Modified scarf osteotomy with capsular interposition as salvage for resection or silicone implant arthroplasty in patients with rheumatoid arthritis. A report of three cases.

This study investigated modified scarf osteotomy as a salvage procedure after resection arthroplasty or silicone implant arthroplasty to preserve mobility of the first metatarsophalangeal (MTP) joint after hallux valgus surgery in patients with rheumatoid arthritis (RA). We investigated three feet with rheumatoid forefoot deformities that showed recurrence of forefoot deformity or breakage of the implant after resection or silicone implant arthroplasty in the first MTP joint. All feet were treated using modified scarf osteotomy with capsular interposition. All cases achieved obvious correction after modified scarf osteotomy despite resection of the first MTP joint and consequently showed both radiographic and clinical improvements. Modified scarf osteotomy offers potential as a definitive salvage procedure after resection arthroplasty or silicone implant arthroplasty for forefoot deformity in patients with RA, because the procedure can realign the first MTP joint obviously with preservation of the range of motion. Concomitant medial capsular interposition into the newly formed first MTP joint is also recommended where possible, to protect the edges of the proximal basal phalanx and distal first metatarsal and also to smoothen the motion of newly formed first MTP joint.

Characteristics of Intermetatarsal Angle Between the Second and Fifth Metatarsals (M2-M5A) in the Rheumatoid Foot.

BACKGROUND: Increasing of intermetatarsal angle between the first and second metatarsals (M1-M2A) has been reported as a risk factor for recurrence of hallux valgus (HV) deformity, on the other hand, increasing of intermetatarsal angle between the second and fifth metatarsals (M2-M5A) has been reported as a risk factor for resubluxation of the metatarsophalangeal (MTP) joint of the lesser toe after rheumatoid forefoot surgery. In this study, parameters related to increasing M2-M5A were investigated, as compared with M1-M2A and M1-M5A. METHODS: Radiographic parameters including M1-M2A, M1-M5A, and M2-M5A were retrospectively evaluated for 119 lower limbs from 68 patients with rheumatoid arthritis (RA). To clarify the clinical importance of these intermetatarsal angles, relationships with results from the timed up-and-go (TUG) test were also investigated. RESULTS: M1-M5A showed no correlation with mid-hind foot parameters, whereas M1-M2A and M2-M5A correlated with valgus/varus parameters. An increased M1-M2A was associated with lateral shift of the loading axis in the tibial plafond, whereas an increased M2-M5A was associated with medial shift, but M1-M5A showed no associations. M2-M5A/M1-M2A was significantly lower (1.7) in the normal TUG group than in the delayed TUG group (2.8) (p=0.045). CONCLUSIONS: Different patterns of spread are seen for the forefoot. One has a predominantly increased M1-M2A with lateral shift of the loading point in the tibial plafond, whereas the other has a predominantly increased M2-M5A with medial shift of the loading point in the tibial plafond. M2-M5A also should be calculated, and M2-M5A/M1-M2A might be meaningful in understanding physical mobility in RA patients.

Association of Decreased Physical Activity with Rheumatoid Mid-Hindfoot Deformity/Destruction.

Foot/ankle problems remain important issues in rheumatoid arthritis (RA) patients. Although forefoot deformity generally takes a major place in surgical treatment, concomitant mid-hindfoot deformity is also commonly seen. In this situation, it can be easy to overlook that mid-hindfoot deformity can also induce or exacerbate clinical problems behind the forefoot events. Thus, the relationship between mid-hindfoot deformity/destruction and physical activity/ADL was investigated. Radiographic findings of 101 lower limbs (59 patients) were retrospectively evaluated. Alignment parameters in the lower extremity and joint destruction grade (Larsen grade) were measured. The timed-up-and-go (TUG) test, modified health assessment questionnaire (mHAQ), pain, self-reported scores for the foot and ankle (SAFE-Q), and RA disease activity were investigated to assess clinical status. The relationships among these parameters were evaluated. Subtalar joint destruction was correlated with TUG time (r = 0.329), mHAQ score (r = 0.338), and SAFE-Q: social functioning (r = 0.332). TUG time was correlated with the HKA (r = -0.527), talo-1st metatarsal angle (r = 0.64), calcaneal pitch angle (r = -0.433), M1-M5A (r = -0.345), and M2-M5A (r = -0.475). On multivariable linear regression analysis, TUG time had a relatively strong correlation with the talo-1st metatarsal angle (ß = 0.452), and was negatively correlated with calcaneal pitch angle (ß = -0.326). Ankle joint destruction was also correlated with TUG time (ß = 0.214). Development of structural problems or conditions in mid-hindfoot, especially flatfoot deformity, were related with decreased physical activity in RA patients. Wearing an insole (arch support) as a preventative measure and short foot exercise should be considered from the early phase of deformity/destruction in the mid-hindfoot in the management of RA.

