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

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Recurrence of planter pain

Preoperative hammer toe Bone remnants (p=0.5628)

Recurr

ence o

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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)

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Distance between proximal phalanx and metatarsal stump (p=0.0345*)

Recurr

ence o

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Pain(-)

Pain(+)

Pain(-)

Pain(+)

Pain(-)

Pain(+)

Pain(-)

Pain(+)

(+) (-)

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Recurrence of hammer toe

Bone remnants (p=0.156)

Recurr

ence o

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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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