A clinical classification system for rheumatoid forefoot deformity

Background and purpose

In the present study a classification system for the rheumatoid forefoot is reported with its intra- and interobserver reliability and clinical relevance. The classification is based on the sequence of anatomical changes resulting from the loss of integrity of the MTP joints, loss of motion and changes regarding the quality and position of the plantar soft tissues. It is hypothesized that with progression of the amount of deformity of the MTP joint(s), patients have more pain and functional loss.

Patients and methods

In total 94 patients were included in the study following precise inclusion criteria. The forefeet of the patients were classified according to the introduced classification system by two observers in order to determine the intra- and interobserver reliability. The relation of the suggested classification between pain, function scores, and plantar foot pressure measurements was examined.

Results and conclusion

According to the Cohen's kappa and the ICC, the intra- and inter-observer reliability were high. Despite the large variation between subjects in a certain grade, a clear trend was found between increase in classification and VAS for pain, FFI difficulty with activities, and plantar peak pressure under the metatarsals. The suggested classification is of clinical relevance and can be used to develop therapeutical algorithms and to test interventions.     

Metatarsal head resection for rheumatoid deformities of the forefoot

Thirty-five feet in 21 patients, who had had metatarsal head resection for painful rheumatoid forefoot deformities, were analyzed retrospectively. All patients but one were allowed to ambulate 48 hours after surgery. The follow-up period averaged 29 months. A grading system was devised to assess the clinical results based upon pain relief, capacity to ambulate, shoe wear, cosmesis, and use of walking aids. Using this system, the results were 46% excellent, 34% good, 17% fair, and 3% poor. One patient developed a superficial wound infection, which healed uneventfully. Bony impingement was observed on follow-up roentgenograms of 67% of the resectional arthroplasties. This finding was generally asymptomatic, and it did not correlate with the clinical outcome. Smooth wire fixation was used in some of the feet, but it did not improve the results either roentgenographically or clinically.     

Joint-preserving surgery in rheumatoid forefoot: preliminary study with more-than-two-year follow-up

The authors propose a joint-preserving surgery for rheumatoid forefoot deformities as an alternative to the "classic" surgical approach to the rheumatoid forefoot. The main principle is joint preservation by shortening osteotomies of all the metatarsals performed at the primary location of the rheumatoid forefoot lesions, namely the metatarsophalangeal (MTP) joints and metatarsal heads. A scarf osteotomy is normally performed on the first ray. A Weil osteotomy is performed on the lesser metatarsals. Excellent correction of the hallux valgus deformity in the rheumatoid forefoot can be achieved with a scarf osteotomy in 92% of cases without the need for MTP joint arthrodesis. Similarly, 86% of the lateral metatarsal heads can be preserved using Weil osteotomies.     

The impact of hindfoot deformities for the recurrence of hallux valgus after joint-preserving surgeries for rheumatoid forefoot deformities

BackgroundRecurrence of hallux valgus (HV) is a common complication after forefoot surgery for rheumatoid forefoot deformities. The aim of this study is to evaluate the impact of hindfoot malalignment on recurrence.MethodsThis was a retrospective observational study designed to analyze the radiographic outcomes of 87 feet in 64 patients with rheumatoid arthritis treated with a joint-preserving surgery for HV deformity. Differences in hindfoot alignment preoperatively between the recurrence and nonrecurrence groups was compared.ResultsThere were no significant differences in hindfoot alignment preoperatively between groups. To estimate the impact of technical problems, the HV and intermetatarsal angles measured from radiographs 3 months postoperatively were compared between groups. The HV angles in the recurrence group were significantly larger than those in the nonrecurrence group (p = 0.02).ConclusionsThere were no significant differences between preoperative hindfoot malalignment and postoperative recurrence of HV in rheumatoid forefoot surgeries.     

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.     

A rare reason for prolonged pain and disability after forefoot surgery

We report diagnosis and adaequate surgical therapy a rare case of prolonged postoperative pain and swelling after fore-foot surgery caused by a chondroma of the neck of the talus. Resection and bone grafting resulted in a asymtomatic patient 42 weeks after surgery.     

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.

