Plantarflexion opening wedge medial cuneiform osteotomy for correction of fixed forefoot varus associated with flatfoot deformity

BACKGROUND: Flatfoot presents as a wide spectrum of foot deformities that include varying degrees of hindfoot valgus, forefoot abduction, and forefoot varus. Medial displacement calcaneal osteotomy, lateral column lengthening, and subtalar fusion can correct heel valgus, but may not adequately correct the fixed forefoot varus component. The purpose of this study was to determine the effectiveness of plantarflexion opening wedge medial cuneiform (Cotton) osteotomy in the correction of forefoot varus. METHODS: Sixteen feet (15 patients) had plantarflexion opening wedge medial cuneiform osteotomies to correct forefoot varus associated with flatfoot deformities from several etiologies, including congenital flatfoot (six feet, average age 37 years), tarsal coalition (five feet, average age 15 years), overcorrected clubfoot deformity (two feet, ages 17 years and 18 years), skewfoot (one foot, age 15 years), chronic posterior tibial tendon insufficiency (one foot, 41 years), and rheumatoid arthritis (one foot, age 56 years). RESULTS: Standing radiographs showed an average improvement in the anterior-posterior talo-first metatarsal angle of 7 degrees (9 degrees preoperative, 2 degrees postoperative). The talonavicular coverage angle improved an average of 15 degrees (20 degrees preoperative, 5 degrees postoperative). The lateral talo-first metatarsal angle improved an average of 14 degrees (-13 degrees preoperative, 1 degree postoperative). Correcting for radiographic magnification, the distance from the mid-medial cuneiform to the floor on the lateral radiograph averaged 40 mm preoperatively and 47 mm postoperatively (average improvement 7 mm). All patients at followup described mild to no pain with ambulation. There were no nonunions or malunions. CONCLUSIONS: Opening wedge medial cuneiform osteotomy is an important adjunctive procedure to correct the forefoot varus component of a flatfoot deformity. Advantages of this technique in comparison to first tarsometatarsal arthrodesis include predictable union, preservation of first ray mobility, and the ability to easily vary the amount of correction. Because of the variety of hindfoot procedures done in these patients, the degree of hindfoot correction contributed by the cuneiform osteotomy alone could not be determined. We have had excellent results without major complications using this technique.     

第1跖列稳定术联合第2-5跖骨头切除术治疗晚期类风湿关节炎前足畸形

目的:介绍第1跖列稳定联合第2-5跖骨头切除术治疗晚期类风湿关节炎(rheumatoid arthritis,RA)前足畸形的手术方式并对中短期临床疗效进行评价。方法:2006年10月至2010年8月收治的晚期RA前足畸形97例患者进行回顾性分析。其中,男9例,女88例;单足65例,双足32例;年龄36～67岁,平均54岁;病程6～32年,平均17年。所有病例存在严重的拇外翻同时合并第1跖跗关节不稳,第2-5跖趾关节脱位及僵硬。采用第1跖列稳定联合第2-5跖趾关节成形术对其进行治疗。通过影像学资料测量拇外翻角(Hallux valgus angle,HVA),跖骨间角(intermetatarsal angle,IMA),并采用JSSF(Japanese Society for Surgery of the Foot)评分对临床疗效进行评估。结果:97例患者中失访5例(7足),平均随访37个月(6～52个月),其中1例术后1年因急性心肌梗死死亡。术前JSSF评分(33.2±8.2)分,末次随访时改善至(67.3±3.1)分(P<0.01);HVA由术前(50.0±11.8)°纠正至术后(21.2±3.2)°(P<0.01);IMA由术前(15.5±3.6)°纠正至术后(9.7±6.6)°(P<0.01)。发生跖趾关节骨不连4足;术后8～11月摄片发现第1楔骨内高密度改变3足;出现拇内侧切口延迟愈合9足;跖趾关节内固定感染2足;跖跗关节内固定感染1足;第2-5跖趾关节术后16足畸形复发。结论:晚期RA患者的前足病变涉及范围广,畸形严重。采用第1跖趾关节融合联合Lapidus术式重建第1跖列的外形及稳定性,跖骨头切除术纠正第2-5跖趾关节畸形的方式重建前足疗效可靠。该术式适用于重度拇外翻合并IMA增大及第1跖跗关节不稳,同时存在第2-5跖趾关节僵硬性半脱位的患者。     

Metatarsal osteotomy in rheumatoid arthritis

Thirty-eight feet in 28 patients with rheumatoid forefoot deformity were operated on with a proximal valgus osteotomy of the first metatarsal bone to reduce splaying of the forefoot. Each patient also underwent additional surgical procedures for associated conditions of the forefoot. The mean follow-up period was 3.7 years. Both the entire forefoot and the medial border of the foot were substantially improved in all but 2 cases. Residual symptoms were slightly more pronounced in the anterior footpad and the lesser toes (5 cases). A proximal valgus osteotomy of the first metatarsal bone, performed in combination with other surgical procedures, affords a good correction of the rheumatoid foot deformity with long-term improvement.     