Modified Scarf Osteotomy with Medial Capsule Interposition for Hallux Valgus in Rheumatoid Arthritis: A Study of Cases Including Severe First Metatarsophalangeal Joint Destruction.

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 (ß = -0.39, p = 0.02) and a significant positive correlation between the preoperative DAS28-CRP score and the HVA at final follow-up (ß = 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.

Sporotrichal Tenosynovitis Diagnosed Helpfully by Musculoskeletal Ultrasonography.

A 72-year-old man presented with persistent oligoarthritis and positive results for rheumatoid factor and was suspected of having rheumatoid arthritis (RA). However, the musculoskeletal ultrasonography (MSUS) findings were not consistent with those of typical RA. He had undergone surgery for carpal tunnel syndrome, which allowed both histopathological and microbiological examinations to be performed. A synovial tissue culture was positive for Sporothrix schenckii, and he was diagnosed with sporotrichal tenosynovitis. He received anti-fungal therapy, and the sporotrichal tenosynovitis resolved. This case suggests that MSUS is a useful modality, and sporotrichal tenosynovitis, though rare, should be considered in the differential diagnosis of RA.

Computer assisted planning and custom-made surgical guide for malunited pronation deformity after first metatarsophalangeal joint arthrodesis in rheumatoid arthritis: a case report.

Arthrodesis of the first metatarsophalangeal (MTP-1) joint is a widely used procedure for the treatment of hallux valgus in patients with MTP-1 degeneration, severe or recurrent deformity, or inflammatory arthritis. In this case, ten years earlier, the patient's MTP-1 joint had been fused in a severe pronation deformity position. Subsequently, a laterally shifted tibial sesamoid and osseous rising of the phalanx base caused painful callosities. To correct the pronated deformity accurately, a custom-made surgical guide based on a three-dimensional computer tomography (3D-CT) simulation system was used. After correction of the deformity, the MTP-1 joint was again fused. Adequate correction was achieved, and the patient no longer complains of pain and can perform full weight-bearing on the forefoot. The difficulty and importance of placing the MTP-1 joint in an adequate rotational position in MTP-1 joint arthrodesis surgery were confirmed, as was the utility of 3D evaluation and a custom-made surgical guide for rotational adjustment between the metatarsal and the proximal phalanx. We believe that this system should be one of the indicators for adjusting the rotation, especially in revision MTP-1 joint fusion surgery.

Involvement of valgus hindfoot deformity in hallux valgus deformity in rheumatoid arthritis.

The involvement of valgus hindfoot deformity in hallux valgus deformity was confirmed in a rheumatoid arthritis case with a destructive valgus hindfoot deformity. Correction of severe valgus, calcaneal lateral offset, and pronated foot deformity instantly normalized hallux valgus deformities postoperatively. Thus, careful hindfoot status evaluation is important when assessing forefoot deformity, including hallux valgus, in rheumatoid arthritis cases.

Effect of correction of hindfoot valgus deformity on ankle joint pain relief in rheumatoid arthritis cases: A report of two cases.

We often see painful ankle joint destruction with painful hindfoot valgus deformity in rheumatoid arthritis. Our policy in such cases has been to first correct the hindfoot deformity in the subtalar joint with fusion, but then ankle joint pain has been observed. Two women with rheumatoid arthritis underwent correction and fusion surgery for hindfoot valgus deformity. They had been using wheelchairs because of severe pain in the ankle joint and hindfoot despite extensive medical treatment. After surgery, both patients complained of no pain in the hindfoot. Furthermore, dramatic pain reduction in the ankle joint was also observed especially in a case without ankle joint instability. Consequently, the patients could walk without any support. Correction of valgus hindfoot deformity contributes to centralizing the weight-bearing line in the ankle joint, leading to ankle joint pain relief. It appears possible to preserve the ankle joint without additional ankle surgery even in rheumatoid arthritis cases, if ankle is stable.

