Article

Long-term results of the modified Hoffman procedure in the rheumatoid forefoot

Department of Trauma and Orthopaedics, Ninewells Hospital, Dundee DD1 9SY, United Kingdom.
The Journal of Bone and Joint Surgery (Impact Factor: 4.31). 05/2005; 87(4):748-52. DOI: 10.2106/JBJS.C.01696
Source: PubMed

ABSTRACT Rheumatoid arthritis commonly affects the forefoot, causing metatarsalgia, hallux valgus, and deformities of the lesser toes. Various types of surgical correction have been described, including resection of the lesser-toe metatarsal heads coupled with arthrodesis of the great toe, resection arthroplasty of the proximal phalanx or metatarsal head, and metatarsal osteotomy. We report the results at an average of five and a half years following thirty-seven consecutive forefoot arthroplasties performed in twenty patients by one surgeon using a technique involving resection of all five metatarsal heads.
All patients were treated with the same technique of resection of all five metatarsal heads through three dorsal incisions. All surviving patients were asked to return for follow-up, which included subjective assessment (with use of visual analogue pain scores, AOFAS [American Orthopaedic Foot and Ankle Society] foot scores, and SF-12 [Short Form-12] mental and physical disability scores), physical examination, and radiographic evaluation.
All results were satisfactory to excellent in the short term (six weeks postoperatively), and no patient sought additional surgical treatment for the feet. A superficial infection subsequently developed in two feet, and two feet had delayed wound-healing. At an average of 64.9 months postoperatively, the average AOFAS forefoot score was 64.5 points and the average hallux valgus angle was 22.3 degrees . There were no reoperations.
Resection of all five metatarsal heads in patients with metatarsalgia and hallux valgus associated with rheumatoid arthritis can be a safe procedure that provides reasonable, if rarely complete, relief of symptoms.

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    ABSTRACT: Für die Behandlung des rheumatischen Vorfußes hat sich die operative Metatarsalköpfchenresektion etabliert. Die rekurrierende Lateraldeviation der Kleinzehen und schmerzhafte Plantarkeratosen stellen jedoch weiterhin eine Herausforderung bei der Behandlung dieser Patienten dar.Das Ziel dieser Arbeit ist es, herauszufinden, ob die Kombination der Metatarsalköpfchenresektion 2–4 mit einer Arthrodese des Hallux und einer Resektion der Schwielen über einen plantaren Zugang zu einem guten Ergebnis bei Patienten mit rheumatischen Vorfußveränderungen führt.15 Patienten (20 Füße) wurden klinisch und radiologisch mithilfe des AOFAS-, Miehlke- und Larsen-Scores nachuntersucht.Der Follow-up lag bei 3,5 (1,5–7,5) Jahren. Der Hallux wurde nach dem AOFAS-Score mit durchschnittlich 81/90 Punkten, die Kleinzehen mit 90/100 Punkten bewertet. Schmerzfreiheit wurde bei 18 Füßen und geringe Schmerzen bei 2 Füßen angegeben. 14 Füße (70%) wurden im Miehlke-Score als sehr zufrieden stellend beurteilt. Bei allen unseren Patienten zeigte sich eine harmonische Resektionskaskade. Alle Patienten gaben an, die Operation habe ihre Lebensqualität verbessert und sie würden die Operation noch einmal durchführen lassen.Unser Patientenkollektiv liegt nach Großzehengrundgelenkarthrodese, in Kombination mit einer Metatarsalköpfchenresektion der Zehen 2–5 über einen plantaren Zugang, in einem guten Vergleichsstand gegenüber den in der Literatur beschriebenen Ergebnissen.
    Der Orthopäde 01/2007; 36(5). · 0.67 Impact Factor
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    ABSTRACT: Objective: to evaluate the long-term results from reconstruction of the forefoot in patients with rheumatoid arthritis who underwent arthrodesis of the metatarsophalangeal joint of the hallux, resection arthroplasty of the heads of the lateral metatarsals and correction of the deformities of the smaller toes through arthrodesis on the proximal interphalangeal joint or closed manipulation.Methods: seventeen patients (27 feet) who underwent forefoot reconstruction surgery by means of arthrodesis of the first metatarsophalangeal joint, resection of the heads of the lateral metatarsals and correction of the deformities of the smaller toes,were studied retrospectively. The mean follow-upwas 68 months (12 to 148 months); the mean agewas 52 years (range: 20 to 75 months); and four patients were male and 13 were female. Results: the results were classified as excellent in 17 feet, good in two, fair in four and poor in two. The mean score on the AOFAS scale was 70 points; 21 feet (78%) were found to be asymptomatic; and six feet (22%) presented some type of symptom. Three feet presented pseudarthrosis, and one of these successfully underwent revision of the arthrodesis. There was no significant difference in scoring on the AOFAS scale or in the consolidation rate, between using a plate and screws and using Kirschner wires for fixation of the arthrodesis. Conclusion: arthrodesis on the first metatarsophalangeal joint with resection arthroplasty on the heads of the lateral metatarsals and correction of the deformities of the smaller toes, which was used in forefoot reconstruction in rheumatoid patients, showed good long-term results with a high satisfaction rate among the patients and clinical-functional improvement.
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