Rev. bras. ortop. vol.49 número2

w w w . r b o . o r g . b r

Original

Article

Clinical

and

functional

evaluation

of

forefoot

reconstruction

in

patients

with

rheumatoid

arthritis

夽

,

夽夽

Marco

Túlio

Costa

_,

_Ricardo

_Cardoso

_Backer,

_Ricardo

_Cardenuto

_Ferreira

DepartmentofOrthopedicsandTraumatology,FernandinhoSimonsenWing,SchoolofMedicalSciences,SantaCasadeSãoPaulo,São Paulo,SP,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received23November2012 Accepted12July2013 Availableonline2April2014

Keywords:

Forefoot,human Rheumatoidarthritis Arthrodesis

a

b

s

t

r

a

c

t

Objective:toevaluatethelong-termresultsfromreconstructionoftheforefootinpatients withrheumatoidarthritiswhounderwentarthrodesisofthemetatarsophalangealjointof thehallux,resectionarthroplastyoftheheadsofthelateralmetatarsalsandcorrectionof thedeformitiesofthesmallertoesthrougharthrodesisoftheproximalinterphalangealjoint orclosedmanipulation.

Methods:seventeenpatients(27feet) whounderwent forefootreconstructionsurgeryby meansofarthrodesisofthefirstmetatarsophalangealjoint,resectionoftheheadsofthe lateralmetatarsalsandcorrectionofthedeformitiesofthesmallertoes,werestudied retro-spectively.Themeanfollow-upwas68months(12–148months);themeanagewas52years (range:20–75months);andfourpatientsweremaleand13werefemale.

Results:theresultswereclassifiedasexcellentin17feet,goodintwo,fairinfourandpoor intwo.ThemeanscoreontheAOFASscalewas70points;21feet(78%)werefoundtobe asymptomatic;andsixfeet(22%)presentedsometypeofsymptom.Threefeetpresented pseudarthrosis,andoneofthesesuccessfullyunderwentrevisionofthearthrodesis.There wasnosignificantdifferenceinscoringontheAOFASscaleorintheconsolidationrate, betweenusingaplateandscrewsandusingKirschnerwiresforfixationofthearthrodesis.

Conclusion: arthrodesisofthefirstmetatarsophalangealjointwithresectionarthroplastyon theheadsofthelateralmetatarsalsandcorrectionofthedeformitiesofthesmallertoes, whichwasusedinforefootreconstructioninrheumatoidpatients,showedgoodlong-term resultswithahighsatisfactionrateamongthepatientsandclinical-functional improve-ment.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

夽_{Pleasecitethisarticleas:CostaMT,BackerRC,FerreiraRC.Avaliac¸ãoclínico-funcionaldareconstruc¸ãodoantepénospacientes}

portadoresdeartritereumatoide.RevBrasOrtop.2014;49:167–173.

夽夽

WorkperformedintheFootandAnkleGroup,DepartmentofOrthopedicsandTraumatology,FernandinhoSimonsenWing,Schoolof MedicalSciences,SantaCasadeSãoPaulo.

∗ _{Correspondingauthor.}

E-mail:[email protected](M.T.Costa).

2255-4971/$–seefrontmatter©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.

Avaliac¸ão

clínico-funcional

da

reconstruc¸ão

do

antepé

nos

pacientes

portadores

de

artrite

reumatoide

Palavras-chave:

Antepéhumano Artritereumatoide Artrodese

r

e

s

u

m

o

Objetivo: avaliarosresultadosemlongoprazodareconstruc¸ãodoantepénospacientes comartritereumatoidesubmetidosàartrodesedaarticulac¸ãometatarsofalângica(MTF)do hálux,artroplastiaderessecc¸ãodascabec¸asdosmetatarsoslateraisecorrec¸ãodas deformi-dadesnosdedosmenorespormeiodeartrodesedaarticulac¸ãointerfalângicaproximal(IFP) oumanipulac¸ãofechada.

Métodos:foramestudadosretrospectivamente17pacientes(27pés)submetidosàcirurgiade reconstruc¸ãodoantepécomartrodesedaprimeiraarticulac¸ãoMTF,ressecc¸ãodascabec¸as dosmetatarsoslateraisecorrec¸ãodasdeformidadesnosdedosmenores.Oseguimento médiofoide68meses(12a148),amédiadeidadefoide52anos(20a75meses)equatro pacienteseramdosexomasculinoe13dofeminino.

