 49 feet (74%), good in 9 feet, fair in 7 feet and poor in 1 foot. Five feet had residual stiffness and 11 residual pain. Mean HVA and IMA decreased from 32° to 14° and from 15° to 11° respectively. CONCLUSION In intermediate to severe stages of the disease, joint preserving surgery by Scarf osteotomy of the first MTP joint and Weil osteotomy of the lesser metatarsals may be performed as an alternative to joint-sacrificing procedures and should be considered as a complement to the various surgical treatments of the rheumatoid forefoot.
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Affiliation(s)
- Mainudden Bhavikatti
- Department of Orthopaedic Surgery, Darlington Memorial Hospital, Darlington, UK.
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35
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Walker R, Redfern D. (ii) The foot in systemic disease: management of the rheumatoid or diabetic patient. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.mporth.2011.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Krause FG, Fehlbaum O, Huebschle LM, Weber M. Preservation of lesser metatarsophalangeal joints in rheumatoid forefoot reconstruction. Foot Ankle Int 2011; 32:131-40. [PMID: 21288411 DOI: 10.3113/fai.2011.0131] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A standard rheumatoid forefoot reconstruction consists of arthrodesis of the first metatarsophalangeal (MTP) joint and resection arthroplasty of the lesser metatarsal heads. However, preservation of the metatarsal heads has gained renewed interest since the medical treatment of rheumatoid arthritis has improved dramatically. MATERIAL AND METHODS Nineteen consecutive patients with severe rheumatoid forefoot deformities underwent 24 forefoot reconstructions including first MTP arthrodesis with lesser MTP resection arthroplasty (resection arthroplasty group, ten feet), arthrolysis (arthrolysis group, six feet), or a combination of both (combined group, eight feet). Subjective, functional, and radiographic results were evaluated at 28 and 133 months (mean) followup. RESULTS The overall AOFAS Forefoot Score at short- and long-term followup improved significantly (all p < 0.0001). There were no substantial differences between groups with regard to subjective rating, function, use of orthopaedic aids or shoewear, and walking capacity. Radiographic evaluation revealed a significant increase in axial malalignment of the lesser toes at long-term followup in all groups (all p < 0.018). Sagittal malalignment increased substantially in the resection arthroplasty group only. Reoperation rate was comparable among all groups, and a single third MTP arthrolysis (3%, 1/40) was converted to resection arthroplasty. CONCLUSION In combination with first MTP arthrodesis, arthrolysis with preservation of all or only the lateral lesser MTP joints in rheumatoid forefoot reconstruction was a viable and durable alternative to resection arthroplasty when the joint destruction was mild to moderate.
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Affiliation(s)
- Fabian G Krause
- Department of Orthopaedic Surgery, University of Bern, Switzerland
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Lui TH. Technical tips: Modified resection arthroplasty for correction of rheumatoid forefoot deformity. Foot Ankle Surg 2010; 16:74-7. [PMID: 20483138 DOI: 10.1016/j.fas.2009.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Revised: 05/25/2009] [Accepted: 05/26/2009] [Indexed: 02/04/2023]
Abstract
Forefoot deformity occurs in nearly 90% of patients with rheumatoid arthritis. Resection arthroplasty of the lesser metatarsophalangeal joints is one of the commonest procedures performed in case of patients failed to respond to conservative treatment. Kirschner wires are used to stabilize the resection arthroplasty sites. We present a modified technique to improve the sagittal plane alignment by bending of the wires dorsally at the site of resection arthroplasty.
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Affiliation(s)
- Tun Hing Lui
- Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong, China.
