Surgery of the Forepart of the Foot in Rheumatoid Arthritis

Foot & Ankle ◽  
1982 ◽  
Vol 3 (3) ◽  
pp. 173-180 ◽  
Author(s):  
Nathaniel Gould
Keyword(s):  
Rheumatoid Arthritis ◽  
Metatarsal Head ◽  
Metatarsal Osteotomy ◽  
Great Toe ◽  
Extensor Tendons ◽  
Lateral Drift ◽  
First Metatarsal ◽  
The Past ◽  
Silastic Implant

The purpose of this paper is to introduce a surgical approach to treatment of severe forefoot deformities of rheumatoid arthritis. Briefly, the surgery consists of base of the first metatarsal osteotomy to correct metatarsus primus varus, and metatarsal head resection beginning with the fifth metatarsal and carried around in crescentic fashion through the necks of the other metatarsals, so that as an end result the great toe is the longest, the second next to the longest, etc. The short extensor tendons are dissected to their insertions and, since they have drifted laterally into the “valleys” pulling the toes into lateral drift with them, they are usually sacrificed. The long extensor tendons are appropriately lengthened to proper tension. All the toes are straightened by plantar capsulotomies, dermotomies, and long flexor tenotomies, and the toes held straight with C-.045 wire in shishkabob fashion. Then, under direct vision, each wire is drilled up into the metatarsal shaft, aligning the toes into parallel cosmetic fashion. In the early cases, a single stem silastic implant was utilized but for the past 5 years now the double stem silastic implant is employed for the first MTP joint and is inserted “upside down” in order to give its greater power towards the floor. A cast is not used, but the patient ambulates on a well-padded bandaged foot by the second or third day. Twenty patients (40 feet) were operated upon (17 females and 3 males, ages 28 to 72 years, average 47 years), with a follow-up of 3 to 5 years. Pain relief has been remarkable. Good great toe function has been obtained in all cases with excellent power to the floor and a satisfactory range of dorsiflexion ability. About 67% have developed some mild recurrence of hallux valgus, but none so severe that it has been disabling. All patients have been pleased with their final results.

scholarly journals Distal Chevron Osteotomy Increases Anatomic Intermetatarsal Angle in Hallux Valgus

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0016
Author(s):  
Jeremy Y. Chan ◽  
Naudereh B. Noori ◽  
Stephanie Chen ◽  
Glenn B. Pfeffer ◽  
Timothy P. Charlton ◽  
...  
Keyword(s):  
Hallux Valgus ◽  
Case Series ◽  
Metatarsal Head ◽  
Rank Test ◽  
Metatarsal Osteotomy ◽  
Recurrence Rates ◽  
Intermetatarsal Angle ◽  
First Metatarsal ◽  
Chevron Osteotomy

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Loss of correction in hallux valgus (HV) deformity following distal chevron metatarsal osteotomy (DCO) has been demonstrated in short-term follow-up with HV recurrence rates of up to 75% reported in the long-term. The purpose of this study was to evaluate the radiographic effect of the DCO on the anatomic and mechanical axes of the first metatarsal. Our hypothesis was that patients undergoing DCO would have improvement in the mechanical metatarsal axis but worsening of the anatomic axis. Methods: This was a retrospective single surgeon case series of all patients who underwent DCO for HV between 2017 and 2019. Patients were included if they had both preoperative and postoperative weightbearing foot radiographs. The primary outcomes were the change in anatomic first-second intermetatarsal angle (a1-2IMA, defined by the metatarsal diaphyseal axis) and the change in mechanical first-second intermetatarsal angle (m1-2IMA, defined by the axis from the center of the metatarsal head to the metatarsal base). Secondary outcomes included the change in hallux valgus angle (HVA) and medial sesamoid position (medial sesamoid in relation to the mechanical axis of the metatarsal). Change in second-third intermetatarsal angle (2-3IMA, defined by the metatarsal diaphyseal axis) was measured to control for any inconsistencies in radiographic technique. Given the relatively small patient cohort, the non-parametric Wilcoxon signed rank test and Mann Whitney U test were used for statistical analysis. Results: 41 feet were included for analysis with a mean follow-up of 20.4 weeks. The a1-2IMA increased significantly (mean, 4.0 degrees, p<0.001) while the m1-2IMA decreased significantly (mean, 4.6 degrees, p<0.001) following DCO. There was a significant improvement in HVA (mean, 13.2 degrees, p<0.001). No changes were noted in 2-3IMA (mean, 0.0 degrees, p=0.834). (Table 1) Medial sesamoid position was improved in 22 feet (53.7%). Patients with improved sesamoid position were noted to have a significantly larger decrease in m1-2IMA (mean, 5.3 versus 3.8 degrees, p=0.01) and a smaller increase in a1-2IMA (mean, 3.4 versus 4.7 degrees, p=0.02) compared to patients with no improvement in sesamoid position. Conclusion: Distal chevron osteotomy for HV is associated with an increase in the anatomic intermetatarsal angle despite improvements in the m1-2IMA, HVA and medial sesamoid position. Patients with improved sesamoid position were associated with greater correction of the mechanical first metatarsal axis. Our findings may suggest the presence of intermetatarsal instability, which could limit the power of DCO in HV correction for more severe deformities and provide a mechanism for HV recurrence. [Table: see text]