Resultados: osresultadosforamclassificadoscomoexcelenteem17pés,bomemdois, reg-ularemquatroeruimemdois.Apontuac¸ãomédiadaescalaAofas(AmericanOrthopaedic FootandAnkleSociety)foide70pontos,21pés(78%)encontravam-seassintomáticose seis(22%)apresentavamalgumtipodesintoma.Trêspésapresentarampseudoartrose.Um delesfoisubmetidoàrevisãodaartrodesecomsucesso.Nãohouvediferenc¸asignificativa napontuac¸ãodaescalaAofasenosíndicesdeconsolidac¸ãocomousodeplacaeparafusos oufiosdeKirschnernafixac¸ãodaartrodese.

Conclusão: a artrodese daprimeira articulac¸ão MTFcomartroplastia deressecc¸ão das cabec¸asdosmetatarsoslateraisecorrec¸ãodasdeformidadesnosdedosmenores,usada nareconstruc¸ãodoantepédospacientesreumatoides,demonstroubonsresultados em longoprazo,comelevadoíndicedesatisfac¸ãodospacientesemelhoriaclínico-funcional.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Rheumatoidarthritisisachronic andprogressivesystemic disease that presents incapacitating manifestations in the musculoskeletalsystemand may affectthe footand ankle in up to 90% of the cases. Half of them are located in the forefoot.1,2 _{The involvement of the forefoot is}

char-acterized by chronic synovitis in the metatarsophalangeal (MTP)joints,capsulardistensionandlossofintegrityofthe collateral ligaments.3 _{Presenceofchronic capsule-ligament}

instability, destruction ofthe joint cartilage and reabsorp-tion of the subchondral bone lead to typical deformities inthe forefoot.Hallux valgusis the commonestcondition in the first ray. The smaller toes typically present in rigid clawform,andwithsubluxationordislocationofthelateral MTPjoints.Progressionofthedeformitiesalsoleadsto dis-tal migrationof the plantarpad and favors appearance of metatarsalpain,ulcerationsandpainfulplantarcalluses,1–3

whichcausedifficultyinwalkingandinusingconventional footwear.

Surgical treatment is indicated when the conserva-tive measures fail to relieve the symptoms, and it has the main objectives of relieving the pain caused by syn-ovitis and joint destruction, correcting the deformities, improving the gait pattern and adapting the feet to shoes.1–3

Historically,avarietyofprocedureshavebeendescribedfor treatingrheumatoidforefeetandtheyhavetypicallyinvolved

correctionofdeformitiesoftheMTPjointofthesmallertoes bymeansofresectionarthroplastyofthemetatarsalheads orthebaseoftheproximalphalanx,orboth.Deformitiesin the smallertoescan becorrected bymeans ofresectionof thedistalportionoftheproximalphalanx,arthrodesisofthe proximal interphalangeal jointor closed manipulation and intramedullaryfixation.Theoptionsforcorrectionofhallux valgusincluderesectionarthroplastyofthemetatarsalhead ortheproximalphalanxofthehallux;jointreplacementusing metallicorsiliconeimplants;andarthrodesisoftheMTPofthe hallux.1–3

Withevolutionofthesurgicaltechniquesandbetter under-standingofthedeformities,arthrodesisoftheMTPjointofthe halluxhasbecomethetreatmentmethodmostusedfor cor-rectingdeformitiesofthefirstray.4–6_{Thisprocedurestabilizes}

theMTPofthehalluxandallowsthistoreceivegreater pres-sureduringgait.Throughthis,actionbydeformingforceson theMTPjointsofthesmallertoesisprevented,therebyhelping towarddiminishingmetatarsalpainandpromotinglong-term resultsthataremoresatisfactory(painrelief,maintenanceof alignmentandpatientsatisfaction).5–9

