Objective To evaluate the clinical effectiveness of the first metatarsophalangeal (MTP) joint arthroplasty versus arthrodesis for rheumatoid forefoot deformity. Methods The randomized controlled trials (RCTs) about the first MTP joint arthroplasty vs. arthrodesis for rheumatoid forefoot deformity published by February 2012 were searched in the databases such as CNKI, Ovid, MEDLINE, CBM, EMbase, WanFang Data, The Cochrane Library (Issue 1, 2012), and KJEBM. Two reviewers independently screened studies, extracted data, and evaluated the methodological quality according to the inclusion and exclusion criteria. Then meta-analysis was conducted using RevMan 5.1 software. Results A total of 4 RCTs were included. Among total 206 (269 feet) patients involved in, 98 (130 feet) were in the arthroplasty group, while the other 108 (139 feet) were in the arthrodesis group. The results of meta-analysis showed that the arthrodesis group was superior to the arthroplasty group in the footwear (MD=−0.88, 95%CI −1.55 to −0.22, P=0.01), and the alignment (MD=−5.04, 95%CI −8.94 to −1.14, Plt;0.000 01) with significant differences. But there were no significant differences between the two groups in patient satisfaction, metastatic lesions, pain, activity and weight-bearing of Hallux. Conclusion Based on the current studies, arthrodesis is superior to arthroplasty in treating rheumatoid forefoot deformity. For the quality restrictions and possible publication bias of the included studies, more double blind, high quality RCTs are required to further evaluate the effects.
Objective To evaluate the surgical treatment and effectiveness of rheumatoid forefoot reconstruction with arthrodesis of the first metatarsophalangeal joint and arthroplasty of lesser metatarsal heads. Methods Between January 2007 and August 2009, 7 patients with rheumatoid forefoot were treated by reconstruction with arthrodesis of the first metatarsophalangeal joint and arthroplasty of lesser metatarsal heads. They were all females with an average age of 62 years (range, 56-71 years) and with an average disease duration of 16 years (range, 5-30 years). All patients manifested hallux valgus, hammer toe or mallet toe of 2-5 toes, 5 feet complicated by subluxation of the second metatarsophalangeal joint. The improved American Orthopaedic Foot amp; Ankle Society (AOFAS) score was 36.9 ± 6.4. The hallux valgus angle was (46 ± 5)°, and the intermetarsal angle was (12 ± 2)° by measuring the load bearing X-ray films preoperatively. Results All incisions healed by first intention after operation. The X-ray films showed bone fusion of the first metatarsophalangeal joint at 3-4 months after operation. Seven patients were followed up 2.9 years on average (range, 2-4 years), gait was improved and pain was rel ieved. The hallux valgus angle decreased to (17 ± 4)° and the intermetarsal angle was (11 ± 2)° at 3 months postoperatively, showing significant differences when compared with preoperative values (P lt; 0.05). The improved AOFAS score was 85.3 ± 5.1 at 2 years postoperatively, showing significant difference when compared with preoperative score (t=4.501, P=0.001). One patient had recurrent metatarsalgia at 4 years after operation. Conclusion Arthrodesis of the first metatarsophalangeal joint and arthroplasty of lesser metatarsal heads for rheumatoid forefoot reconstruction can correct hallux valgus, remodel the bearing surface of the forefoot, and rel ieve pain, so it can be considered as a procedure that provides improvement in the cl inical outcome.
Objective To investigate the operative procedure and the cl inical results of reverse lateral tarsal artery flap in treating forefoot skin and soft tissue defect. Methods From August 2007 to April 2009, 11 patients with forefoot skin and soft tissue defect were treated with reverse lateral tarsal artery flaps, including 7 males and 4 females aged from 16 to 60 years(36 years on average). Of 11 cases, defects were caused by crash in 5 cases, by grind contusion in 3 cases and the course disease was 4-12 hours; by tumor extended resection in 3 cases and the disease course was 3-12 months. There were 5 wounds on the dorsum of first metatarsophalangeal joint, 2 on the dorsum of the first toes, and 4 on the dorsum of distal part of metatarsal bones. The area of defect ranged from 4 cm × 2 cm to 6 cm × 5 cm. There were 6 cases of tendon exposure, 4 cases of tendon defect with bone exposure, and 1 case of tendon defect with open dislocation of metatarsophalangeal joint. The flap was designed with dorsal artery of foot as its pedicle. The plantar perforating branch was designed as its rotating point. And the flaps were transferred retrogradely to repair the forefoot wounds. The flap area ranged from 4.5 cm × 2.5 cm to 6.5 cm × 4.5 cm. The lateral dorsal nerve of foot was anastomosed with the nerve in wound area in 7 cases. Donor site was covered by full thickness skin graft. Results Partial necrosis occurred and was cured by dressing change, followed by skin graft in 2 cases. The flaps survived and primary heal ing was achieved in the other 9 cases. All the skin grafts of donor site survived and primary heal ing wasachieved after operation. All the patients were followed up for 6 months to 2 years, averaged 13 months. The texture and color of the flap were similar to skin at the recipient site. All patients returned to normal in walking and running and no ulceration occurred. The two point discrimination was 5-12 mm 6 months after operation in 7 patients who received nerve anastomosis, while only protective sensation recovered partly in the other 4 patients whose cutaneous nerve were not anastomosed. Conclusion Reverse lateral tarsal artery flap has the perfect shape and its blood vessel is constant. The blood pedicle is thick and long enough when transferred retrogradely. The flap is a good choice in the treatment of forefoot skin and soft tissue defect.
