Radiographic Factors Associated with Painful Callosities After Forefoot Surgery in Patients with Rheumatoid Arthritis

ABSTRACT Objectives Operative procedures for rheumatoid forefoot deformities have gradually changed from arthrodesis or resection arthroplasty to joint-preserving surgery. Though joint-preserving arthroplasty has yielded good outcomes, painful plantar callosities may occur postoperatively. This study aimed to reveal the radiographic factors associated with painful callosities after joint-preserving surgery for forefoot deformities in patients with rheumatoid arthritis (RA). Methods We retrospectively evaluated 166 feet in 133 patients with RA who underwent forefoot joint-preserving arthroplasty, including proximal rotational closing-wedge osteotomies of the first metatarsal, between January 2012 and December 2015. Logistic regression analysis was performed with the objective variable set as the presence/absence of painful plantar callosities at the final observation and the explanatory variables set as several radiographic factors including postoperative relative first metatarsal length (RML), amount of dorsal dislocation of the fifth metatarsal (5DD), and arc failure of the lesser toes. Results At the final follow-up, forty-two of the 166 feet (25.3%) had painful callosities under the metatarsal heads postoperatively. Logistic regression analysis showed that the RML, 5DD, and lesser toes’ arc failure were significantly associated with painful callosities. Conclusions We identified RML, 5DD, and arc failure of the lesser toes were associated with painful plantar callosities after the surgery.

Triple Pelvic Osteotomy In The Treatment of Pincer Type Of Femoroacetabular Impingement Syndrome.

Purpose: Femoroacetabular impingement (FAI) syndrome is a dynamic cause of hip arthritis, and it is commonly diagnosed in young adults without any other causes of hip joint pain. Pincer type of FAI in this study, is typically present in active middle-aged females. Methods: Eighteen patients diagnosed only with pincer type FAI received triple pelvic osteotomy reverse in type between 2011 and 2020. The average age of the patients was 37.3 years (28.0-45.0). The joint preserving surgery consisted of open dislocation and trochanteric flip osteotomy. We chose to do in series of selected patients only a triple pelvic osteotomy reverse in type as a extraarticular procedure in order to safely address intraarticular arthritis. Results: After surgery, the Harris Hip Score increased from 55.1 to 91.4. The patients experienced a greater range of motion in the hip and less pain. Medium-term follow-up indicated that the surgeries were successful. In our series treated with triple pelvic osteotomy 22% (4 in 18 patients) after the operation appeared clinically rear pelvic FAI test. This result was not taken as significant due to small sample size (CI 95%). After the operation we used special guidelines and we postponed total hip replacement. We did no additional operation to selected patients.Conclusion: This technique is a safe procedure to restore hip mobility. This is an extraarticular operation, and therefore it helps this process inside the joint.

The Combination of Modified Mitchell’s Osteotomy and Shortening Oblique Osteotomy for Patients with Rheumatoid Arthritis: An Analysis of Changes in Plantar Pressure Distribution

The present study aims to evaluate changes in plantar pressure distribution after joint-preserving surgery for rheumatoid forefoot deformity. A retrospective study was performed on 26 feet of 23 patients with rheumatoid arthritis (RA) who underwent the following surgical combination: modified Mitchell’s osteotomy (mMO) of the first metatarsal and shortening oblique osteotomy of the lateral four metatarsals. Plantar pressure distribution and clinical background parameters were evaluated preoperatively and one year postoperatively. A comparison of preoperative and postoperative values indicated a significant improvement in the visual analog scale, Japanese Society for Surgery of the Foot scale, and radiographic parameters, such as the hallux valgus angle. A significant increase in peak pressure was observed at the first metatarsophalangeal joint (MTPJ) (0.045 vs. 0.082 kg/cm2; p < 0.05) and a significant decrease at the second and third MTPJs (0.081 vs. 0.048 kg/cm2; p < 0.05, 0.097 vs. 0.054 kg/cm2; p < 0.05). While overloading at the lateral metatarsal heads following mMO has been reported in previous studies, no increase in peak pressure at the lateral MTPJs was observed in our study. The results of our study show that this surgical combination can be an effective and beneficial surgical combination for RA patients with mild to moderate joint deformity.