Sample

and

methods

Seventeenpatients(27feet)withadiagnosisofrheumatoid arthritisandsevereforefootdeformitywereincludedinthis study.These patients underwent reconstructive surgery by meansofthetechniqueofarthrodesisofthefirstMTPjoint ofthehalluxandresectionarthroplastyoftheheadsofthe lateralmetatarsals,performedbytheFootandAnkleGroup ofSanta Casa de Misericórdia de São Paulo, between Jan-uary1998andMarch2010.All ofthesepatientshadsevere halluxvalgusdeformitiesassociatedwithpain,rigid deformi-tiesofthesmallertoesandmetatarsaltransferpainonthe headsofthelateralmetatarsals.Patientswhounderwent sur-gicalcorrectionbymeansofthetechniqueunderexamination butwhosepostoperativefollow-upwaslessthan12months wereexcluded.Themeanslengthoffollow-upwas68months (range:12–148).Fourpatientsweremaleand13werefemale. Themeanageatthetimeofthesurgerywas52years(range: 20–75years).

Severehalluxvalgusassociatedwithincapacitatingpain, rigiddeformitiesofthesmallertoesandmetatarsaltransfer ofpainontheheadsoflateralmetatarsalsledtothesurgical indication,whilepatientswhosepostoperativefollow-upwas lessthan12monthswereexcluded.

Thepatientswereevaluatedbymeansofpersonal inter-views and clinical examinations. They were asked about whether theyhad any painin theirforefeet; whether they wereabletouseconventionalclosedfootwear;andwhattheir degreeofsatisfactionwas,regardingthefinalresultsfromthe surgicalprocedure.Intheclinicalexamination,wenotedthe alignment,thepositionofthefootwhenbearingweightand thepresenceorabsenceofhalluxdeformities.Followingthis, withthepatientsittingontheexaminationtable,we investi-gatedthepresenceofmetatarsalpainandpainatthemedial eminenceofthehallux.Themedicalfileswerereviewedto establishthe preoperativecomplaints,location ofthe pain, severityofthedeformitiesandpresenceofearlyorlate post-operativecomplications.

Radiographicexaminationswereperformedin dorsoplan-tarandlateralviewsontheforefootwithload-bearing.The preoperative radiographs were recovered from the radio-graphicarchivesoftheMedicalandStatisticalFilingService (SAME)ofSantaCasadeMisericórdiadeSãoPaulo.Theimages wereevaluatedwithregardtopresenceorabsenceof consol-idationand thetypeoffixationusedforarthrodesisofthe MTPofthehallux.Thehalluxvalgusangle(HVA),10_i.e.the

angleformedbetweenthelinesthatbisectthediaphysisof theproximalphalanxandthediaphysisofthefirstmetatarsal, andtheanglebetweenthefirstandsecondmetatarsals (inter-metatarsalangleI-II(IMAI-II),10_{i.e.theangleformedbetween}

the linesthat bisect the diaphyses ofthe first and second metatarsals)weremeasured.

Wecompared the fixation method used for arthrodesis of the MTP of the hallux with the radiographic parame-ters obtainedfrom the final radiographsand observed the consolidationratesandangularcorrectionsobtained.We cor-relatedthefixationmethodwiththefunctionalclinicalresults accordingtotheAOFASscale11_{fortheMTPjointofthe}

hal-lux.

TheAOFASfunctionalscale11 _{wasusedtoquantitatively}

measure the postoperativeresults inorder toevaluate the MTPjointofthehallux.Thisscalerangesfrom0to100points andtakesinto considerationitemsrelatingtopain,activity level,deformityandmobility.Wedividedtheresultsintotwo groups:scoreslessthan70pointsandscoresgreaterthanor equalto70points.Wecomparedthesegroupsinrelationto ageatthetimeofthesurgery;initialdegreeofdeformity (eval-uatedbymeasuringtheHVAandIMAI-II);andthepresence orabsenceofconsolidationonthecurrentradiographs.

The resultswere also classified in accordance with the criteriadrawnup byMannandThompson,4 _whoevaluated

thepresenceofpainintheforefootandthecapacitytouse closed footwear. The surgical result was considered to be excellentwhenthepatientsdidnotcomplainofpainwhen theywerestandinguprightandwerecapableofusing conven-tionalclosedfootwear;goodwhentheydidnotpresentpainful complaints,but wereonlyabletomakeuseofopenshoes; moderatewhentherewassomeresidualpainbut lessthan beforetheoperation;andpoorwhentherewasno improve-mentorevenworseningofthepain.