     

第一跖趾关节融合术与成形术治疗类风湿前足畸形疗效的系统评价

 目的 比较第一跖趾关节融合术与成形术治疗类风湿前足畸形的临床疗效。方法 计算机检索PubMed(1990年1月至2012年6月)、CNKI(1990年1月至2012年6月)、OVID(1996年1月至2012年6月)、中国生物医学文献光盘数据库、EMBASE(1966年1月至2012年6月)、万方数据库(1990年1月至2012年6月)和Cochrane Library(2011年第3期),搜集第一跖趾关节融合术与关节成形术比较治疗类风湿前足畸形的随机对照研究,对纳入的文献选择患者满意度、趾区负重、AOFAS穿鞋评分、外观评分、足功能指数评分、外翻角、第一、二跖骨间角、手术时间、并发症作为系统评价的指标。采用RevMan 5.1进行分析。结果 共纳入5项研究,285例患者。Meta分析显示：第一跖趾关节融合术的AOFAS穿鞋评分、外观评分优于第一跖趾关节成形术［MD=-0.88,95%CI(-1.55,-0.22),P=0.010;MD=-5.04,95%CI(-8.94,-1.14),P=0.01］,矫正第一、二跖骨间角、外翻角的能力较成形组好［MD=1.43,95%CI(0.37,2.48),P=0.008;MD=13.27,95%CI(11.44,15.09),P< 0.00001］、并发症少［OR=2.32,95%CI(1.06,5.05),P=0.03］。而患者满意度、足功能指数评分,两组疗效相当。结论 第一跖趾关节融合术联合二至五趾跖骨头切除成形术治疗类风湿前足畸形,可有效缓解疼痛、改善足的外观及功能、术后并发症少,其疗效优于第一跖趾关节成形术。     

初次全膝关节置换术后并发症及翻修手术的原因分析

目的 探讨初次全膝关节置换术后30 d内相关并发症发生情况及翻修手术的相关因素.方法 收集2001年1月至2012年12月在北京协和医院骨科进行初次全膝关节置换术患者的临床资料,假体均为固定平台假体,采用骨水泥固定,排除翻修病例及血友病关节炎患者.共有1 920例患者(2 779例次全膝关节置换手术)纳入研究,男性323例,女性1 607例;年龄25～86岁,平均(66±9)岁.骨关节炎1 720例(89.58％),类风湿关节炎168例(8.75％),强直性脊柱炎12例(0.63％),继发骨关节炎20例(1.04％).随访患者术后30 d内发生的主要系统并发症、局部并发症及发生的翻修手术及相关因素.结果 随访截至2013年12月,共有1 854例患者(2 693个关节)获得随访,失访率为3.44％.术后平均随访67个月,死亡3例.41例(2.21％)患者出现系统并发症,其中最常见的为呼吸系统并发症(0.49％,9/1 854)及心血管并发症(0.38％,7/1 854).术后经超声证实的症状性深静脉血栓形成发生率为3.02％ (56/1 854),其中7例发生肺栓塞.术后发生局部并发症24例(1.29％),包括伤口愈合不良、伤口感染、神经损伤.59个关节接受翻修手术治疗,常见原因包括感染后松动(1.19％,32/2 693)和术后关节僵硬(0.37％,10/2693).结论 初次全膝关节置换术后30 d内最常见系统并发症为呼吸系统及心血管系统并发症.感染后松动是术后翻修最常见的原因.     

Fractured rheumatoid elbow: treatment with Souter elbow arthroplasty--a clinical and radiologic midterm follow-up study.

We report the results in 26 patients who had 32 preoperative fractures treated with Souter elbow arthroplasty. All were rheumatoid patients with a mean disease duration of 29.7 years (range, 10 to 43). Six of the fractures were of the olecranon and 26 of the distal humerus. The time interval between fracture and arthroplasty was 9 months (mean; range, 0 to 48). Fragments were not excised, and osteosynthesis was performed. The follow-up was 2.6 years (mean; range, 0.5 to 8), when 20 of the fractures had united and 12 had not. K-wire fixation, either alone or in combination with cerclage or PDS suture, and bone grafting led to satisfactory results. Union was verified in 14 of 17 cases treated with this technique. There were no severe early complications. Six patients had late complications. In 3 cases, loosening of the humeral component was observed radiologically. One patient had a hematogenous deep infection 4 years after the operation, and 2 patients had avulsion rupture of the triceps tendon. Fracture in the badly destroyed elbow can be more reasonably treated with an arthroplasty than with an attempt of osteosynthesis before arthroplasty. If excision of the fragments is avoided, original, or near original, anatomy of the elbow joint can be better restored and acceptable outcome obtained with elbow arthroplasty.     