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Roukis TS. Scarf and Weil metatarsal osteotomies of the lateral rays for correction of rheumatoid forefoot deformities: a systematic review. J Foot Ankle Surg 2010; 49:390-4. [PMID: 20421174 DOI: 10.1053/j.jfas.2010.02.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Indexed: 02/03/2023]
Abstract
Scarf osteotomy of the first ray combined with Weil distal oblique shortening osteotomies of the lateral rays has recently been proposed for the treatment of global rheumatoid forefoot deformities because of the perceived benefit of sparing the metatarsal-phalangeal joints. Furthermore, it has been proposed that undergoing this form of global forefoot reconstruction is reliable based on specific preoperative and intraoperative techniques used to realign the individual rays. Finally, it has been proposed that performing global forefoot reconstruction in the rheumatoid patient population can be safely performed and does not prevent the ability to perform revision surgery. The author undertook a systematic review of electronic databases and other relevant sources to identify material relating to Scarf osteotomy of the first ray combined with Weil distal oblique shortening osteotomies of the lateral rays for the treatment of global rheumatoid forefoot deformities. Information from peer-reviewed journals, as well as from non-peer-reviewed publications, abstracts and posters, textbooks, and unpublished works, was also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they involved patients undergoing Scarf osteotomy of the first ray combined with Weil distal oblique shortening osteotomies of the lateral rays, evaluated patients at mean follow-up of 12-months or longer duration, commented on the reliability of metatarsal realignment, and included details of complications, as well as the incidence and severity of wound-healing complications. Two studies were identified that met the inclusion criteria involving only 8 patients (8 feet) with 1 patient undergoing surgical revision in the form of arthrodesis secondary to development of a septic first metatarsal-phalangeal joint. Partial incision dehiscence developed in 2 patients, 1 healed with local wound care and the other led to the septic first metatarsal-phalangeal joint mentioned previously. Finally, stress fracture of the third metatarsal and fourth metatarsals developed that healed without problems in one other patient. Rather than providing strong evidence for or against the use of Scarf osteotomy of the first ray combined with Weil distal oblique shortening osteotomies of the lateral rays for the treatment of global rheumatoid forefoot deformities, the results of this systematic review make clear the need for methodologically sound prospective cohort studies and randomized controlled trials that focus on the use of this form of surgical intervention.
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Affiliation(s)
- Thomas S Roukis
- Limb Preservation Service, Vascular/Endovascular Surgery Service, Department of Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA.
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Abstract
Rheumatoid arthritis is an autoimmune disorder that presents in females more often than males, and may affect people belonging to any age group. This disease shows no regional or ethnic preference. Although genetic and environmental causes have been proposed, the definitive cause of immunologic susceptibility, as well as viral and bacterial infectious processes that may cause rheumatoid arthritis, have not been identified. This article discusses various reconstructive forefoot surgeries to correct rheumatoid arthritis and the perioperative care of the patients who undergo surgery, along with the radiographic and magnetic resonance imaging findings associated with the disease.
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Niki H, Hirano T, Okada H, Beppu M. Combination joint-preserving surgery for forefoot deformity in patients with rheumatoid arthritis. ACTA ACUST UNITED AC 2010; 92:380-6. [DOI: 10.1302/0301-620x.92b3.23186] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Proximal osteotomies for forefoot deformity in patients with rheumatoid arthritis have hitherto not been described. We evaluated combination joint-preserving surgery involving three different proximal osteotomies for such deformities. A total of 30 patients (39 feet) with a mean age of 55.6 years (45 to 67) underwent combined first tarsometatarsal fusion and distal realignment, shortening oblique osteotomies of the bases of the second to fourth metatarsals and a fifth-ray osteotomy. The mean follow-up was 36 months (24 to 68). The mean foot function index scores for pain, disability and activity subscales were 18, 23, and 16 respectively. The mean Japanese Society for Surgery of the Foot score improved significantly from 52.2 (41 to 68) to 89.6 (78 to 97). Post-operatively, 14 patients had forefoot stiffness, but had no disability. Most patients reported highly satisfactory walking ability. Residual deformity and callosities were absent. The mean hallux valgus and intermetatarsal angles decreased from 47.0° (20° to 67°) to 9.0° (2° to 23°) and from 14.1° (9° to 20°) to 4.6° (1° to 10°), respectively. Four patients had further surgery including removal of hardware in three and a fifth-ray osteotomy in one. With good peri-operative medical management of rheumatoid arthritis, surgical repositioning of the metatarsophalangeal joint by metatarsal shortening and consequent relaxing of surrounding soft tissues can be successful. In early to intermediate stages of the disease, it can be performed in preference to joint-sacrificing procedures.