Patients’ satisfaction with the surgical procedure was assessedusingthescaleofJohnsonetal.12_{Itwasinvestigated}

whethertheywerecompletelysatisfied,satisfiedwithslight reservations,satisfiedwithmajorreservationsordissatisfied.

Surgicaltechnique

ThefirstMTPjointwastreatedbymeans ofadorsal longi-tudinal incision of around5cm, centered on the joint and deepened over the medial edge of the long extensor ten-donofthehallux.Thecapsuleandthecollateral ligaments werereleased;thejointcartilageoftheproximalphalanxand metatarsalheadwereremoved;andmedialexostectomywas performed.Thearthrodesiswasfixedusingaplateandscrews, single screwsbetween fragments or two 2.0mm Kirschner wires.Kirschnerwireswereusedif,accordingtothesurgeon’s assessmentduring the operation,the bonequality didnot allowfixationofgreaterrigidity.Arthrodesiswasperformed inthepositionrecommendedintheliterature,withvalgusof around10◦_{,dorsiflexionof20}◦_{andneutralrotation.}1–6

TheMTPjointofthesmallerfingerswasexposedbymeans oftwodorsalincisionsofaround5cminthesecondandfourth intermetatarsal spaces.The collateral ligament,the dorsal portion of the capsule and intermetatarsal ligament were released circumferentiallyaroundthe baseofthe proximal phalanxandthemetatarsalheadandneck.Themetatarsal headswereresectedinthedistalofthemetaphysiswiththe aidofasaw,startingwiththesecondmetatarsaland progres-sivelyrepeatingthisfortheotherlateralmetatarsals,taking caretomaintainthemetatarsalformula.

After the operation, all the patients used sandals with weight-bearingontheforefoot,andloadingwasallowedas tolerated. The dressing was changed every weekuntil the stitcheswereremoved,15–20daysafterthe operation.The patientcontinuedtousethesandalsuntiltherewere radio-graphic indications of consolidation of the arthrodesis of theMTP ofthehallux (between10 and12 weeksafterthe operation),whenthesandalswerewithdrawnanduseof com-fortable footwear was allowed. TheKirschner wires ofthe smallertoes were removed asoutpatientprocedures,eight weeksaftertheoperation.TheKirschnerwiresofthe MTP ofthehallux wereremoved onlyafterconsolidationofthe arthrodesis.

Results

Allthepatientswereevaluatedbythesameexaminer,who didnotparticipateinthetreatment.ThemeanAOFASscore fortheMTPjointofthehalluxobtainedinthefinal evalua-tionwas70pointsoutofapossible90points(range:25–88).It wasconsideredthatthemaximumAOFASscorefortheMTP ofthehalluxwas90pointsbecauseofthelossofjointmobility inthefirstMTPafterarthrodesis,whichimpededtheuseof thisparameterasameansofevaluatingpostoperative func-tion.WhenthepainparameteroftheAOFASscorefortheMTP ofthehalluxwasevaluatedseparately,themeanvaluewas observedtobe34outofthe40pointspossible(range:20–40). Weobservedtwocases(twofeet)withdeepinfectioninthe operativewoundinthedorsumofthefootandskinnecrosisat thesiteofthearthrodesisoftheMTPofthehallux.Thesecases occurredinpatientswhoweresmokers,andbothunderwent serialdebridementand intravenousantibiotictherapyuntil theinfectiousconditionhadbeenresolved.Therewasalsoone case(onefoot)withsuperficialinfection,whichwasresolved bymeansoforalantibiotictherapyandserialdressings.One footpresentedvascularcomplicationsduringtheimmediate postoperativeperiodandevolvedwithnecrosisand amputa-tionofthethirdtoe.

We observed the presence of pseudarthrosis in three feet,aslatecomplications.Oneofthemunderwentrevision surgery,withsubsequentconsolidation.Theother twofeet inwhichconsolidationofthearthrodesisoftheMTPofthe halluxwasnotachievedoccurredinpatientswhopresented deepinfectionofthe operativewoundand skinnecrosisas earlycomplications.Oneofthesecasesevolvedwithchronic osteomyelitis.Thesynthesis materialand devitalized bone wereremoved,andprolongedintravenousantibiotictherapy wasadministered,whichledtoresolutionoftheinfectious condition.However,thispatientcontinuedtopresentpainful symptomsinthefirstMTPjointandtherewasrecurrenceof thevalgusdeformityofthehallux.Intheothercase,complete resolutionoftheinfectiousconditionwasachievedthrough debridementandantibiotictherapy,althoughpseudarthrosis wasseentobepresentlaterinthepostoperativefollow-up. Both ofthe casesthat presenteddeep infection and pseu-darthrosisoccurredinpatientswhosmoked.

