Patient-Reported and Radiographic Outcomes of Joint-Preserving Surgery for Rheumatoid Forefoot Deformities

Abstract

Background: Rheumatoid arthritis (RA) is an autoimmune disorder and a chronic inflammatory disease that can damage joints throughout the body. As dramatic improvements in medical treatment have contributed to reduced progression of joint destruction, surgical methods for the treatment of RA-related forefoot deformities have gradually changed from joint-sacrificing to joint-preserving. The aim of this study was to assess the long-term outcomes, including patient-reported outcomes, of joint-preserving surgery for forefoot deformities associated with RA. Methods: This retrospective study included 105 feet in 89 patients with RA who were treated during the period of January 2012 to May 2015 and had a minimum of 5 years of follow-up (mean, 6.0 ± 0.9 years). The patient-reported outcome measure used was the Self-Administered Foot Evaluation Questionnaire (SAFE-Q), which was completed preoperatively and at the latest follow-up (n = 53 feet). The hallux valgus angle (HVA), the intermetatarsal angle (IMA), and the position of the medial sesamoid were measured preoperatively, at 3 months postoperatively, and at the latest follow-up. Cases of delayed wound-healing, hallux valgus recurrence, nonunion at the osteotomy sites, and reoperation were recorded. Kaplan-Meier survival curves were used to determine the estimated survivorship, with reoperation as the end point. Results: Scores of all 5 subscales of the SAFE-Q demonstrated significant improvement at the latest follow-up. The average HVA and IMA decreased significantly 3 months postoperatively, and these measurements remained significantly lower than the preoperative values (p < 0.01). The position of the medial sesamoid at the latest follow-up improved significantly (p < 0.01). Delayed wound-healing was found at the site of surgery in 21 (20.0%) of the 105 feet. Recurrence of hallux valgus was observed in 11 (10.5%) of the feet. There was no case of nonunion at any osteotomy site. Eleven (10.5%) of the feet required reoperation. The estimated survivorship of the studied joint-preserving surgery at 7 years, with reoperation as the end point, was 89.5%. Conclusions: Satisfactory long-term patient-reported and radiographic outcomes after joint-preserving surgery for forefoot deformities associated with RA can be achieved. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Scarf and Akin Osteotomy with Intra-Articular Stepwise Lateral Soft Tissue Release for Correcting Hallux Valgus Deformity in Rheumatoid Arthritis

“…In the present study, the recurrence rate of HV deformities was 13.9%, which was not worse compared with that reported in previous studies on joint-preserving surgery in patients with RA (0-40%) [11,[13][14][15][16]37,38]. Reported risk factors for recurrent HV after joint-preserving procedures in patients with RA include severe preoperative deformity, high preoperative RA disease activity, splayfoot, and hindfoot malalignment [13,15,39,40].…”

“…In a retrospective study of 35 feet, Ebina et al reported that joint-preserving arthroplasty, including modified scarf osteotomy for the hallux and off-set shortening osteotomy for the lesser toes, significantly improved all SAFE-Q subscale scores [24]. Another retrospective study by Yano et al including 105 feet demonstrated that joint-preserving surgery including proximal rotational closing-wedge osteotomy of the first metatarsal and shortening oblique osteotomies of the lesser toes also significantly improved all SAFE-Q subscale scores [16]. Additionally, Chao et al reported a significant improvement in the Short Form 36 score postoperatively in a retrospective study of 37 feet that were treated with a joint-preserving procedure of the first MTP joint, including Ludloff, scarf, and chevron osteotomies [14].…”

“…The evaluations at the most recent follow-up as at February 2021 were used for the analysis of outcomes. Based on the results of a previous study by Yano et al reporting the improvement of the self-administered foot evaluation questionnaire (SAFE-Q) score by joint-preserving forefoot arthroplasty in patients with RA [16], a sample size estimation for detecting a significant difference in the SAFE-Q score by operative procedures was done, assuming a standard deviation of 20 and a difference of 20, with a desired power of 0.80 and an α level of 0.05. The required sample size was estimated as 34, and 36 feet in the present study was considered enough to research the clinical outcomes.…”

Combination of Modified Scarf Osteotomy and Metatarsal Shortening Offset Osteotomy for Rheumatoid Forefoot Deformity

“…Furthermore, as limitations, investigations in longer periods with a more increased number should also be done, because RA is a chronic and progressive disease. However, we believe that the combined surgery is one of the novel surgical procedures for rheumatoid forefoot deformity, as well as other novel combined joint-preserving forefoot surgeries [ 6 , 11 , 12 ] ( Table 8 ).…”

“…We have been choosing the combination surgery of modified scarf osteotomy for the correction of hallux alignment [ 1 , 2 , 3 ] and metatarsal shortening offset osteotomy for the reduction of dislocated/subluxated metatarsophalangeal (MTP) joints in lesser toes [ 2 , 4 ]. These procedures were reported to be useful for the reconstruction of rheumatoid forefoot deformity, as well as other joint-preserving surgical procedures [ 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 ]. In this study, responses to a self-administered foot evaluation questionnaire (SAFE-Q) were also included to evaluate the combination surgery, and risk factors for recurrence of hallux valgus (HV) deformity and lesser toe MTP joint subluxation were also investigated.…”