Dramatic improvements in medical treatment of rheumatoid arthritis (RA) have led to marked reductions in joint damage and deformities. Consequently, surgical methods for treating RA-related foot problems have gradually evolved from joint-sacrificing to joint-preserving procedures. In a recent issue of The Journal of Bone & Joint Surgery, Yano et al. reported on outcomes of 105 feet in RA patients treated with joint-preserving methods followed up for a mean of 6 years.
What the Researchers Did:
- Performed a proximal rotational closing-wedge osteotomy of the first metatarsal and modified shortening oblique osteotomies of the lesser metatarsals
- Recorded Self-Administered Foot Evaluation Questionnaire (SAFE-Q) scores preoperatively and at latest follow-up
- Measured hallux valgus angle (HVA), intermetatarsal angle (IMA), and medial sesamoid position before surgery, 3 months after surgery, and at the latest follow-up
- Tracked delayed wound healing, hallux valgus recurrence, nonunion, and reoperations
- Calculated Kaplan-Meier survivorship with reoperation as the endpoint
What the Researchers Found:
- Surgery was associated with significantly improved median SAFE-Q scores, relative to preoperative values.
- The average HVA, IMA, and grade of medial sesamoid positioning decreased significantly, compared with preoperative measurements.
- Kaplan-Meier survivorship at 7 years was 89.5%.
- Delayed wound healing was found in 20% of the feet (all wounds healed with nonoperative treatment), hallux valgus recurrence in 10.5% of the feet, and reoperation in 10.5% of the feet.
Yano et al. emphasize several advantages of joint-sparing over joint-sacrificing surgery: preserved range of motion, stability of the metatarsophalangeal joint, and improved plantar-pressure distribution. However, these advantages and the “satisfactory” long-term outcomes noted above come with substantial complications that foot-and-ankle surgeons will strive to address in the future.
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Shahriar Rahman, MS, in response to a recent study in Foot and Ankle Clinics of North America.
It makes sense that orthopaedic conditions with multiple etiologic factors have a corresponding variety of treatment options. So it is with hallux valgus (bunion deformity). In the June 2018 edition of Foot and Ankle Clinics of North America, Smyth and Aiyer1 focus on the pathoanatomy of hallux valgus and various approaches to selecting an operative option.
With more than 100 different operative procedures described to correct hallux valgus, it can be challenging to pick the “right” procedure for each patient. The etiology of hallux valgus includes intrinsic factors (e.g., a long first metatarsal, the shape of the metatarsal head, and soft-tissue imbalances across the hallux metatarsophalangeal [MP] joint) and extrinsic factors (e.g., high-heeled, narrow toe-box shoes). Other kinematic factors of the foot, such as hypermobility of the first ray, are associated with hallux valgus, as is pes planus (flatfoot). Whatever the etiology, hallux valgus almost always progresses in a relatively predictable manner.1
Careful preoperative analysis is required to successfully treat hallux valgus, with the goal of restoring static and dynamic balance around the first MP joint. For optimum outcomes, a soft-tissue procedure (e.g., modified McBride procedure) is now commonly combined with osseous corrective techniques. The chevron osteotomy, which has been modified in multiple ways, achieves acceptable outcomes with reportedly high patient satisfaction levels, as does a percutaneous distal metatarsal osteotomy.2
More severe deformities are usually treated with proximal first metatarsal osteotomies—such as a proximal chevron, Ludloff osteotomy, or Scarf osteotomy—to increase the possible angular correction of the metatarsal. While these procedures are more “powerful” correction options, some studies have shown recurrence rates up to 30% at 10 years of follow up.1,2 In cases of severe deformity accompanied by arthritis of the tarsometatarsal (TM) joint, a modified Lapidus procedure may be an option for stabilizing the first TM joint. Hallux MP arthrodesis is also considered in patients who have severe deformity, arthritis, and neuromuscular disorders, and for the revision of a previously failed hallux valgus surgery.
There is currently no consensus as to which procedure is the gold standard for treating hallux valgus. Despite multiple comparative studies assessing the outcomes of different techniques, the decision ultimately depends on surgeon and patient preferences.
Shahriar Rahman, MS is a consultant orthopaedic surgeon at the Ministry of Health & Family Welfare in Bangladesh and a member of the JBJS Social Media Advisory Board.