Inthemostrecentclinicalexamination,14patients(21feet) (78%)didnothaveanycomplaints.Sixpatients(6feet)(22%) presentedsometypeofsymptom.Threepatients(3/27feet;

Table1–Meanangularcorrectionamongthepatients withrheumatoidarthritiswhounderwent

reconstructionoftheforefootbymeansofarthrodesisof themetatarsophalangealjointofthehallux.

Pre-op(mean) Post-opfinal

(mean)

Angular correction

(mean)

HVA 41◦ ₁₇◦ ₂₄◦

IMAI-II 15◦ ₁₁◦ ₄◦

HVA,halluxvalgusangle;IMAI-II,intermetatarsalanglebetween thefirstandsecondmetatarsals.

11%)wereobservedtopresentplantarmetatarsalpainalone; twopatients(2/27;7%)presentedpainanddeformityinthe halluxalone.Oneofthesewasoneofthecasesthatevolved withpseudarthrosis.Theotherpatient(onefoot), who pre-senteddeepinfectionandpseudarthrosisoftheMTPofthe hallux,evolvedwithpainanddeformityinthehalluxin asso-ciationwithmetatarsalpainandwasasmoker.

UsingthecriteriaofMannandThompson,4_{theresultswere}

classifiedasexcellentin19feet(71%),goodintwo(7%), moder-ateinfour(15%)andpoorintwo(7%).Regardingthepatients’ satisfactionwiththesurgicalprocedureaccordingtothescale ofJohnsonetal.,12_{10patients(15feet)werefoundtobe}

com-pletelysatisfiedwiththeresultsfromthesurgery,five(10feet) weresatisfiedwithslightreservationsandtwo(twofeet)were dissatisfied.

Theangularcorrectionobtainedinthepatientswho under-wentforefootreconstructionisdemonstratedinTable1,along withthepre-andpostoperativemeanvaluesfortheHVAand IMAI-II.

Weevaluatedthefixationmethodusedinarthrodesisof theMTPofthehalluxandcorrelatedtheradiographic param-eters with the clinical-functional results according to the AOFASscale,asdemonstratedinTable2.Wedidnotfindany significantdifferencesinAOFASscoresoncomparingthe fix-ationofthearthrodesisontheMTPofthehalluxusingaplate andscrewsversusKirschnerwires.Likewise,wedidnotfind anydifferencesinconsolidationratesbetweenthesetwo fixa-tionmethods.Themeanangularcorrectionswerealsosimilar. Theclinical-functionalresultsexpressedusingtheAOFAS scaleweredividedintotwogroups:scoreslowerthan70points

Table2–Comparisonbetweenthetypesoffixationin relationtotheclinicalandradiographicparametersof patientswithrheumatoidarthritiswhounderwent forefootreconstruction.

Plate/screws (18/26feet)

Wires(8/26 feet)

AOFAS(MTP) 69/90 70/90

Consolidation 83% 87%

Pseudarthrosis 17% 13%

CorrectionIMAI-II(mean) 4◦ _3.5◦

CorrectionHVA(mean) 23◦ ₂₇◦

Table3–Distributionofthefeetoperatedaccordingto theAOFAScriteriaandcomparisonwiththeclinicaland radiographicparametersofpatientswithrheumatoid arthritiswhounderwentforefootreconstruction.

