SLR - March 2021 - Priya Patel

Patient-Reported and Radiographic Outcomes of Joint-Preserving Surgery for Rheumatoid Forefoot Deformities: A Retrospective Case Series with Mean Follow-up of 6 Years

Reference: Yano K, Ikari K, Tobimatsu H, Okazaki K. Patient-Reported and Radiographic Outcomes of Joint-Preserving Surgery for Rheumatoid Forefoot Deformities: A Retrospective Case Series with Mean Follow-up of 6 Years. J Bone Joint Surg Am. 2021 Jan 20. doi: 10.2106/JBJS.20.01144. 

Level of Evidence:

Scientific Literature Review 

Reviewed By: Priya Patel, DPM
Residency Program: Inspira Medical Center – Vineland, NJ

Podiatric Relevance: Many of our patients have rheumatoid arthritis (RA), a chronic inflammatory disorder that can affect joints and create forefoot deformities. Interestingly, advances in RA therapy have reduced the progression of joint destruction, decreasing the need for joint-sacrificing surgeries to correct deformities. The authors investigated long-term outcomes of joint-preserving surgery (proximal rotational closing-wedge osteotomy of the first metatarsal and modified shortening oblique osteotomies of the lesser metatarsals) for RA forefoot deformities.

Methods: This is a retrospective study of 105 feet from 89 patients with RA who received joint-preserving surgery from January 2012 to May 2015 with a minimum five year follow-up period. Inclusion criteria were patients with symptomatic RA forefoot deformity without previous surgical intervention who failed conservative therapy. Self-Administered Foot Evaluation Questionnaire (SAFE-Q) was completed before surgery and at latest follow-up. HVA, IMA, and medial sesamoid position were measured pre-operatively, three months post-operatively, and at latest follow-up. Complications were also assessed. Kaplan-Meier survival curves were used to determine survivorship with re-operation as the primary endpoint.

Results: Estimated survivorship of this joint-preserving surgery at seven years is 89.5 percent with reoperation needed in 10.5 percent of feet. Significant improvement was noted in the SAFE-Q scores at the latest follow-up. HVA, IMA values from three months postoperatively and at latest follow-up were significantly decreased from preoperative measurements. Medial sesamoid position also significantly improved post-operatively. Complications included delayed wound healing of surgical site (20 percent), recurrence of hallux valgus (10.5 percent), hallux varus deformity (3.8 percent), recurrent lesser MPJ dislocation (7.7 percent), and callosities (17 percent).

Conclusions: The authors concluded that joint-preserving surgery for RA forefoot deformities yields favorable long-term patient-reported and radiographic outcomes. It is difficult to assess reproducibility of results given the retrospective nature of this study that was performed at only one institution. To the authors’ credit, this is the largest series evaluating multiple outcomes of joint-preserving surgery for RA forefoot deformities. The authors point out re-operation rates for joint-sacrificing surgeries are 9-30 percent, which is higher than the 10.5 percent re-operation rate they reported for joint-preserving surgery. Other studies of joint-preserving surgery report re-operation rates 2.5-16.2 percent. Considering the results of this study and similar studies combined with the decreased joint destruction noted with advances in RA therapy, joint-preserving surgery may be an effective treatment option for RA forefoot deformities.

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