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Affiliation(s)
- H. Niki
- Department of Orthopaedic Surgery St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
| | - T. Hirano
- Department of Orthopaedic Surgery St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
| | - H. Okada
- Department of Orthopaedic Surgery St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
| | - M. Beppu
- Department of Orthopaedic Surgery St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
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Mid-term results of joint-preserving procedures by a modified Mann method for big toe deformities in rheumatoid patients undergoing forefoot surgeries. Mod Rheumatol 2009; 20:147-53. [PMID: 20012459 DOI: 10.1007/s10165-009-0253-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 11/02/2009] [Indexed: 10/20/2022]
Abstract
This study aimed to evaluate joint-preserving procedures by a modified Mann method for rheumatoid forefoot deformities and their functional outcomes in the mid-term. Eleven feet in seven patients underwent forefoot surgery using a modified Mann method for the big toe, combined with offset osteotomy or resection arthroplasty of the lesser toes. The mean follow-up period was 3.6 years. The mean score on the Japanese Society for Surgery of the Foot scale for rheumatoid arthritis foot and ankle joints improved from 44.0 to 72.0. The mean hallux valgus angle improved from 39.4 degrees to 20.5 degrees and the mean M1M5 angle improved from 31.1 degrees to 25.8 degrees . However, deformities involving a hallux valgus angle of more than 25.0 degrees recurred in three feet at the latest follow-up, although the patients did not complain of any symptoms from the recurrence. Improvement in the Sharp score for joint space narrowing was observed in the big toe, indicating better congruity of the metatarsophalangeal joint. For restraint of rheumatoid forefoot deformities, a modified Mann method, combined with offset osteotomy or resection arthroplasty, was satisfactory for not only improving the foot function, but also preserving the metatarsophalangeal joint mobility.
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Simonsen O, Vuust M, Understrup B, Højbjerre M, Bøttcher S, Voigt M. The transverse forefoot arch demonstrated by a novel X-ray projection. Foot Ankle Surg 2009; 15:7-13. [PMID: 19218058 DOI: 10.1016/j.fas.2008.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2007] [Revised: 04/02/2008] [Accepted: 04/16/2008] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Metatarsalgia is often treated by metatarsal osteotomy. Exact knowledge of the normal anatomy of the forefoot is essential for pre-operative planning. The objective of this study was to investigate the forefoot arch during maximal loading in a randomly selected population sample. METHODS Two hundred subjects randomly selected from a municipality representative of Denmark were invited to interview and forefoot X-ray examination, including a novel horizontal X-ray projection by which the height of each metatarsal from the floor can be measured under maximal loading. RESULTS One hundred and thirty-four subjects (79%) presented themselves for interview and X-ray examination. The study group was representative of the randomly selected population sample in terms of age, sex and incidence of metatarsalgia. The study verified that the interrelated geometry of the metatarsal heads in the AP plane corresponds to a parabola as suggested previously (Le Lièvre's parabola). Also in the horizontal plane, the metatarsal heads generally form an arch, the transverse forefoot arch (TFA). Mean height was 3.91mm (S.E.=0.10). The individual height of the TFA varied from -1 to 10mm and was dependent on the width of the forefoot. The relative height of the arch (arch height divided by forefoot width) was independent of age and sex. A non-significant tendency towards a lower arch among subjects with metatarsalgia was observed. CONCLUSION This population study demonstrated that the metatarsal heads constitute arches in both planes (Le Lièvre's parabola in the AP plane and the transverse forefoot arch in the horizontal plane). This knowledge is essential for pre-operative planning in metatarsal osteotomy for metatarsalgia. Formulae for calculating the individual location of each metatarsal head were obtained.
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Affiliation(s)
- O Simonsen
- Orthopaedic Division, North Denmark Region, Aalborg Hospital Part of Aarhus University Hospital, Aalborg Ø, Denmark.
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Symeonidis PD. Foot & Ankle International, the AOFAS logo. Foot Ankle Int 2009; 30:284. [PMID: 19321110 DOI: 10.3113/fai.2009.0284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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