AOFAS<70 points(10/27

feet)

AOFAS≥70

points(17/27 feet)

Meanageinyears 63 46

Consolidationof

arthrodesisoftheMTPof thehallux

70% 100%

InitialIMAI-II(mean) 15◦ ₁₅◦

InitialHVA(mean) 29◦ ₄₈◦

MTP, metatarsophalangealjoint; IMA I-II,intermetatarsal angle betweenthefirstandsecondmetatarsals;HVA,halluxvalgusangle.

andscoregreaterthanorequalto70points,asdemonstrated inTable 3. We observed differences between thesegroups regardingthemeanage atthe timeofthe surgeryandthe consolidationratesassessedfromthefinalradiographs.The meanagewas46yearsinthegroupwithAOFASscoresgreater thanor equalto70points, whilethe meanageamongthe feetwithscoresless than70 pointswas63 years.Thefeet withhigherAOFASscoresalsoachieved100%consolidation, whereasthegroupwithscoreslessthan70pointsachieved 70%consolidationinthefinalradiographicevaluation.

Discussion

Manysurgicalprocedureshavebeendescribedfortreating hal-luxvalgusanddeformitiesofthesmallertoesinpatientswith rheumatoidarthritis.In1912,Hoffman13_{describedresection}

ofallofthemetatarsalheadsbymeansofasingleplantar inci-sion.Otherauthors14–16_{modifiedtheoperativetechniqueover}

timeanddemonstrateddifferentresultsaccordingtothetype ofincision(dorsalorplantar),14,15_{repositioningoftheplantar}

padorexcisionofthemetatarsalheadsorproximalphalanx ofthetoes.14,15

Initially,treatmentofthefirstraycontinuedtobethemost controversialpointinforefootreconstructioninrheumatoid patients.14 _{Overtime,resectionofthebaseoftheproximal}

phalanx(Kellerprocedure)15_{andresectionoftheheadofthe}

first metatarsal (Mayo procedure)17 _{became popular. These}

procedureshavedemonstratedhighrecurrenceratesfor hal-luxvalgus,metatarsalpainandplantarcalluses.15,18

Henryand Waugh7 _{and Mann and Thompson}4

demon-stratedthatstablerealignmentofthefirstrayisadetermining factorforobtainingbetterresultsfromreconstructingthe fore-footinthesepatients,giventhatarthrodesisoftheMTPofthe halluxincreasestheplantarpressureonthemedialcolumn ofthefootduringgaitandpreventstheactionofdeforming forcesontheMTPjointsofthesmallertoes,therebyhelping todiminishmetatarsalpain.

Throughthis,arthrodesisofthe MTPjointofthehallux hasbecomethetreatmentmethodmostusedforcorrecting deformitiesofthehalluxandhasledtobetterresultsinterms ofpainrelief,functionalimprovement,maintenanceof align-mentandpatientsatisfaction.6,8,9

Inourstudy,wefoundamongthe27feetevaluatedthat71% oftheresultswereexcellentand7%weregood,withamean follow-upof68months,accordingtothecriteriadeveloped by Mann and Thompson.4 _{This demonstrates the}

clinical-functionalimprovementandpatients’satisfactionwiththis typeofprocedure.MannandThompson4_{foundthat78%of}

their resultswere excellent among18 feet thatunderwent arthrodesis ofthe MTP ofthe hallux and resection of the metatarsalheads,withameanfollow-upof49months.Using thesameassessmentcriteria,butwithresectionarthroplasty oftheheadsofallthemetatarsals,ratherthanarthrodesisof theMTPjointofthehallux,Thomasetal.19_{foundthatonly}

30%oftheirresultsweregoodorexcellentinevaluating37 feetwithameanfollow-upof65months.

Mostofthestudieshaveevaluatedtheclinical-functional resultsfromforefootreconstructionsurgerybymeansofthe AOFASscalefortheMTPjointofthehallux.Coughlin6_founda

meanAOFASscoreof69pointsamong47feetthatthey evalu-ated;Kadambandeetal.8_{studied66feetandreportedamean}

AOFASscoreof65points;andHeitkemperetal.9_obtainedthe

bestresults:ameanscoreof81pointsamong20feetthatwere evaluatedwithameanfollow-upof42months.

