Rheumatoid Forefoot Deformities Research Articles

Plantar pressure and surgical indication of toe arthroplasty for rheumatoid forefoot deformity

Objectives: The objective of this study is to clarify the surgical indication for rheumatoid forefoot deformity according to background characteristics and plantar pressure.Methods: Patients with rheumatoid arthritis were divided into a non-surgical group (group N) and a surgical group (group S). The former consisted of 225 ft, and the latter consisted of 88 ft. DAS28, Japanese Society for Surgery of the Foot rheumatoid arthritis foot and ankle scale (JSSF scale) and hallux valgus angle (HVA) were evaluated as background characteristics. Distribution of peak pressure as plantar pressure was measured in nine sections.Results: In groups N and S, the mean DAS28 was 3.6 and 3.0, the mean JSSF scale was 81.1 and 63.0, and the mean HVA was 19.9° and 35.3°, respectively. The mean peak pressure of group S at the first and third metatarsophalangeal joints was significantly higher compared with group N. Significant differences between the two groups were also seen in Δ pressure (the difference between the maximum and minimum peak pressure values). The cut-off values were 75.0 for JSSF scale, 24.9° for HVA and 3.94 kg/cm2 for Δ pressure.Conclusions: The combined assessment of HVA and Δ pressure was found to be useful as an indication for surgical treatment of the forefoot.

Fusion of the First Metatarsophalangeal Joint and Second to Fifth Metatarsal Head Resection for Rheumatoid Forefoot Deformity

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.

Outcome of Joint-Preserving Arthroplasty for Rheumatoid Forefoot Deformities.

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. 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. 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. 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 III, comparative case series.

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

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.

Results of Surgical Treatment of Rheumatoid Forefoot Deformities

Results of Surgical Treatment of Rheumatoid Forefoot Deformities

Rheumatoid forefoot reconstruction: Outcome of 1st metatarsophalangeal joint fusion and the Stainsby procedure in the lesser toes

BackgroundRheumatoid arthritis is a chronic inflammatory disease involving connective tissue and joints. The most common rheumatoid forefoot deformities are hallux valgus and clawed lesser toes. There are a number of surgical procedures that have been described offering symptomatic relief and anatomical correction. ObjectivesThis prospective case series aims to assess outcome in patients with rheumatoid forefoot deformities who underwent a novel combination of 1st metatarsophalangeal joint fusions and Stainsby procedures. MethodsThirteen procedures were performed on 12 consecutive patients with an age range of 55–71 (mean=62) between 02/2009 and 05/2011. AOFAS scoring was performed preoperatively and again six and 12 months post-surgery. Hallux valgus (HVA) and intermetatarsal angles (IMA) were measured preoperatively and six weeks and six months postoperatively. ResultsThe mean AOFAS score increased from 46 to 72, 12 months postoperatively. The mean HVA reduced from 48° preoperatively to 14° six months postoperatively. The IMA decreased from 15° to 10° six months postoperatively. ConclusionsThe novel approach of 1st metatarsophalangeal fusion combined with lesser toe metatarsal head sparing is an effective procedure that reduces forefoot deformity and pain.

A short-term result of arthroplasty by shortening osteotomy for rheumatoid forefoot deformities

A short-term result of arthroplasty by shortening osteotomy for rheumatoid forefoot deformities

Proximal rotational closing-wedge osteotomy of the first metatarsal in rheumatoid arthritis: clinical and radiographic evaluation of a continuous series of 35 cases

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.

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.

Efficacy of the first metatarsophalangeal joint arthrodesis versus resection arthroplasty for rheumatoid forefoot deformity :a systematic review