The Early Outcome Of the Bernese Periacetabular Osteotomy For Hip Dysplasia In Multiple Epiphyseal Dysplasia

Background:Multiple epiphyseal dysplasia (MED) is a rare congenital bone dysplasia. Patients with MED develop secondary hip osteoarthritis as early as third to the fourth decade. Currently, there is no consensus on how to prevent or slow the process of secondary hip osteoarthritis.The Bernese periacetabular osteotomy is a joint preserving surgery to reshape acetabulum and extend coverage for the hip, however, there is no established evidence of the effectiveness for the MED hips.Patients and methods:A retrospective series of 6 hips in 3 patients with multiple epiphyseal dysplasia treated with the Bernese periacetabular osteotomy were reviewed. The average age at the time of surgery was 14.3 years (range: 11.4 to 17.2 y). Radiographic parameters were analyzed preoperatively and 1-year postoperatively. The hip function was evaluated by the Harris Hip Score (HHS) before and after surgery. Results:The mean follow-up time was 1.7 years. The mean LCEA increased from 3.8° to 47.1° (p = .02), ACEA increased from 7.3° to 35.1° (p = .02), and AI decreased from 27.8° to 14.6° (p=.04). The femoral head coverage ratio increased from 66.8% to 100% (p= .02). The procedure achieved femoral head medialization by decreasing central head distance from 86.7mm preoperatively to 82.7mm postoperatively, however, without statistical significance. (p = .699). The improvement of clinical outcomes by mean HHS was significant from 67.3 preoperatively to 86.7 postoperatively (p=0.05).Conclusion:Bernese PAO is a feasible option for treatment of the hip problems in MED patients. It reshapes acetabular and femoral morphology 3-dimensionally. In our study, the short-term follow-up results showed obvious functional and radiographic improvement. A long-term follow-up is necessary in the future.

Anterolateral Necrotic Lesion Serves as an Early Warning Sign of Developing Collapse in Osteonecrosis of the Femoral Head

Objective: Load bearing capacity of the bone structure of anterolateral weight-bearing area plays an important role in the progressive collapse in osteonecrosis of the femoral head (ONFH). The purpose of this study is to assess the efficacy of combined evaluation of anteroposterior (AP) and frog-leg lateral (FLL) view to diagnose collapse.Methods: Between December 2016 to August 2018, a total of 478 hips from 372 patients with ONFH (268 men, 104 women; mean age 37.9±11.4 years) were retrospectively evaluated. All patients received standard AP and FLL views of hip joints. Japanese Investigation Committee (JIC) classification system was used to classified necrotic lesion in AP view. Anterior necrotic lesion was evaluated by FLL view. All patients with precollapse ONFH underwent non-operative hip preserving therapy. The collapse rate was calculated and compared with Kaplan–Meier survival analysis with radiological collapse as endpoints.Results: Forty-four (44/478, 9.2%) hips were classified as type A, 65 (65/478, 13.6%) as type B, 232 (232/478, 48.5%) as type C1, and 137 (137/478, 28.7%) as type C2. Three hundred cases (300/478, 62.5%) were collapsed at the initial time point. Two hundred and twenty six (226/300, 75.3%) hips and 298 (298/300, 99.3%) hips collapse were identified with AP view and FLL view, respectively. An average follow-up of 37.0±32.0 months was conducted to evaluate the occurence of collapse in 178 precollapse hips. During follow-up period, collapse occurred in 89 hips (50.0%). Seventy-seven (77/89, 86.5%) hips was determined with AP view alone and 85 (85/89, 95.5%) hips were determined with combination of AP and FLL views. The collapse rate at five years were reported as 0% and 0%, 16.2% and 24.3%, 58.3% and 68.1%, and 100% and 100% according to combination of AP and FLL views or AP view alone for types A, B, C1, and C2, respectively.Conclusion: The collapse can be diagnosed more accurately by combination of AP and FLL views. Besides, JIC type A and type B ONFH can be treated with conservative hip preservation, but precollapse type C2 ONFH should be treated with joint-preserving surgery. Type C1 needs further study to determine which subtype has potential risk of collapse.

RADIOGRAPHIC FOLLOW-UP AFTER MILD SLIPPED CAPITAL FEMORAL EPIPHYSIS: WHAT IS THE INCIDENCE OF SUBSEQUENT SURGERY FOR FEMORACETABULAR IMPINGEMENT?