Metatarsal osteotomy in rheumatoid arthritis

Thirty-eight feet in 28 patients with rheumatoid forefoot deformity were operated on with a proximal valgus osteotomy of the first metatarsal bone to reduce splaying of the forefoot. Each patient also underwent additional surgical procedures for associated conditions of the forefoot. The mean follow-up period was 3.7 years. Both the entire forefoot and the medial border of the foot were substantially improved in all but 2 cases. Residual symptoms were slightly more pronounced in the anterior footpad and the lesser toes (5 cases).

A proximal valgus osteotomy of the first metatarsal bone, performed in combination with other surgical procedures, affords a good correction of the rheumatoid foot deformity with long-term improvement.     

Medial column procedures in the correction of adult acquired flatfoot deformity

AAFD is a complex problem with a wide variety of treatment options. No single procedure or group of procedures can be applied to all patients with AAFD because of the variety of underlying etiology and grades of deformity. As the posture of the foot progresses into hindfoot valgus and forefoot abduction through attenuation of the medial structures of the foot, the medial column begins to change shape. The first ray elevates and the joints of the medial column may begin to collapse. Careful physical examination and review of weight-bearing radiographs determines which patients have an associated forefoot varus deformity that may require correction at the time of flatfoot reconstruction. Correction of an AAFD requires a combination of soft-tissue procedures to restore dynamic inversion power and bony procedures to correct the hindfoot and midfoot malalignments. If after these corrections forefoot varus deformity remains, the surgeon should consider use of a medial column procedure to recreate the “triangle of support” of the foot that Cotton described.5 If the elevation of the medial column is identified to be at the first NC or the first TMT joint, then the joint should be carefully examined for evidence of instability, hypermobility, or arthritic change. If none of these problems exist, then the surgeon can consider use of the joint-sparing Cotton medial cuneiform osteotomy to correct residual forefoot varus. However, if instability, hypermobility, or arthritic change is present, then the surgeon should consider use of an arthrodesis of the involved joint to correct residual forefoot varus. Either procedure provides a safe and predictable correction to the medial column as part of a comprehensive surgical correction of AAFD.     

Bilateral arthrodesis of the medial foot joints in a patient with rheumatoid arthritis

Patients with rheumatoid arthritis (RA) often have foot problems. The subtalar and particularly talonavicular joints are affected most frequently. The posterior tibial tendon has an important role in mid-foot stability. In RA patients, chronic inflammation of this tendon or talonavicular joint arthritis can results in posterior tibial tendon rupture. This leads to a collapsed talonavicular joint and forefoot instability, first with talonavicular and later Chopart's joint involvement. This shows as a planovalgus foot, with the forefoot in pronation and the heel in valgus deviation. In a 61-year-old RA patient, ruptures of the posterior tibial tendon due to rheumatoid inflammation occurred bilaterally, with subsequent deviation and instability of the forefoot. Arthrodesis with a medial column screw-Midfoot Fusion Bolt was carried out on the left foot and 4 months later on the right foot. At 7 months after the left and 4 months after the right foot surgery, the patient was free from pain, both feet were stable under loading and the forefoot was firm. The planovalgus deformity was corrected, as well as a valgus deviation of the great toe. Radiography showed a good position of the screws and complete healing of the medial foot joints.     