Objective To investigate the operative procedures and cl inical outcomes of the modified superficial peroneal neuro-fasciocutaneous flap in repairing soft tissue defect of forefoot. Methods From May 2006 to May 2009, 5 male patients (aged 40-63 years) with soft tissue defect of forefoot were treated with the modified superficial peroneal eurofasciocutaneous flap. Tendons and bones were exposed in all cases. Defect was caused by object crash (4 cases) and traffic accident (1 case). The sizes of soft tissue defects of forefoot were 4 cm × 2 cm-8 cm × 4 cm. Rotating point of the modified superficial peroneal neuro-fasciocutaneous flap pedicled with the peripheral vessels network of ankle joint was at the level of tibiotalar joint. The flaps ranging from 5 cm × 4 cm to 10 cm × 6 cm were adopted to repair soft tissue defects of forefoot. The donor sites were either sutured directly or covered with intermediate spl it thickness skin grafts. Results All flaps survived and all wounds healed by first intention. Skin graft at donor site survived completely in all cases. All patients were followed up 6-18 months (mean 11 months). The appearance, texture, and function of the flap were satisfactory. There was a protective sensibil ity in all flaps without abrasion or ulceration, and the two-point discrimination of the flaps was 10-13 mm. The walking pattern was normal. No obvious discomfort was observed at the skin-graft donor sites. Conclusion With rel iable blood supply, no sacrifice of vascular trunks, favorable texture, and thickness, the modified superficial peroneal neuro-fasciocutaneous flap pedicled with the peripheral vessels network of ankle joint is useful to repair skin soft tissue defect of the forefoot.
Objective To investigate the operative techniques and cl inical results of the superficial peroneal neurofasciocutaneous flap based on the distal perforating branch of peroneal artery in repairing donor site defect of forefoot. Methods From March 2005 to October 2007, 15 patients (11 males and 4 females, aged 20-45 years with an average of 33.6 years) with finger defects resulting from either machine crush (12 cases) or car accidents (3 cases) were treated, including 12 cases of thumb defect, 2 of II-V finger defect and 1 of all fingers defect. Among them, 6 cases were reconstructed with immediate toe-to-hand free transplantation after injury, and 9 cases were reconstructed at 3-5 months after injury. The donor site soft tissue defects of forefoot were 6 cm × 4 cm-12 cm × 6 cm in size, and the superficial peroneal neruofasciocutaneousflaps ranging from 10 cm × 4 cm to 14 cm × 6 cm were adopted to repair the donor site defects after taking the escending branch of the distal perforating branch of peroneal artery as flap rotation axis. The donor sites in all cases were covered with intermediate spl it thickness skin grafts. Results All flaps survived and all wounds healed by first intention. All reconstructed fingers survived completely except one index finger, which suffered from necrosis. Over the 6-18 months follow-up period (mean 11 months), the texture and appearance of all the flaps were good, with two-point discriminations ranging from 10-13 mm, and all patients had satisfactory recovery of foot function. No obvious discomfort and neuroma were observed in the skin-graft donor sites. The feel ing of all the reconstructed fingers recovered to a certain degree, so did the grabbing function. Conclusion Due to its rel iable blood supply, no sacrifice of vascular trunks, favorable texture and thickness and simple operative procedure, the superficial peroneal neurofasciocutaneous flap based on the distal perforating branch of peroneal artery is effective to repair the donor site defect in forefoot caused by finger reconstruction with free toe-to-hand transplantation.