Mini Invasive Floating Metatarsal Osteotomy for Diabetic Foot Ulcers Under the First Metatarsal Head: A Case Series

2020 ◽  
pp. 153473462093457
Author(s):  
Eran Tamir ◽  
Yossi Smorgick ◽  
Guy Zvi Ron ◽  
Ron Gilat ◽  
Gabriel Agar ◽  
...  
Keyword(s):  
Diabetic Neuropathy ◽  
Diabetic Foot ◽  
Case Series ◽  
Metatarsal Head ◽  
Minimal Invasive ◽  
Foot Ulcers ◽  
Metatarsal Osteotomy ◽  
Diabetic Foot Ulcers ◽  
First Metatarsal

Diabetic foot ulcers under the first metatarsal head are difficult to treat and prevent recurrence. The aim of this study is to summarize the results of a distal first metatarsal minimally invasive floating osteotomy for ulcers under the first metatarsal head in patients with diabetic neuropathy. We reviewed files of patients with diabetic neuropathy undergoing a floating first metatarsal osteotomy. Demographic and clinical data were collected and analyzed to determine success and complications. We found records for 21 patients (mean age 64) with University of Texas 1A ulcers. The ulcer’s mean age was 11.2 months. Following surgery, the ulcer completely resolved after a mean of 3.7 (2 to 11) weeks in 19 patients. During the first year, there were 4 complications related to the surgery (including 3 infections). At latest follow-up, 17/21 (81%) patients had healed with satisfactory results. Minimal invasive floating distal osteotomy of the first metatarsal can cure and prevent recurrence of diabetic foot ulcers under the first metatarsal head in 80% of the patients, but the ability to provide close follow-up and prompt response are prerequisites.

Radiographic Changes in the First Metatarsal Head after Distal Chevron Osteotomy Combined with Lateral Release Through a Plantar Approach

1994 ◽  
Vol 15 (6) ◽  
pp. 285-292 ◽  
Author(s):  
Ruth Lourdes Thomas ◽  
Francisco J. Espinosa ◽  
E. Greer Richardson
Keyword(s):  
Range Of Motion ◽  
Avascular Necrosis ◽  
Metatarsal Head ◽  
Lateral Release ◽  
Metatarsal Osteotomy ◽  
First Metatarsal ◽  
Distal Metatarsal Osteotomy ◽  
Clinically Significant ◽  
Radiographic Changes