- Smyth NA & Aiyer AA 2018, ‘Introduction: Why Are There so Many Different Surgeries for Hallux Valgus?’, Foot and Ankle Clinics, 23, no.2, pp.171-182.
- Adams SB, 2017, JBJS Clinical Summary: Hallux Valgus (Bunion Deformity), viewed 27 may 2018, https://jbjs.org/summary.php?id=188
Related Articles from JBJS Essential Surgical Techniques
- Hallux Valgus Correction With Bunionectomy, Lateral Release, And Proximal Opening Wedge Osteotomy Using Wedge-plate Fixation
- Lateral Soft-tissue Release With Medial Transarticular Or Dorsal First Web-space Approach Combined With Distal Chevron Osteotomy For Moderate-to-severe Hallux Valgus
- Treatment Of Advanced Stages Of Hallux Rigidus With Cheilectomy And Proximal Phalangeal Osteotomy
- Arthrodesis Of The Hallux Metatarsophalangeal Joint
It is well accepted that kids with Legg-Calve-Perthes (LCP) disease do best when their condition is diagnosed and managed before 6 years of age. Surgical treatment is often recommended for children 6 years and older who have more severe femoral-head involvement, and orthopaedists perform combined pelvic and femoral varus osteotomies on some of those children.
In the February 1, 2107 edition of The Journal, Mosow et al. compare 10-year outcomes in 52 LCP patients who underwent combined osteotomies (mean age at surgery of 7.9 years) with results reported in the literature for single pelvic or femoral osteotomies. Although the postoperative radiographic and functional results after combined osteotomy were good, they were overall no better than those reported in the literature for either osteotomy alone.
The authors admit that in the absence of a randomized study design, these findings should be interpreted with caution, but they conclude that “it is not recommended that combined osteotomies for this age group routinely be used.”
Ulnar shortening osteotomy is a widely accepted procedure for surgical treatment of ulnar impaction syndrome, but many techniques require special instrumentation to achieve accurate shortening, adequate fixation, and sufficient rotational control. In the November 2, 2016 issue of The Journal of Bone & Joint Surgery, Papatheodorou et al. report on outcomes in 164 patients who underwent so-called “step-cut” osteotomies for positive ulnar variances that ranged from +1 to +6 mm.
The technique itself, which utilizes a standard neutralization plate and lag screw for fixation, is summarized and illustrated in the article. The authors emphasize that the step-cut approach does not require special jigs or instrumentation.
Patients were followed for a median of 66 months. The overall union rate was 98.8%; postoperative ulnar variance ranged from –1 to +1.5 mm after a mean overall ulnar shortening of 2.5 mm. All patients had significant postoperative improvements in pain, range of motion, grip strength, and Mayo Modified Wrist Score. Plate removal due to irritation was necessary in only 12 (7.3%) of the patients.
The authors also found in these patients “a lower rate of degenerative changes at the distal radioulnar joint compared with rates reported in previous studies.” They attribute this to the relatively small amount of ulnar shortening with the step-cut procedure, which they surmise “diminishes the rate of articular incongruity and hence arthritis of the distal radioulnar joint.” On the cost side of the matter, the authors noted that at their institution, special ulnar osteotomy systems cost almost 10 times more than a standard neutralization plate.
The article, “Guiding Femoral Rotational Growth in an Animal Model” by Arami, et al. is an intriguing variation on the common applications of guided growth in pediatric patients. Implants that bridge the physis to inhibit growth in a given anatomic location are widely used to correct angular deformity or leg-length differences in the growing child and to decrease the need for a more invasive corrective osteotomy.
At present, correction of rotational deformity in the pediatric femur or tibia requires a derotational osteotomy and commonly six weeks of casting postoperatively. This study in rabbits demonstrates the ability of implants to alter the rotational profile in the growing femur by bridging the physis in an oblique orientation, rather than in a vertical orientation used for angular deformity correction.
The authors have elegantly demonstrated histologically the swirling or bending appearance of the physeal columns in treated femora, while controls maintained the normal linear columnar appearance of the physis. This interesting and unique animal study lays the foundation for consideration of using oblique placement of physeal-bridging implants to guide rotational growth in skeletally immature patients, without the need for osteotomy.