Involvement of valgus hindfoot deformity in hallux valgus deformity in rheumatoid arthritis.

The involvement of valgus hindfoot deformity in hallux valgus deformity was confirmed in a rheumatoid arthritis case with a destructive valgus hindfoot deformity. Correction of severe valgus, calcaneal lateral offset, and pronated foot deformity instantly normalized hallux valgus deformities postoperatively. Thus, careful hindfoot status evaluation is important when assessing forefoot deformity, including hallux valgus, in rheumatoid arthritis cases.

Osteochondritis dissecans of the humeral trochlea with cubitus varus deformity. A case report.

Osteochondritis dissecans of the elbow primarily involves the capitellum. We report a rare case of osteochondritis dissecans involving the humeral trochlea in a 19-year-old male with a post-traumatic cubitus varus deformity. Biomechanics suggested that the varus malalignment caused repetitive axial force across the medial elbow, which led to microtrauma to the trochlea during the patient's daily work. In adolescents, post-traumatic cubitus varus can gradually progress to subsequent osteochondritis dissecans of the humeral trochlea.

Long-term results of surgery for forearm deformities in patients with multiple cartilaginous exostoses.

BACKGROUND: Surgical treatment of forearm deformities in patients with multiple cartilaginous exostoses remains controversial. The purpose of the present study was to determine the reasonable indications for operative treatment and to evaluate long-term results of forearm surgery in these patients. METHODS: We retrospectively reviewed twenty-three patients (thirty-one forearms) after a mean duration of follow-up of nearly thirteen years. The mean age at the time of the initial procedure was eleven years. The patients underwent a variety of surgical procedures, including excision of exostoses; corrective procedures (lengthening of the radius or ulna and/or corrective osteotomy of the radius and/or ulna) and open reduction or excision of a dislocated radial head. Clinical evaluation involved the assessment of pain, activities of daily living, the cosmetic outcome, and the ranges of motion of the wrist, forearm, and elbow. The radiographic parameters that were assessed were ulnar variance, the radial articular angle, and carpal slip. RESULTS: Four patients had mild pain, and five patients had mild restriction of daily activities at the time of follow-up. Eight patients stated that the appearance of the forearm was unsatisfactory. Radiographic parameters (ulnar variance, radial articular angle, carpal slip) were initially improved; however, at the time of the final follow-up visit, the deformities had again progressed and showed no significant improvement. The only procedure that was associated with complications was ulnar lengthening. Complications included nonunion (three forearms), fracture of callus at the site of lengthening (two forearms), and temporary radial nerve paresis following an ulnar distraction osteotomy (one forearm). Excision of exostoses significantly improved the range of pronation (p = 0.036). CONCLUSIONS: In our patients with multiple cartilaginous exostoses, corrective osteotomy and/or lengthening of forearm bones was not beneficial. The most beneficial procedure was excision of exostoses. Reasonable indications for forearm surgery in these patients are (1) to improve forearm rotation and (2) to improve the appearance.

Diagnosis of distal radioulnar joint subluxation in patients with rheumatoid wrist by computed tomography.

Subluxation of the distal radioulnar joint (DRUJ) is associated with extensor tendon rupture in patients with rheumatoid arthritis (RA). However, it remains difficult to quantitatively evaluate DRUJ subluxation in RA wrist. We devised a new method for assessing DRUJ subluxation. This study investigated whether the new method, known as the RA subluxation ratio (RASR), or a conventional method was superior for detecting extensor tendon rupture in the RA wrist. Thirty-five RA wrists and 10 wrists of healthy volunteers were scanned using computed tomography. The RA wrists were divided into a tendon rupture group and a nonrupture group. The dorsal surface of the distal radius from Lister's tubercle to the ulnar aspect of the distal radius maintains a planar surface in the RA wrist. Therefore, we defined the RASR as the extent of dorsal subluxation of the ulna relative to this plane. We quantified subluxation of the DRUJ by using the RASR or the modified radioulnar line method, and compared the two methods. The RASR was 0.440 in the rupture group, 0.333 in the nonrupture group, and 0.106 in the healthy volunteers. The RASR was significantly higher than the modified radioulnar line method in the sensitivity of diagnosing tendon rupture.