Rheumatoid Forefoot Reconstruction in Nonrheumatic Patients: Lesser Metatarsal Head Resection versus Osteotomy

In the literature, first metatarsophalangeal joint arthrodesis with lesser metatarsal head resection seems to be a reliable procedure in rheumatoid foot deformity. Maybe this procedure could be proposed in nonrheumatoid severe forefoot deformity (hallux valgus angle >40° and lesser metatarsophalangeal dislocation). The aim of this study was to compare radiological and clinical outcomes between lesser metatarsal head resection and lesser metatarsal head osteotomy in nonrheumatoid patients. Thirty-nine patients (56 feet) suffering from well-defined nonrheumatoid severe forefoot deformity were retrospectively enrolled in our institution between 2009 and 2015. Metatarsal head resection and metatarsal head osteotomy represented 13 patients (20 feet) and 26 patients (36 feet), respectively. In this observational study, a rheumatoid population (21 patients) was included as the control. The clinical outcome measures consisted of American Orthopaedic Foot and Ankle Society score, Foot and Ankle Ability Measurement, and Short Form-36. The radiological outcomes were: intermetatarsal angle, hallux valgus angle, and metatarsophalangeal alignment. Mean follow-up was 24 months. Satisfaction rate was, respectively, 92% for resection, 91% for osteotomy procedure, and 80% for surgery in rheumatoid patients. Short Form-36 global score was, respectively, 80.7 (52.5-96.4), 76 (57.7-93), and 68.3 (22.6-86). No functional outcome difference was found between resection and osteotomy procedures, except that the metatarsal head resection group had poorer results in sports activities than the osteotomy group. Complications were similar between osteotomy and resection (p > .05). The radiological outcomes were improved significantly from preoperative to postoperative. First metatarsophalangeal joint arthrodesis with lesser metatarsal head resection in nonrheumatoid severe forefoot deformity might be a good therapeutic option.     

Application of bone graft to the medial side of the first metatarsal head in the treatment of hallux varus

BACKGROUND: Hallux varus deformity is not frequent, is usually acquired, and is poorly tolerated by patients. A common cause is the resection of an excessive amount of the head of the first metatarsal during an operation performed to correct a hallux valgus deformity. The purpose of this study was to evaluate the results of application of bone graft to the medial aspect of the first metatarsal head in order to restore missing bone after resection of an excessive amount of bone during a bunionectomy. METHODS: Of thirty patients who had a hallux varus deformity that was treated operatively, eight (ten feet) had bone-grafting to the medial aspect of the first metatarsal head. Six patients (seven feet) were available for evaluation at an average of 8.6 years (range, two to twenty-two years) postoperatively. The original reasons for the consultation for the hallux varus deformity were pain in the great toe, discomfort with shoewear, and the cosmetic appearance of the deformity. The pain typically was located on the medial aspect of the great toe and was caused by the pressure of the shoe; the pain usually was aggravated by walking. Preoperatively, the passive range of dorsiflexion averaged 72 degrees (range, 60 to 80 degrees); the passive range of plantar flexion, 12 degrees (range, 10 to 20 degrees); and the varus deformity, 18 degrees. RESULTS: Six of the seven feet had a satisfactory result. The pain associated with the varus deformity had disappeared in all patients. One patient was dissatisfied because of 20 degrees of valgus angulation. The passive range of dorsiflexion averaged 63 degrees (range, 60 to 70 degrees), and all patients had 10 degrees of plantar flexion. Overall, the valgus angulation of the metatarsophalangeal joint averaged 19 degrees (range, 16 to 22 degrees). There was no recurrence or persistence of the varus deformity. In three feet, the joint space was reduced, but this did not jeopardize the clinical result. CONCLUSIONS: A bone graft screwed onto the medial aspect of the metatarsal head provided a good result. This technique is indicated when the varus deformity is related to a previous resection of an excessive amount of bone during a bunionectomy and when the deformity is passively reducible to neutral.     

