Combination of Modified Scarf Osteotomy and Metatarsal Shortening Offset Osteotomy for Rheumatoid Forefoot Deformity

With the progress of medical treatment for rheumatoid arthritis (RA), several joint-preserving forefoot surgical procedures have been established and performed. In this situation, we have been choosing the combined surgery: modified scarf osteotomy for the great toe and metatarsal shortening offset osteotomy for the lesser toes in RA cases. A retrospective observational study of 53 RA patients (mean follow-up period: 4.6 years) who underwent the surgery was completed. RA foot ankle scores were assessed, using the Japanese Society for Surgery of the Foot (JSSF) standard rating system, and a self-administered foot evaluation questionnaire (SAFE-Q) was also checked to evaluate clinical outcomes. For radiological evaluations, deformity parameters were measured using radiographs of the feet with weight-bearing. JSSF hallux and lesser toes scores and the SAFE-Q score showed significant improvement in all indices. HVA, M1-M2A, M1-M5A, M2-M5A, and sesamoid position were significantly improved after surgery. At the final follow-up, the hallux valgus deformity had recurred in 4 feet (7.5%), and hallux varus deformity had developed in 8 feet (15.1%). No case of recurrent hallux valgus deformity required revision surgery. Recurrence of dorsal dislocation/subluxation of the lesser toe MTP joint was seen in 6 feet (11.3%) after surgery. A combination of modified scarf osteotomy for the great toe and modified metatarsal shortening offset osteotomy for the lesser toes is one of the novel surgical procedures for rheumatoid forefoot deformity. Preoperative disease activity of RA negatively affected the clinical score of the hallux. The spread of M2-M5A was a risk factor for resubluxation of the lesser toe MTP joint.

Time Course of Quality of Life Improvement Between Resection Arthroplasty and Metatarsophalangeal Joint-Preserving Forefoot Arthroplasty for Rheumatoid Arthritis

Background: Resection arthroplasty has long been a major treatment option for forefoot deformity caused by rheumatoid arthritis (RA). However, metatarsophalangeal (MTP) joint–preserving surgery is now surpassing classic resection arthroplasty. This study was performed to compare the postoperative results of these 2 operative methods. Methods: Fifty-one toes of 40 patients with RA who underwent resection arthroplasty (resection group) or MTP joint–preserving arthroplasty (preservation group) from 2014 to 2017 for forefoot deformity were followed up for >1 year and were retrospectively analyzed. In the preservation group, open reduction of joint dislocation was performed if needed, and the deformity was corrected by metatarsal shortening osteotomy. The mean follow-up period was 21 months. The Japanese Society for Surgery of the Foot (JSSF) scales (objective outcome measures), the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) (subjective outcome measure), and radiographic indices were compared between the groups. The resection group and preservation group comprised 15 toes of 11 patients and 36 toes of 29 patients, respectively. Results: There were no significant differences in the preoperative radiographic indices, JSSF scales, or SAFE-Q results between the 2 groups. The preservation group showed better JSSF scores at the last follow-up (median hallux scale, 89 vs 74; median lesser scale, 87 vs 79). In the preservation group, the SAFE-Q scores gradually improved with time until 12 months postoperatively. In the resection group, the scores decreased 3 months postoperatively and then improved and reached a plateau 6 months postoperatively. At 12 months postoperatively, there was no significant difference in the SAFE-Q scores between the 2 groups. Conclusions: MTP joint–preserving arthroplasty resulted in superior objective scores to resection arthroplasty in patients with RA forefoot deformity. Although the subjective scores did not differ between the groups at the last follow-up, the time course of postoperative quality of life improvement was different between the 2 surgeries. Level of Evidence: Level III, retrospective comparative study.

Fresh Cadaveric Study of the Distances between the Deep Plantar Arch and the Lesser Metatarsals at Risk During Osteotomy of the Lesser Metatarsals

Category: Midfoot/Forefoot Introduction/Purpose: Osteotomy of the lesser metatarsals is useful to treat forefoot deformity. Although there is the possibility that some arteries supplying the lesser metatarsals are injured during osteotomy, there are few informations about the distances from the deep plantar arch to the lesser metatarsals. This study aimed to identify the distances from the deep plantar arch to the lesser metatarsals and to reveal how osteotomy of the lesser metatarsals might injure the deep plantar arch. Methods: Twenty fresh cadaveric feet were injected with barium through the external iliac artery, and enhanced computed tomography images were assessed. The distance between the deep plantar arch and each lesser metatarsal was measured on both axial and sagittal images. Results: The distances between the deep plantar arch and the second, third, and fourth metatarsals on the axial plane were 0.5, 2.2, and 2.8 mm, respectively. The distances from the distal epiphysis to the line passing through the deep plantar arch perpendicular to the longitudinal axis of the lesser metatarsal on the sagittal plane were 47.0, 45.7, and 46.4 mm, respectively, and those from the proximal epiphysis were 23.0, 21.0, and 18.6 mm, respectively. The deep plantar arch coursed at the level of the middle third, proximal to this third in 11/20 (55.0%), 7/20 (35.0%), and 5/16 (31.2%) feet, respectively. Conclusion: This study suggested that overpenetration into the medial-plantar direction of the second metatarsal or the proximal-plantar direction of the fourth metatarsal during the shaft or proximal osteotomy might injure the deep plantar arch easily. This study also suggested that on the plantar aspect, the shaft or proximal osteotomy about 45-47 mm proximal to the distal epiphysis of the lesser metatarsal or 18-23 mm distal to the proximal epiphysis might damage blood flow of the deep plantar arch.

Treatment of an Intractable Forefoot Ulcer Using Realignment Osteotomy in a Patient with Rheumatoid Arthritis

Forefoot deformities are common among patients with rheumatoid arthritis (RA). Herein, we describe a case of intractable ulceration on the dorsomedial aspect of the right 5th digit, secondary to forefoot deformity, in a 76-year-old woman with a 35-year history of RA. The ulcer was due to a persistent subcutaneous infection. Although the infection was controllable with antibiotics, there was concern of relapse because of the abnormal pressure on the skin due to an overlap of the 4th and 5th digits. We proceeded with surgical correction of the forefoot alignment, including shortening oblique osteotomy of metatarsals 2 through 5, rather than amputation of the 5th digit. Following surgery, targeted antibiotic treatment was provided. The postoperative course was unremarkable, and the patient recovered weight-bearing function without recurrence of pain or ulceration. Forefoot realignment is a feasible option that should be considered for treating intractable foot pain and ulceration secondary to long-lasting RA.