The purpose of this study was to evaluate the development of clinically significant avascular necrosis of the head of the first metatarsal after: (1) distal metatarsal osteotomy of the chevron configuration beginning apically at the center of the metatarsal head and extending into the head metatarsal neck junction and (2) release of the adductor hallucis muscle, the lateral capsulosesamoid ligament, and the lateral head of the flexor hallucis brevis via fibular sesamoidectomy in the majority of procedures (71/77). Although there were initial radiographic findings suspicious of avascular necrosis, subchondral lucencies (28 feet), mottling (40 feet), and focal lucencies (29 feet) in 76% of the feet, at final follow-up (12–43 months, average 25 months) this figure had fallen to 25%. The range of motion of the first metatarsophalangeal joint and articular symptoms were important in this study because of the assumption that these two parameters of evaluation would correspond to the severity of radiographic evidence of avascular necrosis. Only those patients (8 feet) with persistent mottling at final follow-up had a statistically significant decrease in the average range of motion ( P = .013), with 51° total arc of motion compared with 64° total arc of motion for the remainder. There were no patients with persistent radiographic changes suggesting avascular necrosis who complained of pain. We concluded from the radiographic and clinical data that if the primary blood supply to the capsule and head of the metatarsal (the first dorsal intermetatarsal artery) is preserved, an extensive lateral release combined with a distal metatarsal osteotomy of the chevron configuration are unlikely to cause clinically significant avascular necrosis of the first metatarsal head. By clinically significant, we refer to range of motion and articular pain.

Avascular Necrosis of the First Metatarsal Head: Incidence in Distal Osteotomy Combined with Lateral Soft Tissue Release

1994 ◽  
Vol 15 (2) ◽  
pp. 59-63 ◽  
Author(s):  
Drew A. Peterson ◽  
Jeffrey L. Zilberfarb ◽  
Marie A. Greene ◽  
Robert C. Colgrove
Keyword(s):  
Soft Tissue ◽  
Avascular Necrosis ◽  
Metatarsal Head ◽  
Soft Tissue Release ◽  
Radiographic Examination ◽  
Metatarsal Osteotomy ◽  
First Metatarsal ◽  
Valgus Angle ◽  
Adductor Tenotomy

The incidence of avascular necrosis of the metatarsal head following distal first metatarsal osteotomy combined with adductor tendon release has not been documented in a large series of patients. Of 82 consecutive procedures in 64 patients performed between 1986 and 1988, 42 patients (58 procedures) were available for clinical and radiographic examination. Average follow-up was 2.5 years (range 1.0–4.2 years). There were 35 L-shaped and 23 chevron osteotomies which were combined with a lateral soft tissue release that included adductor tenotomy. preoperative hallux valgus angle averaged 25° (range 15–40°), and intermetatarsal angle averaged 12° (range 5–24°). Follow-up amount of correction averaged 13° and 5°, respectively. Eighty-four percent of patients were satisfied with their result. There was one case of avascular necrosis. The patient was asymptomatic at 4.2 years' follow-up, and the remaining patients included two with infections, one hallux varus, and no nonunions.

A Complication of Silastic Hemiarthroplasty in Bunion Surgery

Foot & Ankle ◽  
1984 ◽  
Vol 4 (5) ◽  
pp. 262-266 ◽  
Author(s):  
Richard A. Lemon ◽  
William D. Engber ◽  
Andrew A. McBeath
Keyword(s):  
Foreign Body ◽  
Metatarsal Head ◽  
Silicone Elastomer ◽  
Foreign Body Giant Cell ◽  
Cell Reaction ◽  
Great Toe ◽  
First Metatarsal ◽  
Silastic Implant ◽  
Articulating Surface ◽  
Gross Examination

Seven cases of painful reactive synovitis following great toe Silastic hemiarthroplasty have been observed. All cases were treated successfully with synovectomy and removal of the implant. Microscopic examination of the synovium uniformly demonstrated a chronic foreign-body giant-cell reaction with intracellular and extracellular silicone elastomer particles. Gross examination of the implants showed varying degrees of erosion of the articulating surface. Abrasion of a Silastic implant creates tree-floating silicone elastomer particles that can precipitate a reactive synovitis. The authors believe an irregular, degenerated first metatarsal head is a contraindication to an interpositional Silastic hemiarthroplasty.

scholarly journals Radiographic Outcomes after Fixation of Distal Metatarsal Osteotomy for Hallux Valgus Using a Tension Band Construct