Long-term follow-up of surgery for equinovarus foot deformity in children with cerebral palsy

The factors associated with failed operative intervention in the treatment of equinovarus foot deformity in children with cerebral palsy (CP) were evaluated after long-term follow-up. One hundred eight children with CP who had surgery on the posterior tibialis tendon (split tendon transfer, intramuscular lengthening, or Z-lengthening) on 140 feet were reviewed at a mean age of 16.8 years with 7.3 years of follow-up. The surgery was considered a failure when a 10 degrees or greater varus or valgus hindfoot deformity was present or if an additional operative intervention was required or planned. Involvement of CP, age at operation, and preoperative status of ambulation were significant factors in the outcome of the surgery. Hemiplegic patients demonstrated the best results, regardless of age or surgical procedure. Seventy-five percent of diplegic and quadriplegic patients who were younger than 8 years or who were not capable of community ambulation failed operative intervention, and surgery on the posterior tibialis tendon is not recommended in this group of patients.     

The constant relationship between forefoot and hindfoot as a basis for treating foot deformities

Summary In correcting foot deformities the author observed a constant relationship between the forefoot and the hindfoot. If the forefoot is adducted, the heel automatically goes into the varus position. On the other hand, abduction of the forefoot will result in a valgus position of the heel. This rule was investigated and validified by experiments on cadavers: it was shown that the position of the hindfoot is automatically normalized by the correction of the forefoot. Our observations have been confirmed by treating foot deformities in children and adults. Therefore we believe that surgery of the talo-calcaneal joint in cases of foot deformity is unnecessary.

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Zusammenfassung Zwischen Vorfuß und Rückfuß besteht eine gesetzmäßige Abhängigkeit. Die Adduktion des Vorfußes führt zur Varusstellung der Ferse, die Abduktion zur Valgusposition des Rückfußes. Wird bei einer Fußdeformität der VorfuB korrigiert, so normalisiert sich automatisch die Fersenstellung. Diese Tatsache macht einen gesonderten Eingriff am Talokalkanealgelenk zumeist entbehrlich. Verfasser hat diese Vorfuß-Rückfuß-Beziehung seit Jahrzehnten therapeutisch genutzt. Nunmehr wird im Leichenexperiment die wissenschaftliche Grundlage erarbeitet.

     

Fat grafting for chronic heel pain following surgery for adult flatfoot deformity: Pilot study

IntroductionAutologous fat grafting is now a highly popular technique in plastic and reconstructive surgery, with broad applicability for various surgical procedures. Fat grafting can impart contours and augmentation, nourish tissue, modulate scar tissue, and produce regeneration at the recipient site. In this pilot study, the authors suggest that fat grafting may be useful therapeutic adjunct for cases of chronic heel pain following surgery for adult flatfoot deformity.Materials and methodsEight patients with chronic heel pain following surgery for adult flatfoot deformity underwent autologous subcutaneous heel fat grafting and recorded their levels of pain relief for 6 months postoperatively.ResultsThe authors recorded a statistically significant difference (p < 0.001) between pain scale values recorded before (t0) and six months postoperatively (t6). From t0 to t6, mean pain scale values changed from 8.125 to 2.413.ConclusionsVolumetric enhancement of the subcutaneous heel fat pad significantly ameliorated weight-bearing pain in these patients.     

Retrospective review of forefoot amputations at a Veterans Affairs hospital and evaluation of post-amputation follow-up

BACKGROUND: Forefoot amputations in diabetic and vascular patients often are followed by subsequent amputations. We evaluated the outcomes of forefoot amputations and the efficacy of our care in preventing subsequent amputations. MATERIAL AND METHODS: Charts of all patients undergoing forefoot amputations were reviewed. Comorbid conditions, subsequent amputations, and the nature of pre- and post-amputation care were noted. A subset of patients followed more than 2 years post-amputation was studied to evaluate post-amputation care. RESULTS: Of the 81 patients, 26% underwent subsequent forefoot amputations and 37% underwent subsequent proximal amputations. Forty-one patients followed more than 2 years were divided into 2 groups: those followed closely by foot-care specialists and those followed by primary care providers. The former group experienced fewer amputations, but the difference was not statistically significant. CONCLUSIONS: Previous forefoot amputation is a high-risk factor for repeat amputations. Our post-amputation care did not effectively reduce subsequent amputations.     

