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Resection Arthroplasty for Rheumatoid Forefoot Deformity
Jun-ichi Fukushi, M.D.
Yasuharu Nakashima, M.D.
Yukihide Iwamoto, M.D.
Department of Orthopedic Surgery, Graduate School of Medical Sciences,
Kyushu University, Fukuoka, Japan
Resection Arthroplasty for Rheumatoid Forefoot Deformity
Jun-ichi Fukushi, M.D.
Yasuharu Nakashima, M.D.
Yukihide Iwamoto, M.D.
My disclosure is in the final AOFAS program book. I have no potential conflicts with this presentation.
Patients and Method : 1
Patients : 24 patients (38 feet) 21 women (34 feet) and 3men (4 feet) Average age : 61.9 years Average follow up period : 72 month Surgical procedure : 2nd to 5th MTP:resection of the metatarsal heads (planter incision; LeLievre 1961, Kates 1967) 1st toe: arthrodesis (30 feet) resection (8 feet)
To assess the results of resection arthroplasty for the
rheumatoid forefoot deformities.
Purpose
Patients and Method : 2
Clinical evaluation :
Patient satisfaction : excellent・good・fair・poor
Recurrence of planter pain
Presence/recurrence of hammer toe
Radiological evaluation : 128 lessor toes (32 feet)
① Presence of a deformity in the proximal phalanx
② Distance between proximal phalanx and metatarsal stump
③ Presence of postoperative bone remnant
①
②
③
Results:clinical evaluation
Excellent(no pain) :7 Good(some pain, but acceptable) :22 Fair(improvement of pain) :5 Poor(no improvement) :4
76% were excellent and good
However, 3cases (4feet, 11%) were poor.
Patient satisfaction
Recurrence of planter pain 13 of 128 lesser MTP joints
Recurrence of hammer toe 22 of 128 lesser MTP joints
0.00
0.25
0.50
0.75
1.00
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0.25
0.50
0.75
1.00
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0.25
0.50
0.75
1.00
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‚ ‚è
‚È‚µ
Recurrence of planter pain
Preoperative hammer toe Bone remnants (p=0.5628)
Recurr
ence o
f pa
in
Deformity in proximal phalanx
41
10
74
3
(p=0.0060*)
The recurrence of planter pain was associated with the presence of proximal phalanx deformities (p=0.0060), and was inversely correlated with the distance between proximal phalanx and metatarsal stump (p=0.0345).
(p=0.5561)
0.00
0.25
0.50
0.75
1.00
-2 0 2 4 6 8 10 12 14 16
‚ ‚è
‚È‚µ
Distance between proximal phalanx and metatarsal stump (p=0.0345*)
Recurr
ence o
f pa
in
Pain(-)
Pain(+)
Pain(-)
Pain(+)
Pain(-)
Pain(+)
Pain(-)
Pain(+)
(+) (-)
(+) (-) (+) (-)
0.00
0.25
0.50
0.75
1.00
‚ ‚è ‚È‚µ
‚ ‚è
‚È‚µ
0.00
0.25
0.50
0.75
1.00
‚ ‚è ‚È‚µ
‚ ‚è
‚È‚µ
0.00
0.25
0.50
0.75
1.00
-2 0 2 4 6 8 10 12 14 16
‚ ‚è
‚È‚µ
0.00
0.25
0.50
0.75
1.00
‚ ‚è ‚È‚µ
‚ ‚è
‚È‚µ
Recurrence of hammer toe
Bone remnants (p=0.156)
Recurr
ence o
f ham
mer
toe
Preoperative hammer toe
56
19
51
2
(p=0.0012*)
The recurrence of hammer toe was strongly associated with the presence of preoperative hammer toe deformities (p=0.0012), and was inversely correlated with the distance between proximal phalanx and metatarsal stump (p<0.0001).
(p=0.2282)
Distance between proximal phalanx and metatarsal stump (p<0.0001*)
(-)
(+)
(+) (-)
(+) (-) (+) (-)
(-)
(+)
Deformity in proximal phalanx
Recurr
ence o
f ham
mer
toe
(-)
(+)
(-)
(+)
62 y.o., female : pain recurred in 5th toe Follow up (8 years) Postoperative radiograph Preoperative radiograph
Proliferative change was present in the 5th proximal phalanx. Two weeks after the surgery, the 5th MTP joint got swollen, and pain recurred. Planter callosity recurred in 2 years, followed by ulceration in 4 years after the surgery (satisfaction : poor).
Deformity in 5th proximal phalanx
60 y.o., female : pain recurred in 2nd and 3rd toe
Planter pain recurred in the 2nd and 3rd MTP 3 years after the resection, which required metatarsal trimming. The distance between the proximal phalanx and the metatarsal stump in the 2nd and 3rd MTP was inadequate (arrows) (satisfaction : poor).
Follow up (3 years) Postoperative radiograph Preoperative radiograph
Conclusion
・Resection arthroplasty is a satisfactory method of treatment for symptomatic RA forefoot.
・To avoid a recurrence of metatarsal joint pain, acquiring appropriate gap between proximal phalanx and metatarsal stump is important.
・ In addition, surgeons should pay attention for the existence of preoperative deformities in the proximal phalanx, where additional bone resection or synovectomy may be considered.
Lelievre J. Pathologie due Pied. Masson & Cie, Paris, 1961. Kates A, et al. Arthroplasty of the forefoot. J. Bone Joint Surg. 49B: 552-557, 1997
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