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0042
Author(s):  
Alexander Volpi ◽  
Robert Zbeda ◽  
Christopher Katchis ◽  
Lon Weiner ◽  
Stuart Katchis
Keyword(s):  
Hallux Valgus ◽  
Postoperative Period ◽  
Weight Bearing ◽  
Line Tension ◽  
Tension Band ◽  
Metatarsal Osteotomy ◽  
First Metatarsal ◽  
Distal Metatarsal Osteotomy ◽  
The Mean

Category: Bunion Introduction/Purpose: Hallux valgus is a common deformity of the forefoot. There are over 130 procedures described to correct hallux valgus. Classically, the treatment of mild to moderate hallux valgus is with a distal metatarsal osteotomy. A variety of fixation techniques have been described for use with this osteotomy most of which require partial or non-weight bearing until the osteotomy is healed. Tension Band fixation is a well-known principle in orthopedic surgery. The goal of the present study is to radiographically assess the maintenance of distal first metatarsal osteotomy fixation using a novel tension band device (Re+Line tension band bunion plate system, Nextremity Solutions) with immediate post-operative weight-bearing. Methods: The patient database for one surgeon was retrospectively reviewed for patients that underwent hallux valgus correction with the Re+Line tension band device between 2014 and 2017. Postoperative protocol included a soft dressing, firm surgical shoe, and weight-bearing as tolerated with a cane. Patients were excluded if fixation was achieved with something other than a tension band construct. Radiographs were obtained and reviewed retrospectively by 3 authors. Pre and postoperative hallux valgus (HVA) and intermetatarsal angles (IMA) were measured as described previously in the literature, and the changes in correction compared. Maintenance of correction and hardware integrity were assessed at final follow-up after weight bearing as tolerated in a surgical shoe in the postoperative period. Statistical analysis was performed using a Wilcoxon signed-rank test for the changes in HVA and IMA. Results: There was a total of 72 patients and 76 toes that underwent hallux valgus correction with a tension band construct, at a mean follow-up of 4.36 months. 68 of 72 patients were female. The average age was 60.8 years old. The mean preoperative HVA was 27.1 degrees. The mean postoperative HVA was 6.14 degrees, with a mean correction of 20.22 degrees (p<0.001). The mean preoperative IMA was 14.14 degrees. The mean postoperative IMA was 6.10 degrees, with a mean correction of 7.98 degrees (p<0.001). There was loss of reduction found in 6 of 76 toes (7.89%).There were zero cases of hardware failure. All osteotomies healed at final follow-up. Conclusion: This study shows successful radiographic outcome after hallux valgus correction using a tension band construct and allowing immediate full weight-bearing in a surgical shoe in the postoperative period. Significant deformity correction was achieved and maintained and all osteotomies healed. The Re+Line tension band bunion correction system can be safely used as a successful option to fix distal first metatarsal osteotomies, while allowing patients to fully weight bear in a surgical shoe postoperatively and potentially return to activities faster than when using traditional fixation methods. Future studies are needed to assess functional outcomes and patient satisfaction with this novel technique.

scholarly journals Rheumatoid forefoot reconstruction in the non-rheumatoid patient

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0003
Author(s):  
Devon Nixon ◽  
Richard McKean ◽  
Sandra Klein ◽  
Jeffrey Johnson ◽  
Jeremy J. McCormick
Keyword(s):  
Rheumatoid Arthritis ◽  
Sagittal Plane ◽  
Deformity Correction ◽  
Metatarsal Head ◽  
Rheumatoid Patient ◽  
Radiographic Outcomes ◽  
Radiographic Parameters ◽  
Forefoot Surgery ◽  
Forefoot Reconstruction

