Joint preserving surgery for rheumatoid forefoot deformities improves pain and corrects deformity at midterm follow-up

BackgroundRheumatoid 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.ObjectivesWe 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.MethodThere 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).ResultsMean 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.ConclusionIn 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.     

Rheumatoid forefoot reconstruction. A long-term follow-up study

BACKGROUNDS: The purpose of the present study was to assess the results of reconstruction of the rheumatoid forefoot with arthrodesis of the metatarsophalangeal joint of the great toe, resection arthroplasty of the metatarsal heads of the lesser toes, and open repair of hammer-toe deformity (arthrodesis of the proximal interphalangeal joint) of the lesser toes when this deformity was present. METHODS: A retrospective study of forty-three consecutive patients (fifty-eight feet) with severe rheumatoid forefoot deformities was performed. Six patients (six feet) died before the most recent follow-up, and five patients (five feet) were excluded because a subtotal procedure had been performed. No patient was lost to follow-up. Thus, the study included thirty-two patients (forty-seven feet) in whom reconstruction of a rheumatoid forefoot had been performed by the author. RESULTS: All first metatarsophalangeal joints had successfully fused at an average of seventy-four months (range, thirty-seven to 108 months) postoperatively. The average postoperative hallux valgus angle was 20 degrees and the average postoperative angle subtended by the axes of the proximal phalanx and the metatarsal of the second ray (the MTP-2 angle) was 14 degrees, demonstrating that a stable first ray protected the lateral rays from later subluxation. One hundred and thirty-two (70 percent) of the 188 lesser metatarsophalangeal joints were dislocated preoperatively, compared with thirteen (7 percent) postoperatively. The result of the procedure (as rated subjectively by the patient) was excellent for twenty-three feet, good for twenty-two, and fair for two. There were no poor results. The average postoperative score according to the system of the American Orthopaedic Foot and Ankle Society was 69 points. Postoperative pain was rated as absent in eighteen feet, mild in twenty-five, moderate in four, and severe in none. Fifteen feet were not associated with any functional limitations, twenty-eight were associated with limitation of recreational activities, and four were associated with limitation of daily activities. At the time of the most recent follow-up, no special shoe requirements were reported. Fourteen feet (30 percent) had a reoperation for the removal of hardware from the first metatarsophalangeal joint, a procedure on the interphalangeal joint of the great toe, or additional procedures on the lesser toes or lesser metatarsophalangeal joints. CONCLUSIONS: In the present study, arthrodesis of the first metatarsophalangeal joint, resection arthroplasty of the lesser metatarsal heads, and repair of fixed hammer-toe deformities with intramedullary Kirschnerwire fixation resulted in a stable repair with a high percentage of successful results at an average of six years after the procedures.     

The importance of the valgus hindfoot in forefoot surgery in rheumatoid arthritis

The relationship between hindfoot deformity and forefoot pressure was assessed in 28 rheumatoid patients who had undergone forefoot reconstruction four years previously. Patients with valgus hindfoot deformities tended to have high forefoot pressures whereas those with a normal hindfoot recorded normal pressures on the dynamic pedobarograph. All patients with residual forefoot pain recorded abnormal forefoot pressures. We believe that orthotic control of hindfoot deformities should be considered for those patients who require forefoot surgery as a combination of surgical and orthotic management may offer the best chance of success.     

Hallux metatarsophalangeal arthroplasty in the rheumatoid forefoot

Surgical options for treatment of the hallux valgus deformity in the rheumatoid forefoot are numerous, but long-term results of many of these procedures have been less than satisfactory. Controversy exists as to whether excision or fusion is preferred for the treatment of the hallux metatarsophalangeal (MTP) joint. The role of replacement arthroplasty needs to be evaluated. The available surgical options for treatment of the arthritic first MTP joint in rheumatoid arthritis include arthrodesis, excision of the metatarsal head with or without interposition of the soft tissues, excision of the proximal phalanx, and silicone hinge replacement. This article discusses the various types of arthroplasty of the first MTP joint and the reported outcomes in the rheumatoid forefoot.     

Resection of the forefoot in rheumatoid arthritis.

A long-term review of 272 resections of the metatarsal heads and bases of the phalanges in 128 patients with severe rheumatoid feet is presented. The longest follow-up is 11 years and the average follow-up was 4.7 years. Recurrent deformity and callus formation was usually due to a long metatarsal shaft. The operation, when properly performed, can correct severe deformities of the forefoot with a high percentage of satisfactory results.     

