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 for metatarsalgia.

An oblique osteotomy in the distal half of the metatarsal shaft is described for the treatment of metatarsalgia due to prolapse of one or more of the middle three metatarsal heads. Thirty-eight patients who have had this operation have been followed up for a period of from two to five years. The operation is simple, recovery is rapid and symptoms have been well relieved.     

Metatarsal neck osteotomy for metatarsalgia

Surgical Principles This osteotomy is performed to relieve the pressure exerted by one or more metatarsal heads on the overlying sole of the foot. This pressure can lead to painful plantar callosities. Through a transverse dorsal approach a V-shaped notch down to but not including the plantar cortex is created with a small rongeur. Through manual osteoclasia the head is tilted upward. Full weight bearing helps to maintain the metatarsal head in the corrected position. No internal fixation nor external immobilization are needed.     

Metatarsal neck osteotomy for metatarsalgia

Surgical principle This osteotomy is performed to relieve the pressure exerted by one or more metatarsal heads on the overlying sole of the foot. This pressure can lead to painful plantar callosities. Through a transverse dorsal approach a V-shaped notch down to but not including the plantar cortex is created with a small rongeur. Through manual osteoclasia the head is tilted upward. Full weight bearing helps to maintain the metatarsal head in the corrected position. No internal fixation nor external immobilization are needed.      

Metatarsal osteotomy for the cavus foot

Thirty-nine patients with pes cavus-type deformities were treated with osteotomy of the proximal metatarsals for the cavus component of the deformity. Fifty operations were followed for an average of 15 years, many for up to 26 years. Of the 39 patients, 11 had bilateral involvement. Each patient was clinically evaluated for postoperative mobility and categorized according to the Massachusetts General Hospital rating scale. Excellent or good results were obtained in 84% of the proximal metatarsal osteotomies.     

Metatarsal osteotomy using internal fixation with compression screws

Forty-six metatarsal osteotomies in 25 feet were performed in order to treat forefoot deformity. The authors used an exacting operative procedure based on oblique osteotomies of the metatarsal and rigid internal fixation. All osteotomies healed and only one patient was not satisfied with the operation. This technique provided predictable long-term results in the authors' hands, and also involved an easier postoperative course than conventional methods.     

Correction of hallux valgus. Metatarsal osteotomy versus excision arthroplasty

The long-term retrospective results (followup range, 10-22 years) of an uncontrolled series of basal metatarsal closing wedge osteotomies and Keller's excision arthroplasties performed in patients 14 to 40 years of age are analyzed. In the osteotomy group, 34 patients (50 feet) were available for clinical review and 26 patients (37 feet) were available for radiologic review. In the Keller group, 24 patients (37 feet) were reviewed clinically and 23 patients (34 feet) were reviewed radiologically. Patients were assessed using the Hallux Metatarsophalangeal Interphalangeal Scale of the American Foot and Ankle Society, an additional clinical score, weightbearing radiographs, the patient's record, and clinical investigation. Statistical analysis revealed significantly better results of the clinical and radiologic outcomes after osteotomy. In the osteotomy group, the first metatarsal was elevated dorsally in 14 feet (38%). The incidence of varus deformities was higher with basal osteotomy (18% versus 5.4%). Metatarsalgia occurred similarly in both groups (28% versus 27%). It is known that these techniques should be applied to different patient populations. However, they formerly were used for the same indication. This long-term analysis shows that the Keller arthroplasty should be abandoned for the treatment of hallux valgus in young and active patients. The basal metatarsal closing wedge osteotomy is conceptually the correct treatment for hallux valgus deformity for the younger patient; nevertheless, it is technically demanding and is associated with a higher risk of failure. The long-term results of both procedures are unacceptable for the patient and the surgeon. The short and middle-term results of the newer basal type osteotomies, such as the proximal crescentic osteotomy, the proximal chevron osteotomy, or the proximal oblique osteotomy combined with distal soft tissue releases, suggest a more satisfying long-term outcome.     

Metatarsal head excision for rheumatoid arthritis: 4-year follow-up of 68 feet with and without hallux fusion

Thirty-four painful deformed rheumatoid feet treated by excision of all five metatarsal heads were compared with 34 similar feet in which the lesser metatarsal heads were excised and the first metatarsophalangeal joint was arthrodesed. In the latter group, one third had failure of fusion of the hallux, and this produced the worst results. Metatarsalgia and plantar callosities were more common after excision arthroplasty, but shoe fitting and correction of deformity were better in this group. However, the results were more variable in the fusion group, and the complication and reoperation rates were higher. For this reason, excision arthroplasty, rather than fusion of the hallux, is recommended when the lesser metatarsal heads are removed.     

Metatarsal head excision for rheumatoid arthritis. 4-year follow-up of 68 feet with and without hallux fusion

Thirty-four painful deformed rheumatoid feet treated by excision of all five metatarsal heads were compared with 34 similar feet in which the lesser metatarsal heads were excised and the first metatarsophalangeal joint was arthrodesed. In the latter group, one third had failure of fusion of the hallux, and this produced the worst results. Metatarsalgia and plantar callosities were more common after excision arthroplasty, but shoe fitting and correction of deformity were better in this group. However, the results were more variable in the fusion group, and the complication and reoperation rates were higher. For this reason, excision arthroplasty, rather than fusion of the hallux, is recommended when the lesser metatarsal heads are removed.     

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.     

Femoral corrective osteotomy for malunited supracondylar femoral fracture after TKA in a patient with rheumatoid arthritis

This article presents a case of femoral corrective osteotomy for malunited supracondylar femoral fracture after total knee arthroplasty (TKA) in a patient with rheumatoid arthritis. The patient underwent 1-stage bilateral TKA and 2-stage bilateral total hip arthroplasty 17 years prior at our institution. Her fall 10 years before led to a supracondylar femoral fracture that was treated nonoperatively for 3 months and led to malunion. Complaints of mild right knee pain and remarkable varus deformity were observed. On examination, the right knee was not swollen and tender. Range of motion (ROM) of the right knee was 0° to 130°. The patient needed crutches to ambulate. Knee score and function scores, according to the Knee Society clinical rating system, were 65 and 25 points, respectively. Radiographs after malunion showed remarkable varus knee and the femorotibial angle was 197°. At the time of surgery, the components were stable and bone union was completed. Valgus corrective osteotomy of the femur was performed using a retrograde intramedullary nail, with satisfactory results at 10-year follow-up. The patient is able to walk without a cane and has 0° to 130° ROM. Knee and function scores were 88 and 80 points, respectively. Radiographs showed complete bone union and the femorotibial angle was 179° with no loosening of the prostheses. Femoral corrective osteotomy is recommended for malunited supracondylar femoral fracture after TKA.