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

doi:10.1016/j.foot.2011.12.002

The Foot

Volume 22, Issue 2, June 2012, Pages 81-84

https://doi.org/10.1016/j.foot.2011.12.002 Get rights and content

Abstract

Background

Rheumatoid 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.

Objectives

We 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.

Method

There 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).

Results

Mean 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.

Conclusion

In 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.

Introduction

Rheumatoid arthritis (RA) is a chronic autoimmune disorder that affects the metatarsophalangeal (MTP) joints first in 17% of patients [1]. Symptomatic rheumatoid forefoot deformities may affect as many as 89% of patients with RA [1]. The destructive synovitis results in joint erosion, destructive arthritis, loss of capsular and collateral ligament integrity leading to pain and deformity. Typical deformities include hallux valgus, hammer toe deformities of the lesser toes and subluxation or dislocation of MTP joints. Whilst there are various less commonly performed operative procedures described for the treatment of rheumatoid forefoot deformity including excision arthroplasty, silicone arthroplasty and amputation [2], [3], [4], [5], [6], [7], [8], [9], the current gold standard, and most commonly performed treatment involves arthrodesis of the first MTP joint with resection arthroplasty of the lesser metatarsal heads [2].

There have been few studies on joint preserving surgery for rheumatoid forefoot deformities and it has been previously stated that patients will have poor outcomes in surgical procedures that do not involve fusion of the hallux MTP joint due to recurrent deformities [3], [4], [10]. Scarf osteotomy of the first metatarsal with a harmonised shortening of the lesser metatarsals by Weil osteotomy has been suggested to result in good correction of forefoot deformities at midterm follow-up [5]. The Scarf osteotomy allows for a wide range of fragment displacement and has inherent stability with relatively simple internal fixation [5]. The Weil osteotomy is an oblique shortening osteotomy which has been recommended for the treatment of the subluxed or dislocated joint and correction of lesser toe deformities by reducing the soft tissue tension [11].

Advantages of joint preserving surgery include maintaining available mobility of the first MTP joint which helps compensate for fixed deformity of the mid and hind-foot, as well as preserving the ability to perform revision surgery in future should progressive joint destruction occur. One study of 30 patients (39 feet) who underwent combined first tarsometatarsal fusion and shortening oblique osteotomies of the second to fourth metatarsals reported improvements in foot function at mean follow-up of 36 months [3]. Fourteen patients had persistent forefoot stiffness and four required removal of hardware. Thordarson et al. reported on joint salvage in 15 feet affected by RA and concluded that patients will have poor surgical outcomes in those that do not involve fusion of the hallux MTP joint [10]. Concerns regarding persistent pain, stiffness and recurrence with this treatment strategy remain [3], [10].

The aim of this study was to report the clinical and radiological results of joint preserving surgery for the first MTP joint and lesser toes in 49 patients (66 feet) with rheumatoid forefoot deformities. We hypothesised that joint preserving surgery of the first MTP joint and lesser toes in patients with RA would correct deformity and improve pain at midterm follow-up.

Section snippets

Patients and methods

Between January 2000 and December 2005, 49 consecutive patients with rheumatoid forefoot deformities (66 feet) underwent Scarf osteotomy of the first metatarsal and/or Weil osteotomy of the lesser metatarsals. There were 44 females and 5 males with a mean age of 56.1 years (17–70 years) and mean follow-up of 51 months (40–65 months) (Fig. 1). Patients were diagnosed with their rheumatoid disease at a mean of 10.5 years (5–20 years) preoperatively. Seventeen patients underwent bilateral

Clinical results

Subjectively patients reported their outcome as excellent in 49 feet (74%), good in 9 feet (13.5%), fair in 7 feet (10.5%) and poor in 1 foot (1%). Postoperatively persistent pain was reported in 11 feet, stiffness in 5 feet and recurrence of hallux valgus deformity in 3 feet. Mean preoperative AOFAS score increased from a mean of 39.8 (18–56) preoperatively to 88.7 (48–92) at final follow-up. Preoperatively severe pain was present in 44 feet (67%), moderate pain in 19 feet (29%) and mild pain

Discussion

There have been several different operative procedures described for the treatment of rheumatoid forefoot deformity including excision arthroplasty, silicone arthroplasty and amputation [2], [3], [4], [5], [6], [7], [8], [9]; however the most commonly performed treatment involves arthrodesis of the first MTP joint with resection arthroplasty of the lesser metatarsal heads [2], [14]. Coughlin performed a retrospective review of 32 patients with RA forefoot deformities who underwent arthrodesis

Conflict of interest

None.