More than 20 years’ follow-up of metatarsal neck shortening oblique osteotomy for rheumatoid forefoot deformity

BackgroundIn recent years, advances in pharmacotherapy for rheumatoid arthritis (RA) have dramatically improved the control of disease activity. However, a significant number of patients still develop forefoot deformity. The purpose of this study was to investigate the results of more than 20 years’ follow-up of metatarsal neck shortening oblique osteotomy (SOO) for forefoot deformity in patients with RA.MethodsThe metatarsal neck SOO was performed on 163 feet in 108 patients between January 1985 and December 1996 in the authors’ hospital. For the patients, who met the survey criteria, an observational study was performed clinically and radiologically at the baseline and at more than 20 years after surgery.ResultsA retrospective cohort study was conducted on 36 feet in 22 patients, all of whom were female, and the mean age at surgery was 45.6 (35.0–63.0) years old. The follow-up period was 25.1 (21.0–31.0) years. The presence of painful callosities in the surgically treated feet without revised surgeries decreased from 32 feet (100%) to 4 feet (12.5%) at the last follow-up with mild pain that did not cause any footwear problems. Re-osteotomy at the metatarsal of the lessor toe was performed on four feet in two patients. Radiologically, among 128 toes without revised surgeries, 85% were able to have the joint space preserved, and 89% maintained a pain-free condition without any recurrence of deformity. The mean total Japanese Society for Surgery for the Foot (JSSF) RA foot and ankle score was 64.0/100, and the visual analogue scale (VAS) of overall satisfaction was 62 (0: dissatisfied, 100: highly satisfied). The overall satisfaction had a positive correlation with calcaneal pitch and negative correlation with joint space narrowing at the talocrural joint.ConclusionsMetatarsal neck SOO appeared to be effective for patients with RA. The deformity was corrected and retained for a long time.     

Resection or preservation of the metatarsal heads in rheumatoid forefoot surgery? A randomised clinical trial

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.

Bariatric surgery in adolescents: a long-term follow-up study

BACKGROUND: The benefits of bariatric surgery in adult obese patients are well known, but data are lacking regarding the outcome of the surgery in adolescents. The aim of this study was to retrospectively assess the operative morbidity and mortality, percentage of loss of initial excess weight, and the incidence of long-term complications and reoperations in a cohort of obese patients who underwent biliopancreatic diversion (BPD) before their 18th birthday. METHODS: A total of 76 adolescent subjects underwent BPD between 1976 and 2005. Of these 78 patients, 7 had Prader-Willi syndrome and 1 had Turner syndrome and were excluded from the study. RESULTS: The patient population comprised 52 girls and 16 boys. Their mean age was 16.8 years, mean body weight at operation was 125 kg (mean body mass index 46 kg/m2). Operative mortality was nil. The mean follow-up was 11 years (range 2-23). The mean percentage of loss of initial excess weight at each patient's longest follow-up was 78%. Before surgery, 33 patients were hypertensive (49%), 11 were dyslipidemic (16%), 3 were hyperglycemic, and 2 had type 2 diabetes. At the longest follow-up period after surgery, only 6 patients were hypertensive, and none were dyslipidemic or diabetic. A total of 19 reoperations were performed in 14 patients (20%), including 7 revisions. Eleven patients developed protein malnutrition 1-10 years after BPD. The long-term mortality rate was 4%. At 4 to 23 years after BPD, 18 of the women had given birth to 28 healthy babies. Three women had had a complicated pregnancy. CONCLUSION: Adolescents can undergo malabsorptive bariatric surgery with excellent long-term weight loss results and an incidence of long-term complications similar to that observed during the 30-year evolution of BPD in our experience.     

Percutaneous forefoot surgery for treatment of hallux valgus deformity: an intermediate prospective study

Background

This study aims to illustrate the results of percutaneous forefoot surgery (PFS) for correction of hallux valgus.

Materials and methods

A prospective study of 108 patients, with hallux valgus deformity, who underwent PFS was conducted. The minimum clinical and radiological follow-up was two years (mean 57.3 months, range 22–112).

Results

Preoperative mean visual analog scale was 6.3 ± 1.5 points, and AOFAS scores were 50.6 ± 11 points. At the last follow-up, both scores improved to 1.9 ± 2.4 points and 85.9 ± 1.83 points, respectively. Mean hallux valgus angle changed from 34.3° ± 9.3° preoperatively to 22.5° ± 11.1° at follow-up. At follow-up, 76.5% of the subjects were satisfied or very satisfied. Recurrence of medial 1st MT head pain happened in 22 cases (16.7%).

Conclusions

PFS, in our study, does not improve the radiological and patient satisfaction rate results compared with conventional procedures. The main advantage is a low postoperative pain level, but with an insufficient HVA correction.

Level of evidence

II, prospective study.