Theseauthors’observationswereconfirmedinourstudy. WefoundameanAOFASscoreof70pointsfortheMTPjoint ofthehallux,withameanfollow-upof68months.The fac-torthat contributed towardthegreatest lossofpointswas themobilityoftheMTPjointofthehallux,since arthrode-sisimpedesthe movementofthisjoint.Thistookaway 10 pointsfromtheAOFASscore,thuspreventingthemaximum score from exceeding90 points. Presenceofsome residual painintheforefoot,whichwasobservedinsixofthe27feet, andincapacitytouseconventionalclosedshoeseveninthe absenceofpainfulsymptoms,asobservedintwoofthe27feet, tookawaypointsregardingtheissuesofpainandfunction. Theseareexpectedconditionsamongpatientswith rheuma-toidarthritis,becauseofthechronicandprogressivenatureof thedisease,whichimpedescompleteeliminationofthe symp-toms,evenwhenusingacarefulvalidatedsurgicaltechnique.3

AlthougharthrodesisoftheMTPofthehalluxhasgained popularity overrecent years and hasbecomethe standard procedureforreconstructingrheumatoidforefeet,few stud-ieshavequantifiedtheradiographicalignmentofthefirstray. MannandThompson4_{observedameancorrectionof23}◦_for

thehalluxvalgusangle,whiletheintermetatarsal angleI-II presentedameancorrectionof4◦_.Coughlin6 _alsoobserved

similarvaluesinhisseriesof47feet,withameancorrection of18◦_{forthehalluxvalgusangleand3}◦_{fortheintermetatarsal}

angle I-II.Kadambandeet al.8 _{studied 66feet and founda}

mean correctionof23◦ _{forthe hallux valgusangle and 8}◦

fortheintermetatarsalangleI-II.Wefoundresultssimilarto thoseintheliteratureinthepresentstudy.Inourseries,the halluxvalgusanglewascorrectedbyameanof24◦_,whilethe

intermetatarsalangleI-IIwascorrectedby4◦_.

Other studies havealreadycorrelated arthrodesisofthe MTPofthehalluxwithcorrectionoftheintermetatarsalangle I-II20–22_{andhaveobservedameancorrectionof3}◦_to8◦_inthis

Thedifferentfixationmethodsusedforarthrodesisofthe firstMTPjointwere alsoevaluatedandcomparedwiththe clinical-functionalandradiographicresults.Weobservedthat, independentofwhetherfixationhadbeendoneusingaplate andscrewsorwithKirschnerwires,theclinicalresultswere similar according tothe AOFAS scorefor the MTP joint of thehallux.Likewise,the consolidationratesandthe mean angularcorrectiondidnotdemonstrateanysignificant differ-encesbetweenthe groups.However,biomechanicalstudies havedemonstratedthesuperiorityoffixationusingcrossed screwsbetweenfragmentsorassociationsofplateandscrews withothermethods.Neufeld etal.23 _{comparedthree}

stabi-lization methods for arthrodesisof the MTP of the hallux incadaversanddemonstratedthattheassemblypresented greaterrigiditywhencrossedscrewswereused.Politietal.24

comparedfivetypesoffixationinbiomechanicaltrialsusing syntheticboneanddemonstratedthatfixationwithaplate inassociationwithtwoscrewsbetweenfragmentswasmore stablethan fixation with the plate alone, and that assem-blieswith twocrossed Kirschnerwires presentedthe least rigidity.Althoughtheuseofaplateandscrewshas demon-stratedgreaterrigidityandstabilityinbiomechanicalstudies, wedidnotfindany clinicalstudiescomparingthe consoli-dationratesandclinical-functionalresultsbetweendifferent fixation methods.Moreover, it is known that factors relat-ingtothepatientmayalsoinfluencetheclinical-functional result. Appropriate collaboration during the postoperative period and care to avoid smoking and other risk factors arefundamentalforachievingconsolidationinanygroupof patients.25

Incomparingtheclinical-functionalresultsaccordingto the AOFAS score for the MTP joint of the hallux with the radiographicresults,we observedthatthe consolidationof the arthrodesis influenced the results. The patients who presentedpseudarthrosisatthe finalevaluationhadworse resultsaccordingtotheAOFASscore.

