Modified Scarf Osteotomy with Medial Capsule

765 C OPYRIGHT Ó 2018

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T HE J OURNAL

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B ONE

AND J OINT

S URGERY, I NCORPORATED

A commentary by Michael S. Aronow, MD, is linked to the online version of this article at jbjs.org.

Modified Scarf Osteotomy with Medial Capsule Interposition for Hallux Valgus in Rheumatoid Arthritis Downloaded from https://journals.lww.com/jbjsjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3be73+7zLk/Sq+y6koaZl6Ep8oGuop87+8AoBvh7J400mYizg71tReg== on 05/02/2018

A Study of Cases Including Severe First Metatarsophalangeal Joint Destruction Junichi Kushioka, MD, Makoto Hirao, MD, PhD, Hideki Tsuboi, MD, PhD, Kosuke Ebina, MD, PhD, Takaaki Noguchi, MD, PhD, Akihide Nampei, MD, PhD, Shigeyoshi Tsuji, MD, PhD, Shosuke Akita, MD, PhD, Jun Hashimoto, MD, PhD, and Hideki Yoshikawa, MD, PhD Investigation performed at the Osaka University Graduate School of Medicine, Suita, and the National Hospital Organization, Osaka Minami Medical Center, Osaka, Japan

Background: Arthrodesis of the first metatarsophalangeal (MTP) joint has been recommended for severe hallux valgus deformity in patients with rheumatoid arthritis (RA). However, with the progress of medical treatment of RA, joint preservation surgery has recently been performed. The aim of this study was to investigate the clinical and radiographic outcomes of modified Scarf osteotomy with medial capsule interposition for RA cases including severe destruction of the first MTP joint and to evaluate risk factors for recurrence. Methods: A retrospective observational study of 76 cases (60 patients) followed for a mean of 35.3 months (range, 24 to 56 months) after a modified Scarf osteotomy was performed. Scores on the Japanese Society for Surgery of the Foot (JSSF) RA foot and ankle scale, the JSSF hallux scale, and a self-administered foot evaluation questionnaire (SAFE-Q) were determined along with preoperative and postoperative radiographic parameters. Results: There was a significant improvement, from preoperatively to final follow-up, in the mean JSSF RA foot and ankle score (from 52.2 to 76.9 points) and the mean JSSF hallux score (from 38.2 to 74.5 points). There was a recurrence (hallux valgus angle [HVA] of >20°) in 12 feet (16%). The preoperative DAS28-CRP score (disease activity score [based on 28 joints in the body]-C-reactive protein score) and intermetatarsal angles between the first and second metatarsals (M1M2A) and between the first and fifth metatarsals (M1M5A) were significantly greater in the recurrence group, as were the HVA, M1M2A, M1M5A, and Hardy grade at 3 months after surgery. There was a significant negative correlation between the preoperative DAS28-CRP score and the JSSF RA foot and ankle score at final follow-up (b = 20.39, p = 0.02) and a significant positive correlation between the preoperative DAS28-CRP score and the HVA at final follow-up (b = 0.44, p = 0.001). Conclusions: The modified Scarf osteotomy with medial capsule interposition for hallux valgus deformity improved clinical and radiographic outcomes in RA cases with severe destruction of the first MTP joint. Increased preoperative M1M2A and M1M5A; incomplete reduction of the sesamoid bone; and the HVA, M1M2A, and M1M5A at 3 months after surgery should be evaluated as they are associated with recurrence of the deformity. The preoperative DAS28-CRP score was associated with the clinical and radiographic outcomes after surgery. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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lthough medical treatment for rheumatoid arthritis (RA) has progressed with the introduction of methotrexate and/or biologics, progressive severe foot deformity and destruction still occur. Forefoot deformity,

including hallux valgus, is one of the most frequent disorders in patients with RA. Furthermore, hallux valgus deformity in RA cases is often associated with severe destruction of the first metatarsophalangeal (MTP) joint. Because of the joint

Disclosure: There was no external funding source for this study. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/E714).

J Bone Joint Surg Am. 2018;100:765-76

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http://dx.doi.org/10.2106/JBJS.17.00436

766 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O LU M E 100 -A N U M B E R 9 M AY 2, 2 018 d

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MODIFIED SCARF OSTEOTOMY WITH MEDIAL CAPSULE I N T E R P O S I T I O N F O R H A L LU X VA L G U S I N R H E U M AT O I D A R T H R I T I S

TABLE I Characteristics of Patients with RA and Hallux Valgus Deformity (N = 60) Characteristic Age* (yr) Male:female (no.)