Objective To evaluate the efficacy of the first metatarsophalangeal joint arthrodesis versus resection arthroplasty for rheumatoid forefoot deformity.Methods Randomized controlled studies in the first metatarsophalangeal joint arthrodesis versus resection arthroplasty for rheumatoid forefoot deformity were collected in data bases like Cochrane library (Issue 3,2011),OVID (from January 1996 to June 2012),PubMed (from January 1990 to June 2012),CNKI (from January 1990 to June 2012),CBM,EMBASE (from January 1966 to June 2012) and Wanfang (from January 1990 to June 2012).Software RevMan 5.1 was used to analyze the trials included in terms of patient satisfaction,hallux area weight-bearing,AOFAS score,FFI score,HAV angle,IMA angle,operative time and complications.Results The totals of 5 RCTs were included in the study which involved 285 patients.The results of meta-analysis showed that the efficacy of the arthrodesis group was superior to that of the arthroplasty group in footwear (MD=-0.88,95％CI [-1.55,-0.22],P=0.010)and alignment (MD=-5.04,95％CI [-8.94,-1.14],P=0.01) significantly.The arthrodesis group also has an advantage of IMA and HAV angle correction (MD=1.43,95％CI [0.37,2.48],P=0.008; MD=13.27,95％CI [11.44,15.09],P＜ 0.00001).Significant difference was found between the two groups in the rate of complications.The rate of complication in the arthrodesis group was lower than that of the arthroplasty group (OR=2.32,95％CI [1.06,5.05],P=0.03).No significant difference was found between the two groups in patient satisfaction and FFI score.Conclusion Compared with resection arthroplasty,first metatarsophalangeal joint arthrodesis could be a better choice.It alleviates the pain effectively,improves the appearance and functions of the foot,and has a lower rate of postoperative complications. Key words: Arthritis, rheumatoid; Metatarsophalangeal joint; Arthrodesis; Arthroplasty; Meta-analysis

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.

Proximal rotational closing-wedge osteotomy of the first metatarsal in rheumatoid arthritis: clinical and radiographic evaluation of a continuous series of 35 cases

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. From January 2011 through December 2011, 35 feet were treated with this procedure. Subjective, functional, and radiographic outcomes were surveyed. 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 gradeV or higher preoperatively; 25 of these were gradeIV or lower at the latest follow-up. Rotational closing-wedge osteotomy of the first metatarsal was beneficial for correcting forefoot deformities in RA over the short term.

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.

A case report: Metatarsal shortening oblique osteotomy for rheumatoid forefoot deformities with internal fixation by a headless compression screw

A case report: Metatarsal shortening oblique osteotomy for rheumatoid forefoot deformities with internal fixation by a headless compression screw

Preservation of Lesser Metatarsophalangeal Joints in Rheumatoid Forefoot Reconstruction

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. 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. 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. 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.

Resection Arthroplasty for Rheumatoid Forefoot Deformity -A 5-year Follow-up Study-

Resection Arthroplasty for Rheumatoid Forefoot Deformity -A 5-year Follow-up Study-

Middle-term Result of Arthroplasty for Rheumatoid Forefoot Deformities with Non-weight-bearing Orthosis

Middle-term Result of Arthroplasty for Rheumatoid Forefoot Deformities with Non-weight-bearing Orthosis

A clinical classification system for rheumatoid forefoot deformity

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. 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. 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.

Comparison of Bioreplaceable Interposition Arthroplasty with Metatarsal Head Resection of the Rheumatoid Forefoot

Interposition arthroplasty with bioreplaceable poly-L/D-lactic acid (PLDLA) implants has been studied in Finland with promising results in reconstruction of the rheumatoid hand. We evaluated this material in a series of patients with rheumatoid forefoot deformities. Thirty-five patients were randomized to either PLDLA metatarsophalangeal joint interposition arthroplasty group (16 patients) or to conventional metatarsal head resection group (19 patients). At 3 months after surgery, the function VAS was significantly better in the control group (p = 0.003). The difference disappeared by 12 months. Otherwise, comparison between the two groups did not reveal any statistically significant differences in the AOFAS scores or the pain VAS at 3 or 12 months. Early results after PLDLA interposition arthroplasty of metatarsophalangeal joints were not as promising as previously reported with rheumatoid metacarpophalangeal reconstruction.

Mid-term results of joint-preserving procedures by a modified Mann method for big toe deformities in rheumatoid patients undergoing forefoot surgeries

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° to 20.5° and the mean M1M5 angle improved from 31.1° to 25.8°. However, deformities involving a hallux valgus angle of more than 25.0° 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.