Resection Arthroplasty for Rheumatoid Forefoot Deformity -A 5-year Follow-up Study - Hiroyuki HATTORI, et al. Department of Orthopedic Surgery, Tokyo
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1 Resection Arthroplasty for Rheumatoid Forefoot Deformity -A 5-year Follow-up Study - Hiroyuki HATTORI, et al. Department of Orthopedic Surgery, Tokyo Metropolitan Ohtsuka Hospital Abstract The results of resection arthroplasty for forefoot deformity with rheumatoid arthritis (RA) in 22 feet of 14 patients, after follow-up of more than 5 years, were evaluated clinically and radiologically. Recurrence of callosities or toe deformities had occurred in 31.8% of feet. These complications were associated with the lack of length of the resected lesser metatarsal heads, especially the second. This study analyzed radiographic changes of the hallux valgus angle (HVA) and two intermetatarsal angles, one between the first and second (M1M2) and the other between the first and fifth (M1M5). They were measured before the surgery, 3 weeks and 6 months after the surgery, and at the last follow-up at more than 5 years. The average HVA significantly decreased from 40.6 preoperatively to 9.41 postoperati vely and increased again to 21.1 at 6 months after surgery. However, no deterioration of HVA was detected from 6 months after the surgery to the last follow-up at more than 5 years. The average M1M2 and M1M5 angles also decreased significantly postoperatively (from 13.1 to 11.5 and from 34.3 to 28.4, respectively), and increased again at 6 months after the surgery (13.2 and 32.1, respectively). Again no deterioration of M1M2 and M1M5 angles was detected from 6 months after the surgery to the last follow-up at more than 5 years. In the present study, forefoot resection arthroplasty was a stable procedure for the patient with RA in the long term. The authors have recognized problems with recurrence of callosities or toe deformities associated with poor alignment and length of the resected lesser metatarsal heads, and especially resection of the first and second metatarsal heads should be done with skepticism and caution. Key words : rheumatoid arthritis, forefoot deformity, resection arthroplasty
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5 21 MTP関 節 の 脱 臼 を 認 め,扁 し て い る(図3a) 平 三角 状 変 形 を呈 術 後 のX線 趾 の 骨 切 除 量 も 十 分 で 第2か 線 像 で そ の 後 の 増 悪 は 認 め ず,胼 ら第5中 胝,足 足 骨 の遠 症 例2:63歳,女 性,Class2,Stage II 位 端 は 緩 や か な カ ー ブ を 描 く よ う に 切 除 さ れ, バ ラ ンス も良 好 で あ る(図3b) 術 後6ヵ 月 第2,3,4趾 のX線 な 開 張 足 変 形 を 呈 し て い る(図4a) 術 前 のX線 像 で は 軽 度 の外 反 母 趾 角 の 増 悪 を 認 め る が(図3c),7年 経 過 した 最 終 経 過 観 察 時 のX 図3症 趾 変 形 の 再 発 も無 い(図3d) 像 で は 外 側4 X線 例1X線 像 で 外 反 母 趾 は 認 め な い も の の, でMTP関 像 で は 外 側4趾 像 節 の 脱 臼 を 認 め,著 明 術 後 の の 骨 切 除 量 は 不 卜分 で バ ラ
6 22 ン ス も悪 い(図4b) 2,3趾 術 後5年 のX線 像 で第 の 基 節 骨 と 中 足 骨 は癒 合 し(図4c), 同 部 で の 有 痛 性 胼 胝 を 生 じた た め,中 足骨 の 再 切 除 を 施 行 した(図4d) 種 々 の 手 術 法 が 報 告 さ れ て い る が,進 い(足 底 ま た は 足 背),胼 り術 の 違 い(中 入法 の違 胝 切 除 の 有 無,骨 足 骨 の み,基 切 節 骨 と 中 足 骨), 仮 固 定 の 有 無 の 違 い で あ り,術 後 成績 に は大 き な 違 い は 無 い よ う で あ る2.4,9,12) こ れ ら種 々 の 考 察 切 除 関 節 形 成 術 の 報 告 は い ず れ も患 者 の 満 足 度 RAの 前 足 部 障 害 に 対 す る 切 除 関 節 形 成 術 は 図4症 が 中 心 で あ り,X線 例2X線 像 評 価 も術 前,術 後,最 終 経
7 1523, ) Coughlin, M. J.: Rheumatoid forefoot reconstruction. A long-term follow-up study. J. Bone Joint Surg., 82-1) Clayton, M. L.: Surgery of the forefoot in rheumatoid arthritis. Clin. Orthop.,16: , ) Clayton, M. L.: Surgery of the low extremity in rheu matoid arthritis. J. Bone Joint Surg., 54-A:1517- A: ,2000.
8 24 4) Fowler, A. W.: A method of forefoot reconstruction. J. Bone Joint Surg., 70-B: , ) Fuhrmann, R. A., Anders, J. O.: The long-term results of resection arthroplasties of the first metatarsophalangeal joint in rheumatoid arthritis. Int. Orthop., 25: , ) Hamalainen, M., Raunio, P.: Long-term follow up of rheumatoid forefoot surgery. Clin. Orthop., 340:34-38, ) Hohmann, P.: An operation for severe grades of con tracted or clawed toes. Am. J. Orthop Surg., 9: , ) Kates, A., Kessel, L., Kay, A.: Arthroplasty of the forefoot. J. Bone Joint Surg., 49-B: , ) Moeckel, B. H., Sculoco, T. P., Alexiades, M. M., et al.: The double-stemmed silicone-rubber implant for rheu matoid arthritis of the first metatarsophalangeal joint. Long-term results. J. Bone Joint Surg., 74-A: , ) Patsalis, T., Georgousis, H., Gopfort, S.: Long-term results of forefoot arthroplasty in patients with rheu matoid arthritis. Orthopedics, 19: , ) Tillmann, K.: Surgery of the rheumatoid forefoot with special reference to the plantar approach. Clin. Orthop., 340:39-47, ) Vainio, K.: The rheumatoid foot. A clinical study with pathological and rheumatological comments. Ann. Chir. Gynaecol. Fenn., 45 (Suppll) :1-107, ) van der Heijiden, K.W., Rasker, J.J., Jacobs, J. W., et al.: Kates forefoot arthroplasty in rheumatoid arthri tis. A 5-year follow up study. J. Rheumatol., 19: ,1992.
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