Category: Lesser Toes, Midfoot/Forefoot Introduction/Purpose: Residual pain and recurrent deformity following forefoot surgery can cause significant disability. In patients with rheumatoid arthritis, first metatarsophalangeal (MTP) joint arthrodesis with lesser metatarsal head resection – often referred to as a rheumatoid forefoot reconstruction – has been shown to be a reliable operation for pain relief and deformity correction. Limited data, however, has been published on outcomes of the same forefoot reconstruction operation in the non- rheumatoid patient. Here, we review our experience with this procedure in patients without rheumatoid disease, hypothesizing improved clinical and radiographic outcomes following surgery. Methods: Following chart review and surveying billing codes, we retrospectively identified patients from 2007-2015 without a diagnosis of rheumatoid arthritis who underwent first MTP arthrodesis with lesser metatarsal head resection (rheumatoid forefoot reconstruction). Phone surveys were then conducted to assess clinical outcomes including pain and satisfaction scores. Preoperative and postoperative radiographs were reviewed for 1, 2 intermetatarsal angle (IMA), hallux valgus angle (HVA), 2nd MTP angle (MTP-2), and lesser MTP alignment (in both sagittal and axial planes). Postoperative radiographs were also assessed for radiographic union. Results: We identified 14 non-rheumatoid patients (16 feet) who underwent forefoot reconstruction – of those, 13 patients (15 feet) were successfully contacted via follow-up phone survey. Mean postoperative follow up was 42.3 (range: 12-76) months from surgery to phone interview. Mean postoperative satisfaction scores were 9.1 (out of 10), and no patients required further surgery after forefoot reconstruction. Pain scores significantly decreased from 6.2 preoperatively to 2.0 postoperatively (P<.001). Radiographic parameters (IMA, HVA, MTP-2, and lesser MTP alignment in the sagittal plane) all improved with surgery (P<.05). All 16 feet achieved union of the first MTP arthrodesis. Conclusion: With decreased pain, high satisfaction rates, and improved radiographic parameters, first MTP arthrodesis coupled with metatarsal head resection (rheumatoid forefoot reconstruction) is a viable surgical option for non-rheumatoid patients who have failed prior attempts at forefoot reconstruction or have chronic forefoot pain with deformity.

The Simple Bunion: Anatomy at the Metatarsophalangeal Joint of the Great Toe

Foot & Ankle ◽  
1984 ◽  
Vol 4 (5) ◽  
pp. 229-240 ◽  
Author(s):  
Richard Alvarez ◽  
Ray J. Haddad ◽  
Nathaniel Gould ◽  
Saul Trevino
Keyword(s):  
Metatarsophalangeal Joint ◽  
Valgus Deformity ◽  
Metatarsal Osteotomy ◽  
Great Toe ◽  
First Metatarsophalangeal Joint ◽  
First Metatarsal ◽  
Hallux Valgus Deformity ◽  
Sesamoid Bones ◽  
Proper Interpretation

The pathomechanics for the development of the hallux valgus deformity takes place at the first metatarsophalangeal joint-the sesamoid complex. The sesamoid complex consists of seven muscles, eight ligaments, and two sesamoid bones. When the first metatarsal escapes the complex and drifts medially, the sesamoids remain twisted in situ, several of the ligaments “fail,” and others contract. The authors propose reduction of the metatarsus primus varus by first metatarsal osteotomy and appropriate ligament releases and plications to restore alignment. A detailed understanding of the pathomechanics is essential for proper interpretation of the problems and anticipated lasting surgeries.

The Mayday Distal First Metatarsal Osteotomy for Hallux Valgus: A Review After the Introduction of a New Instrument

1997 ◽  
Vol 18 (1) ◽  
pp. 3-7 ◽  
Author(s):  
G.D. Terzis ◽  
F. Kashif ◽  
M.A.S. Mowbray
Keyword(s):  
Hallux Valgus ◽  
Metatarsophalangeal Joint ◽  
Metatarsal Osteotomy ◽  
Distal Fragment ◽  
Short Term ◽  
First Metatarsophalangeal Joint ◽  
First Metatarsal ◽  
Satisfactory Outcome ◽  
New Instrument

