Resection Arthroplasty for Rheumatoid Forefoot Deformity

Transcription

1 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

2 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.

3 Purpose To assess the results of resection arthroplasty for the rheumatoid forefoot deformities. 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 : 2 nd to 5 th MTP:resection of the metatarsal heads (planter incision; LeLievre 1961, Kates 1967) 1 st toe: arthrodesis (30 feet) resection (8 feet)

4 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

5 Results:clinical evaluation Patient satisfaction 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. Recurrence of planter pain 13 of 128 lesser MTP joints Recurrence of hammer toe 22 of 128 lesser MTP joints

6 Recurrence of planter pain Recurrence of pain (+) (-) Deformity in proximal phalanx (p=60 * ) Pain(-) Pain(+) Distance between proximal phalanx and metatarsal stump (p= * ) Pain(-) Pain(+) Recurrence of pain (+) (-) (+) (-) Preoperative hammer toe (p=0.5561) Pain(-) Pain(+) Bone remnants (p=0.5628) Pain(-) Pain(+) The recurrence of planter pain was associated with the presence of proximal phalanx deformities (p=60), and was inversely correlated with the distance between proximal phalanx and metatarsal stump (p=0.0345).

7 Recurrence of hammer toe Recurrence of hammer toe (+) è (-) Preoperative hammer toe (p=12 * ) (-) (+) è (-) (+) Distance between proximal phalanx and metatarsal stump (p<01 * ) Recurrence of hammer toe (-) (+) Deformity in proximal phalanx (p=0.2282) (+) (-) (+) (-) Bone remnants (p=0.156) (-) (+) The recurrence of hammer toe was strongly associated with the presence of preoperative hammer toe deformities (p=12), and was inversely correlated with the distance between proximal phalanx and metatarsal stump (p<01).

8 62 y.o., female : pain recurred in 5 th toe Preoperative radiograph Postoperative radiograph Follow up (8 years) Deformity in 5 th proximal phalanx Proliferative change was present in the 5 th proximal phalanx. Two weeks after the surgery, the 5 th MTP joint got swollen, and pain recurred. Planter callosity recurred in 2 years, followed by ulceration in 4 years after the surgery (satisfaction : poor).

9 60 y.o., female : pain recurred in 2 nd and 3 rd toe Preoperative radiograph Postoperative radiograph Follow up (3 years) Planter pain recurred in the 2 nd and 3 rd MTP 3 years after the resection, which required metatarsal trimming. The distance between the proximal phalanx and the metatarsal stump in the 2 nd and 3 rd MTP was inadequate (arrows) (satisfaction : poor).

10 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. References: Lelievre J. Pathologie due Pied. Masson & Cie, Paris, Kates A, et al. Arthroplasty of the forefoot. J. Bone Joint Surg. 49B: , 1997