64.3 ± 9.4 (45-85) 2:58

Disease duration* (yr)

22.7 ± 10.8 (4-47)

Follow-up period* (mo)

35.3 ± 10.7 (24-56)

Steinbrocker stage (I, II, III, IV) (%) Steinbrocker class (I, II, III, IV) (%) Preoperative HVA* (°) Larsen grade of first MTP joint (0, 1, 2, 3, 4, 5) (%)

0, 5, 15, 80 5, 90, 5, 0 50.8 ± 12.5 7, 14, 24, 21, 17, 17

Methotrexate usage (%)

70

Biologics usage (%)

40

Biologics† (no.) Prednisolone dosage* (mg/day)

TCZ: 11, IFX: 4, ETN: 3, ADA: 3, GLM: 1, ABT: 2 2.0 ± 2.3 (0-10)

*The data are presented as the mean and SD with the range in parentheses. †TCZ = tocilizumab, IFX = infliximab, ETN = etanercept, ADA = adalimumab, GLM = golimumab, and ABT = abatacept.

Fig. 1

Figs. 1-A through 1-E The modified Scarf osteotomy. Fig. 1-A The osteotomy is parallel to the sole of the foot and extends from 10 mm distal to the first tarsometatarsal joint to 10 mm proximal to the first MTP joint. Fig. 1-B Distal and proximal bone fragments are partially resected by amounts measured preoperatively. Fig. 1-C The amount of bone resection was calculated using a preoperative foot radiograph made with the patient standing. The maximum length of overlapping between the first metatarsal bone and the basal phalanx bone in the longitudinal direction of the first metatarsal bone (between the arrows) was defined as the amount to be resected. To avoid making the second metatarsal head shorter than the newly formed first metatarsal head (dotted line), enough length was resected from the metatarsal shafts of the lesser toes to clear the overlapping of the lesser-toe MTP joints (each of the longitudinal white lines), as described previously10. Fig. 1-D The flap of capsule and soft tissue is interposed into the newly formed first MTP joint and then sutured to the lateral wall of the capsule. Fig. 1-E Closure of the medial aspect of the capsule consists of suturing between soft tissues except for a 10-mm-wide flap of the capsule (arrows), after the flap was interposed into the newly formed first MTP joint.


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Fig. 2

Figs. 2-A and 2-B Two representative cases of mild destruction of the first MTP joint (Larsen grades 0 to 3) that were treated with a modified Scarf osteotomy. 1 = preoperative radiograph of the foot in the standing position (weight-bearing), 2 = postoperative radiograph of the foot made immediately after the forefoot surgery, and 3 = postoperative radiograph of the foot in the standing position made 2 years after the forefoot surgery. Fig. 2-A A foot with a preoperative HVA of 40° and a Larsen grade-3 first MTP joint. Fig. 2-B A foot with a preoperative HVA of 45° and a Larsen grade-3 first MTP joint.

destruction, resection arthroplasty, arthrodesis, or artificial joint replacement surgery has been recommended for RA hallux valgus surgery. However, complications such as recurrence of hallux valgus, pseudarthrosis, interphalangeal joint arthritis, breakage of implants, and bone absorption have been reported with each procedure1. Some of these problems might be avoided with conventional joint-preserving hallux valgus surgery. Several studies of joint-preserving surgery for forefoot deformity have shown good clinical results2-8 in patients with tightly controlled RA. The Scarf procedure is one of the joint-preserving hallux valgus surgical interventions recommended for the correction of moderate-tosevere hallux valgus deformity4. Tanaka recommended a modification of the Scarf procedure using a horizontal osteotomy9. He changed the osteotomy orientation to be parallel to the sole of the

foot. Since 2011, we have used this procedure with further modification (medial capsule interposition) as a modified Scarf osteotomy for hallux valgus deformity even in RA cases with severe destruction of the first MTP joint. The aim of the present study was to investigate the clinical and radiographic outcomes of the osteotomy for RA cases including those with severe first MTP joint destruction and to evaluate factors associated with recurrence of the hallux valgus deformity. Materials and Methods Study Design and Patient Population retrospective observational study of 108 feet in 89 patients who underwent a modified Scarf osteotomy for treatment of hallux valgus deformity with or without painful

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Fig. 3

Figs. 3-A and 3-B Two representative cases of severe destruction of the first MTP joint (Larsen grades 4 and 5) that that were treated with a modified Scarf osteotomy. 1 = preoperative radiograph of the foot in the standing position (weight-bearing), 2 = postoperative radiograph of the foot made immediately after the forefoot surgery, and 3 = postoperative radiograph of the foot in the standing position made 2 years after the forefoot surgery. Fig. 3-A A foot with a preoperative HVA of 52° and a Larsen grade-5 first MTP joint. Fig. 3-B A foot with a preoperative HVA of 47° and a Larsen grade-5 first MTP joint. The white triangles indicate the site of an Akin osteotomy in the proximal phalanx. The Akin osteotomy site was fixed with absorbable thread.