Hypermobility of the first ray

Hypermobility of the first ray is one of the causative components in common foot problems (such as hallux valgus) with a large intermetatarsal angle and metatarsus primus varus. Although not always associated with hallux valgus, hypermobility is a predisposing factor for this deformity, especially in conjunction with extrinsic factors, such as disruption of the plantar first metatarsal cuneiform ligament and tendon-muscle imbalance. Hypermobility is also frequently found in adolescents with hallux valgus, especially when associated with a large intermetatarsal angle. Motion at the first metatarsocuneiform joint occurs in the sagittal and transverse planes. Most studies agree that greater than 4 degrees and greater than 8 degrees, respectively, constitutes excessive motion. Clinically, hypermobility is evaluated by determining sagittal motion (the grasping test) and transverse motion (the clinical squeeze test) and by identifying signs such as the presence of a dorsal bunion, intractable plantar keratosis beneath the second metatarsal head, and arthritis of the first and second metatarsocuneiform joint. Radiographically, hypermobility is evaluated by measurements from the modified Coleman block test (for sagittal motion) and the radiographic squeeze test (for transverse motion) and by the identification of signs, such as cortical hypertrophy along the medial border of the second metatarsal shaft, a cuneiform split, the presence of os intermetatarseum, and the round shape and increased medial slope of the first metatarsocuneiform joint. Usually, treatment for hypermobility of the first ray is operative, but surgery is contraindicated for patients less than 20 years of age (especially when the epiphysis is not closed) and for patients with generalized ligamentous laxity, short first metatarsal, and arthritis of the hallux MTP joint. The authors' surgical treatment of choice is arthrodesis of the tarsometatarsal joint (as part of the hallux valgus correction), exostectomy, capsulorraphy, and distal soft tissue release to correct and stabilize the first metatarsal at the apex of the deformity. The authors have found it unnecessary to include the base of the second metatarsal. The main complications associated with the Lapidus procedure and its modifications are nonunion, malunion, and dorsal elevation of the first metatarsal. Although radiographic nonunion is the most frequent complication, only 25% of the patients with this condition have associated clinical findings; the results have been defined as good or excellent in two series. These results closely equal those in rheumatoid or sedentary patients managed with newer, modified, less traumatic techniques that stabilize the first metatarsocuneiform joint with screws rather than with arthrodesis.     

Calcaneocuboid distraction arthrodesis and first metatarsocuneiform arthrodesis for correction of acquired flatfoot deformity in a cadaver model

BACKGROUND: Lateral column lengthening has been associated with residual forefoot supination and symptomatic lateral overload in treatment of acquired flatfoot. A medial column procedure may be useful to redistribute load to the medial column. We evaluated radiographic and pressure changes in a severe flatfoot model with lateral column lengthening and investigated the effect of an added first metatarsocuneiform arthrodesis. METHODS: Ten cadaver specimens were loaded in simulated double-legged stance, and radiographic and pressure data were collected for all tested states. Calcaneocuboid arthrodesis was done with a 10-mm foam wedge. Residual forefoot varus was corrected through the first metatarsocuneiform joint. RESULTS: Differences in the mean lateral talar-first metatarsal angle, talonavicular angle, talocalcaneal angle, and calcaneal pitch were significant between the intact foot and the flatfoot. After calcaneocuboid distraction arthrodesis and tendon transfer, the lateral talar-first metatarsal angle, talonavicular angle, and calcaneal pitch were significantly different from the flatfoot. After added first metatarsocuneiform arthrodesis, the talonavicular angle was not significantly different from the intact foot. Lateral forefoot pressure increased in the flatfoot after lateral column lengthening but was not significantly different from the intact foot after first metarsocuneiform arthrodesis was added. CONCLUSIONS: Adding first metatarsocuneiform arthrodesis to calcaneocuboid distraction arthrodesis for treatment of flatfoot deformity provided improvement in radiographic and pedobarographic parameters of a severe model of stage II posterior tibial tendon dysfunction.     

Scarf and Weil osteotomies for correction of rheumatoid forefoot deformities: A review of 20 cases

The forefoot is commonly affected in rheumatoid arthritis. Little has been written of the results of metatarsophalangeal joint preservation in rheumatoid arthritis. We describe the results of the Scarf and Weil osteotomy for correction of forefoot deformities in patients with rheumatoid arthritis. Between 1996 and 1999, 17 patients (20 feet) underwent a Scarf osteotomy for their hallux valgus deformity and in 17 feet a Weil osteotomy of the lesser metatarsophalangeal joints. Radiographic examination was performed preoperatively and at a mean follow up of 65 months. A questionnaire was used at a minimum follow up of 6 years. The hallux valgus angle improved from 41° to 28° at follow up. The majority of the patients (79%) were satisfied with the result during follow-up. We found no wound infections, neuralgia or osteonecrosis of the first metatarsal. In three patients, a fusion of the first MTP joint was performed at follow up.In conclusion, the Scarf and Weil osteotomy is a useful method for MTP joint preserving surgery in rheumatoid forefoot deformities without severe impairment of the MTP joints.     