Reconstruction with an osteochondral autograft for advanced osteochondritis dissecans of the elbow.

UNLABELLED: The treatment of large, advanced osteochondritis dissecans of the elbow is controversial. To ascertain whether better results could be obtained using osteochondral autografts, we retrospectively reviewed the results in 10 young athletes (mean age, 14.3 years; range, 12-17 years) who were followed up for a mean of 25.5 months (range, 18-45 months). After abrasion of the fragments, cylindrical osteochondral bone plugs were transferred from a lateral femoral condyle. They were assessed clinically by the Japanese Orthopaedic Association elbow score and radiologically by radiocapitellar congruity. All patients achieved bony union in 3 months. The average Japanese Orthopaedic Association score was 80.6 points before surgery and improved to 93.8 points at followup. The average percentage of radiocapitellar congruity was 35.7% before surgery and improved to 64.2% at followup. Clinical and radiologic results were excellent in eight patients and poor in two. Poor results may be dependent on preexisting osteoarthritis and technical difficulty related to the location of the lesion. In eight patients, a durable load-bearing elbow was obtained with this procedure, which made hyaline-like cartilage resurfacing with healthy subchondral bony support possible. Osteochondral autograft is a reasonable surgical option for an advanced lesion of osteochondritis dissecans of the elbow, although long-term followup is needed to know whether the early results persist. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Entrapment of the flexor digitorum superficials in the radius fracture site.

Entrapment of the flexor tendon after fracture of both forearm bones is very rare. This report describes entrapment of the middle finger flexor digitorum superficialis (FDS) tendon alone in the radius fracture site. A 13-year-old boy fractured both forearms and had closed reduction and a long-arm cast. After the cast was removed he had full middle finger motion with the wrist flexed but was unable to extend the proximal interphalangeal or metacarpophalangeal joints and could extend only the distal interphalangeal joint of the middle finger with the wrist in the neutral or extension position. Entrapment of the middle finger FDS tendon was suspected. After surgical release of the FDS tendon at the fracture site the patient had good functional results.

Capillary vessel network integration by inserting a vascular pedicle enhances bone formation in tissue-engineered bone using interconnected porous hydroxyapatite ceramics.

The aim of the present study was to investigate the possibility of integrating porous hydroxyapatite (HA) ceramics with a capillary vessel network via insertion of a vascular pedicle, and to determine whether this procedure enhances new bone formation in tissue engineering of bone. First, synthetic interconnected porous HA (IP-CHA) was implanted subcutaneously into rat groin with or without insertion of superficial inferior epigastric vessels. At 6 weeks, IP-CHA with vascular insertion contained thick fibrous connective tissue with a number of large blood vessels that seemed to derive from the inserted vascular bundle. Next, IP-CHA loaded with recombinant human bone morphogenetic protein 2 (BMP, 2 or 10 microg/block) was implanted with or without vascular insertion. At 3 weeks, IP-CHA/BMP (10 microg) composite with vascular insertion exhibited abundant new bone formation in the pores of the deep portion close to the inserted vessels. In contrast, IP-CHA/BMP (10 microg) without vascular insertion showed poor bone formation. Histomorphometric analysis demonstrated that vascular insertion significantly increased new bone formation. In IP-CHAs with a lower dose of BMP (2 microg), no bone formation was found, with or without vascular insertion. These results suggest that the present system of integrating a vascular network with IP-CHA is a useful technique for bone tissue engineering.

Shoulder muscle reconstruction in the upper type of the brachial plexus injury by partial radial nerve transfer to the axillary nerve.

Brachial plexus palsy with upper segment C5 and C6 root avulsion can be effectively treated using a part of the radial nerve transferred to the axillary nerve. Shoulder stability and abduction was obtained with good deltoid muscle contraction. When combined with spinal accessory nerve transfer to the suprascapular nerve, the overall functional result was enhanced. Elbow flexion can be reconstructed by partial median nerve transfer to the musculocutaneous nerve. There were no neurologic deficits after nerve surgery.