We present the short-term follow-up of 55 symptomatic hallux valgus deformities in 38 patients, treated operatively with a modification of the spike distal first metatarsal osteotomy, as described by Gibson and Piggott in 1962. The age range of the patients was 17 to 72 years at the time of surgery. The postoperative follow-up period was 12 to 55 months. Excellent and good clinical and radiographic results were recorded in 96.2% of our patients. Two of the patients (3.8%) were dissatisfied; one of them complained of metatarsalgia after the procedure, and the other had stiffness of the metatarsophalangeal joint and metatarsalgia that had been present before surgery. Three others (5.45%) required revision after early postoperative displacement but were asymptomatic subsequently. We concluded that our technique is an effective method of treating mild hallux valgus deformities with the advantages of simplicity, no shortening of the first metatarsal, and no risk of dorsal tilting of the distal fragment. Hallux valgus (lateral deviation of the great toe) is not a single disorder, as the name implies, but a complex deformity of the first ray that sometimes may involve the lesser toes. More than 130 procedures exist for the surgical correction of hallux valgus, which means that no treatment is unique. No single operation is effective for all bunions. 5 , 22 , 29 The objectives of surgical treatment are to reduce pain, to restore articular congruency, and to narrow the forefoot without impairing function, by transferring weight to the lesser metatarsals either by shortening or by dorsal tilting of the first metatarsal. 5 , 19 , 24 , 27 Patient selection is important for a satisfactory outcome after surgery of any kind, and our criteria were age, degree of deformity, presence of arthrosis, and subluxation of the first metatarsophalangeal joint. 1 , 5 , 13 , 19 – 21 , 24 , 29 In this study, we present a new method of treating hallux valgus that has been used at Mayday University Hospital since 1990. The technique was first described at the British Orthopaedic Foot Surgery Society, Liverpool, November 1990, 7 and we now present the short-term follow-up results. The procedure is essentially a modification of the spike osteotomy of the neck of the first metatarsal, as described by Gibson and Piggott. 9 It has the advantages of simplicity, no shortening of the first metatarsal, and no risk of dorsal displacement of the distal fragment.

Comparison of Postoperative Height Changes of the Second Metatarsal Among 3 Osteotomy Methods for Hallux Valgus Deformity Correction

2016 ◽  
Vol 38 (1) ◽  
pp. 20-26 ◽  
Author(s):  
Jun Young Choi ◽  
Yu Min Suh ◽  
Ji Woong Yeom ◽  
Jin Soo Suh
Keyword(s):  
Hallux Valgus ◽  
Deformity Correction ◽  
Metatarsal Head ◽  
Valgus Deformity ◽  
Metatarsal Osteotomy ◽  
Level Of Evidence ◽  
First Metatarsal ◽  
Scarf Osteotomy ◽  
Hallux Valgus Deformity ◽  
Second Metatarsal

Background: We aimed to compare the postoperative height of the second metatarsal head relative to the first metatarsal head using axial radiographs among 3 different commonly used osteotomy techniques: proximal chevron metatarsal osteotomy (PCMO), scarf osteotomy, and distal chevron metatarsal osteotomy (DCMO). Methods: We retrospectively reviewed the radiographs and clinical findings of the patients with painful callosities under the second metatarsal head, complicated by hallux valgus, who underwent isolated PCMO, scarf osteotomy, or DCMO from February 2005 to January 2015. Each osteotomy was performed with 20 degrees of plantar ward obliquity. Along with lateral translation and rotation of the distal fragment to correct the deformity, lowering of the first metatarsal head was made by virtue of the oblique metatarsal osteotomy. Results: Significant postoperative change in the second metatarsal height was observed on axial radiographs in all groups; this value was greatest in the PCMO group (vs scarf: P = .013; vs DCMO: P = .008) but did not significantly differ between the scarf and DCMO groups ( P = .785). The power for second metatarsal height correction was significantly greater in the PCMO group (vs scarf: P = .0005; vs DCMO: P = .0005) but did not significantly differ between the scarf and DCMO groups ( P = .832). Conclusions: Among the 3 osteotomy techniques commonly used to correct hallux valgus deformity, we observed that PCMO yielded the most effective height change of the second metatarsal head. Level of Evidence: Level III, retrospective comparative series.

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