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More than 20 years’ follow-up of metatarsal neck shortening oblique osteotomy for rheumatoid forefoot deformity
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In 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.
The 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.
A 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.
Metatarsal neck SOO appeared to be effective for patients with RA. The deformity was corrected and retained for a long time.
The foot in systemic disease: management of the patient with rheumatoid arthritis or diabetes mellitus
2019, Orthopaedics and Trauma
The foot is commonly affected in systemic diseases such as rheumatoid arthritis and diabetes mellitus. Treating patients who suffer with foot pathology secondary to systemic diseases requires a multidisciplinary approach, following the principles outlined within this review. There is little high level evidence in this field, such as prospective controlled clinical trials, hence much of what we know and practise is based upon the expert opinion of key individuals in specialist centres, to whom we owe a great debt.
Resection or preservation of the metatarsal heads in rheumatoid forefoot surgery? A randomised clinical trial
2019, Foot and Ankle Surgery
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.
Patients suffering from well-defined rheumatoid forefoot deformity were prospectively enrolled in three institutions. This non-blinded study had a randomised clinical design and eligible patients were randomly assigned to undergo either resection of preservation of the MTH. The primary outcome measure consisted of the AOFAS score. Secondary outcome measures were: the FFI, the VAS for pain and the SF-36.
Twenty-three patients (10 in MTH preservation group) were included and analysed. After one year follow-up no significant differences in AOFAS score and additional outcome factors were found. A total of 10 complications in 23 patients were reported.
This randomised clinical study did not show significant clinical difference between a MTH resecting and a preserving procedure in patients suffering from rheumatoid forefoot deformity. Both procedures resulted in considerable improvement of pain and activity scores.
Effectiveness of the Cobb–Stainsby excision arthroplasty
2018, Foot and Ankle Surgery
Citation Excerpt :
However, our study shows that the majority of patients were pleased with both function and cosmesis of their toes following Cobb–Stainsby arthroplasty. Weil’s osteotomy is technically more demanding and can lead to transfer metatarsalgia or worsening of symptoms if malunion, non-union or avascular necrosis occurs [11]. Our study shows that the Cobb–Stainsby was effective in correcting the dorsally displaced alignment of lesser toes in 72 (96%) patients.
Dislocated metatarsophalangeal joints from clawed or hammer toes can be a disabling consequence of several conditions. The Cobb–Stainsby forefoot arthroplasty combines partial phalangectomy (Stainsby) with extensor tendon transfer to the metatarsal head (Cobb). We present a retrospective, three surgeon case series of 215 toes in 126 patients.
Early results and complications were gathered from the medical charts of 126 patients who met the inclusion criteria. Seventy-five patients were contactable by phone with a follow up range of 12–82 months (median follow up 45 months). Primary outcome measures were improvement of pain and function, reduction in plantar callosities and cosmetic improvement of the deformity.
Pre-operatively all patients presented with pain and shoe wear problems. Post-operatively seventy-two patients (96%) were satisfied, 72 (96%) reported pain relief, 55 (73%) were happy with toe control, 61 (81%) were pleased with cosmesis and 56 (75%) reported unlimited daily activities. Superficial wound infections were observed in 13 of the 126 patients (10%) and two in 75 patients (2%) developed recurrent clawing.
Our case series demonstrates improved outcomes over alternatives such as the Weil’s osteotomy.
Fusion of the First Metatarsophalangeal Joint and Second to Fifth Metatarsal Head Resection for Rheumatoid Forefoot Deformity
2017, Journal of Foot and Ankle Surgery
Citation Excerpt :
Many techniques were reported for the management of the great toe and lesser toes for rheumatoid forefoot correction (the relevant published data are summarized in Table 3). Regarding the great toe, the treatment options can be divided as follows: (1) conservative (with no or mild hallux valgus deformity) (1,16); (2) corrective metatarsal osteotomies (2); (3) resection arthroplasty (9); and (4) distal (15) (or proximal) fusion. Controversies remain regarding the ideal management of the first MTP joint.
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.
Sustainability of Forefoot Reconstruction for the Rheumatoid Foot
2016, Journal of Foot and Ankle Surgery
Ninety percent of patients with rheumatoid arthritis will display foot and ankle pathologic features, including hallux valgus, lesser metatarsophalangeal (MTP) joint subluxation/dislocation, and hammertoe deformity. Recently, a trend has ensued toward joint preservation with distal metatarsal osteotomies and various bunion corrective procedures. However, the reference standard remains first MTP joint fusion, lesser metatarsal head resection, and lesser proximal interphalangeal joint fusion. The present retrospective study followed the results of 4 different surgeons who had performed the reference standard rheumatoid forefoot reconstruction from August 2008 to August 2012 on patients with rheumatoid arthritis. Radiographic and statistical analysis of the data from 20 patients determined an overall first MTP joint fusion rate of 90%, often occurring by 108 (range 64 to 202) days postoperatively. Radiographic nonunion occurred in 2 of the 20 patients (10%), although both were asymptomatic, with no revision necessary. Lesser digit deformity revision occurred in 1 patient (5%), and mild to moderate infection developed in 4 patients (20%). The radiographic and clinical follow-up period was 12 months. Our study found that this technique provides exceptional radiographic improvement, an acceptable time to fusion, a low reoperation rate, and minimal complications. In addition, correction of the deformity was maintained at 1 year postoperatively. In conclusion, first MTP joint fusion with lesser metatarsal head resection should remain the reference standard for surgical intervention of the rheumatoid foot.

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

Abstract

Background

Objectives

Method

Results

Conclusion

Introduction

Section snippets

Patients and methods

Clinical results

Discussion

Conflict of interest

Foot Ankle Surg

Foot Ankle Clin North Am

J Clin Epidemiol

Rheumatoid foot. Clinical study with pathological and roentgenological comments

Ann Chir Gynaecol Fenniae (Suppl)

Rheumatoid forefoot reconstruction. A long-term follow up study

J Bone Joint Surg Am

Combination joint-preserving surgery for forefoot deformity in patients with rheumatoid arthritis

J Bone Joint Surg Br

Scarf osteotomy for hallux valgus correction. Local anatomy, surgical technique, and combination with other forefoot procedures

Foot Ankle Clin

Amputation of all toes. A review of forty-seven amputations

J Bone Joint Surg Br