The Rheumatoid Forefoot: Joint-Sparing Vs. Joint-Ablation
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1 AOFAS Symposium 3 Lesser Toe Surgeons Are Not Lesser People Monday, September 22, :00 am - 12:00 pm Moderator: Thomas H. Lee, MD, Westerville, Ohio The Rheumatoid Forefoot: Joint-Sparing Vs. Joint-Ablation John T. Campbell, MD Baltimore, Maryland I) Background A) Pathophysiology 1) Synovitis, pannus 2) Ligament attenuation, failure 3) Joint erosions, cartilage loss, arthritis B) Pathomechanics 1) Hallux (a) Progressive valgus (b) Unloads hallux, transfers stress to lesser MTPs (c) Loss of windlass mechanism, arch flattening, 1 st TMT instability 2) Lesser MTPs (a) Progressive subluxation dislocation (b) Intrinsic minus, claw toe deformity (c) Fat pad migrates distally diminished padding (d) Depresses metatarsal head metatarsalgia, callus, ulceration II) Historical Perspective A) Pan-metatarsal head resection 1) Keller (base proximal phalanx) or Mayo (1 st metatarsal head) 2) Lesser met head +/- phalangeal base resections 3) Pain relief, improved shoewear 4) Not as durable valgus deformity tends to recur (esp. with Keller) B) Implant arthroplasty 1 st MTP 1) Silastic implant 2) Inconsistent pain relief, inadequate restoration hallux WB 3) Durability concerns particulate wear debris, inflammation and erosive synovitis, bone lysis C) Arthrodesis 1 st MTP with lesser MTP resection arthroplasties
2 1) Biomechanical advantage (a) Restores WB to medial column (b) Increased contact area & peak pressure under hallux (c) Offloads/ protects lesser MTPs (d) May decrease peak P-time integral earlier toe-off in stance phase 2) Outcomes (a) Level II/III studies most support fusion (i) Resection patients do have pain relief, satisfaction Some studies show no difference vs. fusion (ii) Various pedobarographic data support fusion > resection (iii) Fusion: better push off hallux, better cadence, more cosmetic, better correction splayfoot, more durable (b) Multiple Level IV series support 1 st MTP arthrodesis (i) Fusion rate % (ii) Maintenance of deformity correction (iii) Excellent pain relief, shoewear tolerance, cosmetic improvement (iv) Durable follow-up as long as 6 years (c) Grade B Recommendation III) Joint-Sparing Alternatives A) Background 1) DMARDs & biologics (a) Less severe forefoot disease on presentation (b) Preferential effects on smaller joint disease? (Nikiphorou et al) 2) Limitations with lesser MTP resection arthroplasties long term (a) Spur formation, bony proliferation (b) Plantar callus (c) Recurrent deformity 3) Thordarson et al series (2002) high rate of failure, recurrent deformity if hallux MTP not fused, revised to fusion 45% 4) Barouk described using Scarf & lesser Weils for joint-sparing in textbook (2005), later series in 2007 (a) 95% satisfactory correction, 55 1 st MTP ROM (b) 15% floating toes, 10% metatarsalgia (c) Only 1/55 revised to fusion on 75 months follow-up B) Indications 1) Mild to moderate deformity 2) Severe claw toe, dislocation? 3) Adequate bone stock 4) Maintained joint space 5) One or two lesser MTP joints affected C) Contraindications