Opening wedge osteotomy of the medial cuneiform before age 4 years in the treatment of forefoot adduction

Thirty-seven feet in 25 children (12 girls, 13 boys) treated surgically with medial cuneiform opening wedge osteotomy to correct forefoot adduction were assessed. Thirteen patients had unilateral deformity. Primary diagnoses were congenital clubfoot (33 feet), congenital forefoot adduction (3 feet), and skewfoot (1 foot). All children underwent operation before age 4 years. The age at operation ranged from 21 to 47 months (mean 35). In 18 feet, allografts were used. In 5 feet, autograft was used. In 14 feet, ceramic material was inserted as opening wedge. Follow-up ranged from 3 to 8 years (mean 4). In four feet, the ossification center of the medial cuneiform was invisible. The correction of the deformity was assessed clinically and radiographically. The first ray angle and talo-first metatarsal angle were evaluated on anteroposterior radiographs, the latter was evaluated on lateral radiographs, also. In 26 feet, normal position of the forefoot was achieved. In five feet, overgrowth of the medial cuneiform in comparison with the normal side was observed. Forefoot adduction persisted in six feet. The ossification center was often divided into two parts by bone graft, and subsequent independent growth of both parts was observed. This technique is safe and useful for correction of forefoot adduction in young children. It can be performed even in cartilaginous bone. The osteotomy causes overgrowth of the medial cuneiform and the medial ray.     

Relationship Between Grading With Magnetic Resonance Imaging and Radiographic Parameters in Posterior Tibial Tendon Dysfunction

The objective of the present study was to elucidate the relationship between the state of the posterior tibial tendon (PTT) on magnetic resonance images and foot deformity. The cases included 34 feet in 27 patients with PTT deformity and the controls included 18 feet in 12 patients who had undergone magnetic resonance imaging for other foot diseases. The PTT was closely examined on the magnetic resonance images and classified using the Conti classification. The control feet with no injury to the PTT were classified as grade 0. The talonavicular coverage angle, lateral talo-first metatarsal angle, medial cuneiform to fifth metatarsal height, calcaneal pitch angle, and varus–valgus angle were measured as radiographic parameters for flatfoot deformation, and the relation between the Conti classification and each parameter was examined statistically. A significant difference was observed in the talonavicular coverage angle between grade 0 and the other grades; the lateral talo-first metatarsal angle between grade 0 and the other grades and between grades 1 and 3; the medial cuneiform to fifth metatarsal height among grades 0, 2, and 3 and grades 1, 2, and 3; the calcaneal pitch angle between grades 1 and 3; and the varus–valgus angle among grades 0, 2, and 3 and between grades 1 and 3. Eversion of the forefoot was observed, along with an advanced collapse in the medial longitudinal arch, from an early stage of PTT injury.     

Arthrodesis compared to Mayo resection of the first metatarsophalangeal joint in total rheumatoid forefoot reconstruction

BACKGROUND: Painful forefoot deformity from rheumatoid arthritis can be treated with resection of the lesser metatarsal heads combined with either resection or arthrodesis of the first metatarsophalangeal (MTP) joint. METHODS: In a prospective, randomized study we compared arthrodesis of first MTP joint with Mayo resection as part of total forefoot reconstruction in patients with painful forefoot deformity from rheumatoid arthritis. The lesser metatarsal heads were resected and extensor tenotomy was done in all patients. Thirty-one patients were randomized to either the arthrodesis or resection group. RESULTS: After a mean followup of 36 (26 to 52) months, the median subjective satisfaction score was 96 points out of 100 in the resection group and 92 points in the arthrodesis group. Significant improvements in pain, handicap, and activity according to Foot Function Index (FFI) were found in both groups (p <0.001 except for handicap in resection group and activity in fusion group were p=0.02). There were no statistically significant differences between the groups in these measures, nor in the patients' willingness to have the procedure again. There were no recurrences of prominences or tenderness under the forefoot in either group and no recurrence of severe hallux valgus in the resection group. The arthrodeses healed in 93%. There was no higher risk for clinically relevant IP joint symptoms after arthrodesis. The operating time was significantly longer in the arthrodesis group but this was not linked to a higher wound infection rate. CONCLUSION: These results indicate that Mayo resection may still be a good choice for the first MTP joint in total forefoot reconstruction in patients with rheumatoid arthritis.     

Rheumatoid forefoot deformity: pathophysiology, evaluation and operative treatment options

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.     

Chevron osteotomy for hallux valgus.

The chevron osteotomy for realignment of the first metatarsal head in metatarsus primus varus deformity has been utilized at the Mayo Clinic since 1976 on 26 feet (18 patients). Follow-up evaluation disclosed excellent relief of pain, good cosmetic correction, and overall patient satisfaction. Radiographic evaluation demonstrated reduction in the angle between the phalanx and the metatarsal bone of the great toe as well as narrowing of the forefoot with a decreased angle between the first and the second metatarsal bones. The stability of the osteotomy, the technical ease, and the absence of secondary difficulties such as transfer metatarsalgia make this procedure preferable when osteotomy of the distal portion of the first metatarsal bone is used for correction of moderate deformity.     