Background: Slipped capital femoral epiphysis (SCFE) is characterized by translation of the proximal femoral epiphysis posterior and medial relative to the metaphysis. The gold standard treatment of mild SCFE, defined as a slip angle <30°, remains in-situ pinning (ISP) to stabilize the epiphysis in its current position after slippage. Methods: 127 hips from 113 individuals met inclusion criteria: mild SCFE (Southwick angle <30°) that underwent ISP with available pre- and post-procedure radiographs. Medical records were reviewed to collect demographic data, preoperative symptoms, surgical details, radiographic measurements, and post-operative follow-up. Six hips were identified as having undergone additional joint preserving surgery of the hip (JPSH) while seven other hips were identified as having undergone screw removal and/or replacement within two years of initial ISP. Anterior-posterior (AP) and frog-leg lateral alpha angles, femoral epiphyseal-metaphyseal offset angle, and Southwick angle were all measured preoperatively, post-operatively, and at final radiographic follow-up. Chi-squared analyses, binary logistic regression models and Kruskal-Wallis tests were used to evaluate the association between clinical and radiographic parameters and the occurrence of additional surgery or screw failure. Results: Demographic variables, including age, body mass index, prodrome pain, sex, laterality, and chronicity were not found to significantly influence the likelihood of additional surgery. Preoperative AP alpha angle, frog-lateral alpha angle, epiphyseal-metaphyseal offset angle, and Southwick angle did not significantly impact the likelihood of additional surgery or screw failure. Radiographic measurements taken after ISP demonstrated that AP alpha angle significantly increased the likelihood of additional surgery. For every one degree increase, the likelihood of additional surgery increased 1.091 times (average 70.264° for no additional surgery and 82.333° for additional surgery, p=0.017). Conclusion: Mild SCFE can progress to residual pain and limited hip motion even after initial treatment with ISP. Of our cohort of 127 hips, six (4.72%) went on to have secondary JPSH while an additional seven (5.51%) presented with screw failure within two years of initial ISP. Increased AP alpha angle after ISP was correlated with an increased likelihood of secondary JPSH. This increased AP alpha angle may contribute to intra-articular pathology due to CAM-type morphology which may lead to the necessity of JPSH. These findings suggest that patients with increased AP alpha angle after ISP may need to be followed long-term for the development of further joint symptoms and may need to be counseled after ISP for mild SCFE for the risk of secondary JPSH. Tables/Figures: [Table: see text][Table: see text][Table: see text]

Femoral cartilage damage occurs at the zone of femoral head necrosis and can be accurately detected on traction MR arthrography of the hip in patients undergoing joint preserving hip surgery

The primary purpose was to answer the following question: What is the location and pattern of necrosis and associated chondrolabral lesions and can they be accurately detected on traction MR arthrography compared with intra-operative findings in patients undergoing hip preservation surgery for femoral head necrosis (FHN)? Retrospective, diagnostic case series on 23 patients (23 hips; mean age 29 ± 6 years) with diagnosis of FHN undergoing open/arthroscopic joint preserving surgery for FHN and pre-operative traction MR arthrography of the hip. A MR-compatible device for weight-adapted application of leg traction (15–23 kg) was used and coronal, sagittal and radial images were acquired. Location and pattern of necrosis and chondrolabral lesions was assessed by two readers and compared with intra-operative findings to calculate diagnostic accuracy of traction MR arthrography. On MRI all 23 (100%) hips showed central FHN, most frequently antero-superiorly (22/23, 96%) where a high prevalence of femoral cartilage damage was detected (18/23, 78%), with delamination being the most common (16/23, 70%) damage pattern. Intra-operative inspection showed central femoral head cartilage damage most frequently located antero-superiorly (18/23, 78%) with femoral cartilage delamination being most common (14/23, 61%). Traction MR arthrography enabled detection of femoral cartilage damage with a sensitivity/specificity of 95%/75% for reader 1 and 89%/75% for reader 2. To conclude, femoral cartilage damage occurs at the zone of necrosis and can be accurately detected using traction MR arthrography of the hip which may be helpful for surgical decision making in young patients with FHN.

Joint-Preserving Surgery for Forefoot Deformities in Patients with Rheumatoid Arthritis: A Literature Review

The combination of first metatarsophalangeal joint arthrodesis and resection arthroplasty of all lesser metatarsal heads has been historically considered the golden standard treatment for rheumatoid forefoot deformities. However, as recent improved management of rheumatoid arthritis have reduced progression of joint destruction, the surgical treatments for rheumatoid forefoot deformities have gradually changed from joint-sacrificing surgery, such as arthrodesis and resection arthroplasty, to joint-preserving surgery. The aim of this literature review was to provide current evidence for joint-preserving surgery for rheumatoid forefoot deformities. We focused on the indications, specific outcomes, and postsurgical complications of joint-preserving surgery in this review.