3 1) Joint destruction, severe arthritis 2) Severe osteopenia compromised fixation 3) Bone loss 4) More severe systemic disease? 5) Recurrence, revision situation D) 1 st MTP 1) Options (a) Scarf osteotomy (b) Proximal osteotomy (c) Distal osteotomy (chevron, Mitchell) (d) Lapidus procedure 2) Level IV series for each technique, no clear preference 3) Improvement in various outcomes scores (AOFAS, VAS, FFI, SF-36, etc.) 4) Angular correction which seems to hold up (max = 75 months) 5) Failure (conversion to fusion) 2%-5% 6) IP arthritis 20-30% E) Lesser MTPs 1) Weil osteotomy / distal oblique osteotomy (a) Most evidence (b) 85% correction, 15% floating toes, 14% redislocation (c) Metatarsalgia 10% - 13% 2) Stainsby procedure (a) Retain met head, resect phalangeal base, reduce plantar plate and fat pad, extensor tendon secured to flexor or through met head to stabilize toe (b) Multiple Level IV series, small numbers, short- to medium-term follow-up (59 months) (i) Pain relief 83-93% (ii) Satisfaction 80-90% (iii) Continued metatarsalgia 8-33%, recurrent deformity 17% 3) Grade B Recommendation (a) Appears promising pending further study (b) Virtually all Level IV case series (c) No pedobarographic analyses IV) Unanswered Questions A) Refine indications B) Optimal technique C) Durability longer term follow-up D) Pedobarographic data how well do joint-sparing techniques restore normal function? E) Outcomes higher level studies, compare to standard approach V) Bibliography
4 Amin A, Cullen N, Singh D. Rheumatoid Forefoot Reconstruction. Acta Orthop Belg, 76: , Barouk LS, Barouk P. Joint-Preserving Surgery in Rheumatoid Forefoot: Preliminary Study with More Than Two Year Follow-Up. Foot Ankle Clin, 12: , Bass EJ, Shariff R, Sirikonda SP. Rheumatoid Forefoot Reconstruction: Outcome of 1 st Metatarsophalangeal Joint Fusion and the Stainsby Procedure in the Lesser Toes. Foot, 24: 56-61, Bhavikatti M, Sewell MD, Al-Hadithy N, Awan S, Bawarish MA. Joint Preserving Surgery for Rheumatoid Forefoot Deformities Improves Pain and Corrects Deformity at Mid-Term Follow-Up. Foot, 22: 81-84, Bolland BJRF, Sauve PS, Taylor GR. Rheumatoid Forefoot Reconstruction: First Metatarsophalangeal Joint Fusion Combined with Weil s Metatarsal Osteotomies of the Lesser Rays. J Foot Ankle Surg, 47 (2): 80-88, Briggs PJ, Stainsby GD. Metatarsal Head Preservation in Forefoot Arthroplasty and the Correction of Severe Claw Toe Deformity. Foot Ankle Surg, 7: , Chao JC, Charlick D, Tocci S, Brodsky JW. Radiographic and Clinical Outcomes of Joint-Preserving Procedures for Hallux Valgus in Rheumatoid Arthritis. Foot Ankle Int, 34 (12): , Coughlin MJ. Rheumatoid Forefoot Reconstruction: A Long-Term Follow-Up Study. J Bone Joint Surg [Am], 82-A: , Dodd L, Atinga M, Foote J, Palmer S. Outcomes after the Stainsby Procedure in the Lesser Toes: An Alternative Procedure for the Correction of Rigid Claw Toes Deformity. J Foot Ankle Surg 50: , Grondal L, Brostrom E, Wretenberg P, Stark A. Arthrodesis versus Mayo Resection: The Management of the First Metatarsophalangeal Joint in Reconstruction of the Rheumatoid Forefoot. J Bone Joint Surg [Br], 88-B: , Hanyu T, Yamazaki H, Murasawa A, Tohyama C. Arthroplasty for Rheumatoid Forefoot Deformities by a Shortening Oblique Osteotomy. Clin Orthop Rel Res, 338: , Hassan K, Rashid MA, Panikkar V, Walters SJ, Henry APJ. Forefoot Reconstruction: Effectiveness of Stainsby Operation in Treating Dislocated Lesser Toes. Foot, 17: , Jeng C, Campbell J. Current Concepts Review: The Rheumatoid Forefoot. Foot Ankle Int, 29: , Kadambande S, Debnath U, Khurana A, Hemmady M, Hariharan K. Rheumatoid Forefoot Reconstruction: 1 st Metatarsophalangeal Fusion and Excision Arthroplasty of Lesser Metatarsal Heads. Acta Orthop Belg,