lesser-toe MTP joint deformities (callosities) from April 2011 to October 2014 was performed. All patients had symptomatic moderate-to-severe hallux valgus deformity (a hallux valgus angle [HVA] of ‡25° with subluxation of the first MTP joint and/or an infectious skin ulcer). Nonoperative treatment, including modification of shoe wear, nonsteroidal anti-inflammatory medications, or arch supports, had failed. Surgeons experienced with the modified Scarf osteotomy performed all procedures. Patients who had undergone previous foot and ankle surgery were excluded. The inclusion criteria were (1) previously diagnosed RA and medications prescribed for that condition; (2) a minimum follow-up duration of 2 years; and (3) availability of dorsoplantar weight-bearing radiographs of the feet that had been made

preoperatively, at 3 months after the surgery, and at the time of the final follow-up. Seventy-six feet (60 patients) met the inclusion criteria. All of the patients were treated with disease-modifying antirheumatic drugs (DMARDs) including methotrexate and/or biologics for the tight control of RA disease activity10. The patients’ characteristics are shown in Table I. Surgical Technique A longitudinal dorsal incision (2 cm) was made between the first and second metatarsals. The adductor hallucis tendon was dissected from the base of the proximal phalanx. The transverse metatarsal ligament was then released, and the capsule between the first metatarsal and the lateral sesamoid

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patients with RA and symptomatic moderate-to-severe hallux valgus deformity, including those with a Larsen grade-0 or 1 first MTP joint (no or almost no erosion), underwent the procedure. As shown in Figure 1-E, the medial capsule was sutured after some shrinkage due to the interposition of the 10-mm-wide flap into the first MTP joint, with the expectation of producing the force needed for varus direction of the hallux. The adductor hallucis tendon was resutured to the capsule and soft tissue of the lateral side of the newly formed first metatarsal head. A modified metatarsal shortening offset osteotomy11 was performed in the feet that required surgical intervention for the lesser toes (Fig. 1-C). Of the 76 feet, 63 underwent a concomitant modified metatarsal shortening offset osteotomy (Figs. 2-A-2, 2-B-2, 3-A-2, and 3-B-2) and 3 underwent a concomitant Akin osteotomy12 (representative case shown in Fig. 3-B). The Akin osteotomy was performed if the first toe touched and pushed the second toe when the opened medial capsule was pinched by Kocher forceps. Range-of-motion exercises for the first MTP joint were started the day after the operation, and full weight-bearing was allowed 2 weeks postoperatively, after fitting for an arch support.

TABLE II Disease Activity and Markers of RA Mean ± SD Preoperative

Final Follow-up

P Value*

DAS28-CRP

3.0 ± 1.0

2.7 ± 0.9

0.62

CRP (mg/dL)

0.6 ± 0.9

0.5 ± 0.6

0.25

MMP3 (ng/mL)

94 ± 73

95 ± 63

0.64

*Wilcoxon signed-rank test.

was split longitudinally from the proximal phalanx to the middle of the first metatarsal shaft. Next, a longitudinal incision was made in the medial aspect of the first metatarsal, and the capsule of the first MTP joint was opened with a 10mm-wide flap. The medial eminence was excised minimally to preserve the distal articular surface of the first metatarsal head. The osteotomy was parallel to the sole of the foot from 10 mm distal to the first tarsometatarsal joint to 10 mm proximal to the first MTP joint (Fig. 1-A). Distal and proximal bone fragments were partially resected (Fig. 1-B), with the amount of resection equal to the length of overlap between the first metatarsal bone and the basal phalanx bone in the longitudinal direction as measured on a preoperative foot radiograph made in the standing position (Fig. 1-C). To avoid making the second metatarsal bone shorter than the first, we resected enough length from the lesser-toe metatarsal shafts to clear the overlapping of the lesser-toe MTP joints. The distal bone fragment was shifted laterally and fixed with AcuTwist screws (Acumed). Next, the flap of capsule and soft tissue was interposed into the newly formed first MTP joint and then sutured to the lateral wall of the capsule in all cases (Fig. 1-D). Because RA is a chronic and progressive disease, all

Clinical Assessment For the clinical assessment, preoperative and postoperative scores were obtained using both the RA foot and ankle scale12 and the hallux scale13 of the Japanese Society for Surgery of the Foot (JSSF) standard rating system13,14. Furthermore, patients completed a postoperative self-administered foot evaluation questionnaire (SAFE-Q)15 at the final follow-up. RA disease activity was evaluated using the DAS28-CRP score (disease activity score [based on 28 joints in the body]-Creactive protein score)16, CRP level (a marker of inflammation), and matrix metalloproteinase-3 (MMP3) (a marker of

TABLE III JSSF Scores Mean ± SD (Median ± IQR) Preoperative

Final Follow-up

P Value*

JSSF RA foot and ankle score General pain (30 points)

23.5 ± 5.6 (20 ± 10)

29.6 ± 1.9 (30 ± 0)