One-day surgery for acquired forefoot deformity: sciatic nerve blockade with mepivacaine vs mepivacaine+ropivacaine: a prospective, randomized study

AIM: The aim of the study was to determine the doses of ropivacaine combined with mepivacaine for sciatic nerve blockade to enable the extension of analgesia without prolonged motor blockade, for the management of very painful operations in one-day surgery. METHODS: After obtaining approval by the ethics committee and written informed consent, we recruited 30 ASA I-III patients undergoing corrective orthopedic surgery of the forefoot in one-day surgery with sciatic nerve blockade. The patients were randomly divided into 3 groups: one control group, treated by 1.5% mepivacaine (300 mg), and two groups differentiated by the dose of 0.5% ropivacaine (25 and 40 mg) used in combination with 1.5% mepivacaine (225 mg). The offset data of the blockade were obtained by a self-assessment form filled in by the patients, and a direct check on discharge by a blinded observer. RESULTS: There was no significant difference in the duration of the blockade among the 3 groups; the extension of analgesia was significant (P<0.003) in the group treated by mepivacaine+ropivacaine 40 mg (mean 477+/-255 min). CONCLUSION: Adequate doses of ropivacaine added to mepivacaine for peripheral blockade produce and increase the duration of analgesia without influencing the criteria for discharge after Day Surgery.     

Extended follow-up after atrial repair for transposition of the great arteries: a younger age at surgery improves late survival

BACKGROUND: Surgical treatment for transposition of the great arteries (TGA) usually involves anatomic repair, although atrial repair is used in cases with special coronary artery patterns. METHODS: Records of all 239 patients surviving at least 30 days after atrial correction of TGA between 1962 and 1987 at the University Hospital in Zurich were reviewed. The mean length of follow-up time was 13.7 years (median 14.9 years; range from 0.05 to 30.1 years). The average age at surgery was 45.7 months (range from 7 days to 24.4 years). One hundred twenty-one patients had a simple TGA, whereas the remaining 118 had a complex TGA. RESULTS: The surviving patients were in NYHA class I at time of follow-up. The most common reasons for death were systemic right ventricular dysfunction and sudden rhythm disturbances. There was a major risk for late cardiac event in patients over 3 years old at operation (p = 0.02) and also in patients with complex TGA (p = 0.03). However, date of surgery, previous surgery, or the postoperative requirement for a pacemaker did not greatly affect late cardiac mortality. CONCLUSIONS: Although the procedure of choice for TGA is the arterial switch operation, the promising findings of the current long-term study, which reports the longest follow-up to date, indicate that the atrial switch operation is a good alternative procedure for the rare cases where the use of arterial switch procedures is limited.     

Non-opioid analgesia improves pain relief and decreases sedation after gastric bypass surgery

PURPOSE: Several non-opioid drugs have been shown to provide analgesia during and after surgery. We compared sevoflurane anesthesia with fentanyl analgesia to sevoflurane and non-opioid drug treatment for gastric bypass surgery and recovery. METHODS: Thirty obese patients (body mass index > 50 kg.m(-2)) undergoing gastric bypass were randomized to receive sevoflurane anesthesia with either fentanyl or a non-opioid regimen including ketorolac, clonidine, lidocaine, ketamine, magnesium sulfate, and methylprednisolone. Morphine use by patient-controlled analgesia (PCA) pump and pain score measured by visual analogue scale were determined in the postanesthesia care unit (PACU) and for the first 16 hr after surgery. Sedation was evaluated in the PACU. Investigators assessing patient outcomes were blinded to the study group. RESULTS: Fentanyl treated patients were more sedated in the PACU compared to the non-opioid group. Non-opioid treated patients required 5.2 +/- 2.6 mg.hr(-1) morphine by PCA during their stay in the PACU while patients anesthetized with fentanyl used 7.8 +/- 3.3 mg.hr(-1) (P < 0.05). Fentanyl and non-opioid treated patients showed no difference in pain score one or 16 hr after surgery. CONCLUSION: Our results show that non-opioid analgesia produced pain relief and less sedation during recovery from gastric bypass surgery compared to fentanyl.