Sagittal Alignment of the First Metatarsophalangeal Joint after Arthrodesis for Rheumatoid Forefoot Deformity

The present study assessed the midterm results of reconstruction for rheumatoid forefoot deformity with arthrodesis of the first metatarsophalangeal (MTP) joint, scarf osteotomy, resection arthroplasty of the metatarsal head of the lesser toes, and surgical repair of hammertoe deformity (arthrodesis of the proximal interphalangeal joint). Special focus was placed on the sagittal alignment of the first metatarsophalangeal joint after arthrodesis. We retrospectively evaluated the postoperative clinical outcomes and radiographic findings for 16 consecutive female patients (20 feet) with symptomatic rheumatoid forefoot deformities. The mean duration of follow-up was 7.9 (range 4 to 13) years. All first MTP joints and first metatarsal bones were fused successfully. The mean value of the American Orthopaedic Foot and Ankle Society and Japanese Society for Foot Surgery clinical scores significantly improved overall, except for 2 patients (10%), who complained of first toe pain at the final follow-up visit owing to sagittal misalignment of the fused first MTP joint. Sagittal alignment of the first metatarsal varies greatly because of the rheumatoid midfoot and hindfoot deformities. Therefore, inclination of the first metatarsal should be considered when determining the first MTP joint sagittal fusion angle.     

Evaluation of scarf osteotomy for management of hallux valgus deformity

Hallux valgus is a complex progressive deformity affecting the forefoot. The main pathologic anatomy concerns the first metatarsophalangeal joint, including a varus or medial deviation of the first metatarsal and pronation deformity in the longitudinal axis. The goal of this study was to evaluate a series of consecutive patients over a 2-year period after a scarf osteotomy of the first metatarsal. A scarf osteotomy was performed on 31 consecutive patients with moderate to severe hallux valgus deformity (intermetatarsal angle, 13-22°; hallux valgus angle, 20-44°). Twenty-nine women and 2 men had an average age of 57 years (range, 21-71 years) at the time of surgery. Preoperative and postoperative evaluations included standing anteroposterior and lateral radiographs, American Orthopaedic Foot and Ankle Score (AOFAS) score, physical examination, and foot pressure analysis by weight-bearing ink prints. Patients were evaluated radiographically and clinically in the initial postoperative period (≤1 month), intermediate postoperative period (2-6 months), and final follow-up (12-36 months). Twenty-eight feet were available for analysis. Five of the 28 feet had concurrent surgeries on the lesser toes for hammer-toe correction or preoperative metatarsalgia. Paired Student t test on the 28 feet showed a statistically significant improvement (P<.0001) between pre- and postoperative intermetatarsal angle, hallux valgus angle, and AOFAS score. One foot had recurrence of the hallux valgus deformity. Paired analysis of variance of the 27 feet without recurrence showed a statistically significant improvement in the pre- and postoperative parameters (P<.0001). From this subset, the multiple-comparison Student-Newman-Keuis post hoc test showed a statistically significant (P<.0001) preservation of the correction in the intermediate follow-up period to final follow-up at an average 28 months.     

Long-term results after metatarsal head resection in the treatment of rheumatoid arthritis

BACKGROUND: In this retrospective study, both the patients' and surgeons' satisfaction with resection of the first through fifth metatarsal heads for long-standing rheumatoid forefoot deformity was evaluated. METHODS: Thirty-four patients (56 feet) had first through fifth metatarsal head resection. After a mean time of 5.3 years, 39 feet (69.6%) (26 patients) were examined clinically and radiographically. RESULTS: The complication rate was 14% (8 of 56). There were four superficial and four deep wound infections. Plantar pressure pain under the resected metatarsal heads occurred in six feet. Most patients rated their cosmetic and functional results as good. Eighteen percent of patients (6 of 34) were satisfied and 78% (26 of 34) were satisfied with reservations. Thirty-three percent of patients (11 of 34) were pain free and 53% (18 of 34) had mild pain. The surgeons assessment of the patients' anatomical correction (cosmesis) was good in 90% (50 of 56) and poor in 10% (6 of 56). CONCLUSIONS: Our results, which are comparable to those of other studies, confirm the success of metatarsal head resection for the treatment of inflammatory forefoot destruction in rheumatoid arthritis to correct deformity, reduce pain, improve ambulation, and offer the patient a greater variety of shoewear.