5 73: 88-95, Louwerens JWK, Schrier JCM. Rheumatoid Forefoot Deformity: Pathophysiology, Evaluation, and Operative Treatment Options. Int Orthop, 37: , Mann RA, Schakel ME. Surgical Correction of Rheumatoid Forefoot Deformities. Foot Ankle Int, 16: 1-6, Mann RA, Thompson FM. Arthrodesis of the First Metatarsophalangeal Joint for Hallux Valgus in Rheumatoid Arthritis. J Bone Joint Surg [Am], 66-A: , McGarvey SR, Johnson KA. Keller Arthroplasty in Combination with Resection Arthroplasty of the Lesser Metatarsophalangeal Joints in Rheumatoid Arthritis. Foot Ankle, 9(2): 75-80, Mulcahy D, Daniels TR, Lau JT-C, Boyle E, Bogoch E. Rheumatoid Forefoot Deformity: A Comparison Study of 2 Functional Methods of Reconstruction. J Rheumatol, 30(7): , Niki H, Hirano T, Okada H, Beppu M. Combination Joint-Preserving Surgery for Forefoot Deformity in Patients with Rheumatoid Arthritis. J Bone Joint Surg [Br], 92-B: , Nikiphorou E, Carpenter L, Morris S, MacGregor AJ, Dixey J, Kiely P, James DW, Walsh DA, Norton S, Young A. Hand and Foot Surgery Rates in Rheumatoid Arthritis Have Declined from 1986 to 2011, but Large Joint Replacement Rates Remain Unchanged. Arthritis Rheum, 66 (5): , Queally JM, Zgraj OS, Walsh JC, Butt AJ, D Souza LG. Use of the Modified Stainsby Procedure in Correcting Severe Claw Toe Deformity in the Rheumatoid Foot: A Retrospective Review. Foot, 19: , Rosenbaum D, Timte B, Schmiegel A, Miehlke RK, Hilker A. First Ray Resection Arthroplasty versus Arthrodesis in the Treatment of the Rheumatoid Foot. Foot Ankle Int, 32: , Shi K, Hayashida K, Tomita T, Tanabe M, Ochi T. Surgical Treatment of Hallux Valgus Deformity in Rheumatoid Arthritis: Clinical and Radiographic Evaluation of Modified Lapidus Technique. J Foot Ankle Surg, 39 (6): , Takakubo Y, Takagi M, Tamaki Y, Sasaki A, Nakano H, Orui H, Ogino T. Mid-Term Results of Joint- Preserving Procedures by a Modified Mann Method for Big Toe Deformities in Rheumatoid Patients Undergoing Forefoot Surgeries. Mod Rheumatol, 20; , Thomas S, Kinninmonth AWG, Kumar CS. Long-Term Results of the Modified Hoffman Procedure in the Rheumatoid Forefoot. J Bone Joint Surg [Am], 87-A: , Thordarson DB, Aval S, Krieger L. Failure of Hallux MP Preservation Surgery for Rheumatoid Arthritis. Foot Ankle Int, 23: , 2002.
6 Torikai E, Kageyama Y, Suzuki M, Ichikawa T, Nagano A. Comparison between Resection Arthroplasty Alone and Resection Arthroplasty with Arthrodesis of the First MTP Joint for Rheumatoid Forefoot Deformities. Med Rheumatol, 18: , Trieb K, Hofstaetter SG, Panotopoulos J, Wanivenhaus A. The Weil Osteotomy for Correction of the Severe Rheumatoid Forefoot. Int Orthop, 37: , Vandeputte G, Steenwerckx, Mulier T, Peeraer L, Dereymaeker. Forefoot Reconstruction in Rheumatoid Arthritis Patients: Keller-Lelievre-Hoffmann versus Arthrodesis MTP1-Hoffmann. Foot Ankle Int., 20(7): , Yano K, Ikari K, Iwamoto T, Saito A, Naito Y, Kawakami K, Suzuki T, Imamura H, Sakuma Y, Hiroshima R, Momohara S. Proximal Rotational Closing-Wedge Osteotomy of the First Metatarsal in Rheumatoid Arthritis: Clinical and Radiographic Evaluation of a Continuous Series of 35 Cases. Mod Rheumatol 23: , 2013.
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