Ageatthetimeofthesurgeryalsoinfluencedthe clinical-functionalresultaccordingtotheAOFASscoreforthe MTP jointofthehallux,sincethepatientsincludedinthegroup withAOFASscoresgreater thanor equalto70 presenteda mean age of46 years,whereas the group with scoresless than 70 had a mean age of63 years.Thesmaller number ofmusculoskeletalabnormalitiesandlowerinitialsystemic involvementofthe disease in the youngerpatients proba-bly explain these findings,given that rheumatoid arthritis isachronicand progressivediseaseand thatthedegreeof osteoarticularinvolvementincreaseswiththedurationofthe disease.3

Surgical treatment forpatients with rheumatoid arthri-tis is a challenge for orthopedic surgeons because of the potentialriskofpostoperativecomplications.3_{Thesepatients}

presenthigherriskofcomplicationsbecauseofthesystemic nature of the disease, use of immunosuppressant medi-cations and severity of their deformities.26 _{Typically, they}

presentsignificantosteopenia,whichbooststheriskof fail-ure of bone fixation during surgical interventions, as well asfrequently presenting associatedvasculitis, which leads tofragilityofthesubcutaneoustissueandcompromisesthe healing of surgical wounds.3 _{The percentage of}

complica-tionsobservedinourserieswascompatiblewithwhathas

been presentedinthe literature. Thepersistence or recur-rence ofmetatarsal pain that was observed infour of the 27 feet (15%) was concordant with the percentage found in other studies, which has ranged from 10% to 36%.5,7–9

This may be minimized through meticuloussurgical tech-nique: correct positioning is attained for the arthrodesis of the MTP of the hallux and all the fragments or bone spiculesareremovedduringresectionofthelateralmetatarsal heads. However, thechronic and progressivenature ofthe disease prevents this complication from being completely eliminated.3

PseudarthrosisfromarthrodesisoftheMTPofthehalluxis alsoanexpectedcomplicationamongthesepatients.3_Inthe

literature,theseratesmayrangefrom0to26%,4–6,8,27_whichis

compatiblewiththerateof11%(3/27feet)foundinthepresent study.Acarefulsurgicaltechniqueinpreparingthe arthrode-sisanduseofreliablefixationmethodswithgreaterrigidity andstabilitycontributetowarddiminishingtheseratesand increasingthepercentageconsolidation.

The great majority of these patients also use powerful immunosuppressant drugs, which theoretically boosts the risk ofinfection and problems with the healing of opera-tive wounds.3 _{In a reviewarticle, Nassar and Cracchiolo}26

demonstrated that the rate of problems with the healing of operative woundsin patients with rheumatoid arthritis who undergosurgicalproceduresintheforefootmayrange from 0% to 11%, and also that superficial or deep infec-tion ofthe operativewoundmayoccur in0%to8%ofthe cases. In the present study, we found that 8% (2/27 feet) hadproblemswithwoundhealing,whichwascharacterized bydeep skinnecrosisand delayedhealingoftheoperative wound.Wealsofoundinfectionin12%(twofeetwithdeep infection and one with superficial infection). These num-bers were concordant with those publishedby Nassar and Cracchiolo26_{anddemonstratedthatthepotentialriskof}

com-plicationswasinherenttosurgicaltreatmentamongpatients withrheumatoidarthritis,becauseofthesystemicnatureof thedisease,thechronicuseofimmunosuppressantsandthe severityofthedeformities,whichadddifficultytothesurgical procedures.26

Although wefound the expectedcomplication ratesfor forefootreconstructionsurgeryinpatientswithrheumatoid arthritis, and these rates were concordant with what was found in the previous literature;4–8,26,27 _{we observed that}

smokingwasadeterminingfactorforcomplicationstoappear inourstudy,despitethesmallnumberofcases.Theharmful effectsofcigarettesonorthopedicsurgeryhavealreadybeen widelystudiedandproven.28_{Thus,ithasbeendemonstrated}

thatsmoking increasestheriskofpseudarthrosis,29

dimin-ishesbonedensity,30 _{causesproblemsrelatingtohealingof}

operative wounds and increases the risk ofinfection.31 _In

Conclusions

ThetechniqueofarthrodesisofthefirstMTPjointin associ-ationwithresectionarthroplastyoftheheadsofthelateral metatarsalsandcorrectionofthedeformitiesofthesmaller toes,whichwasusedtoreconstructthesevereforefoot defor-mitiesofthesepatients withrheumatoid arthritis,showed goodlong-termresultswithahigh satisfactionrateamong thepatientsandclinical-functionalimprovementaccording totheAOFASscale fortheMTPjoint ofthehallux andthe evaluationcriteriaproposedbyMann.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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