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

Overview Introduction Modified Scarf osteotomy combined with metatarsal shortening offset osteotomy of the lesser toes provides stable forefoot realignment with preservation of the motion of the first metatarsophalangeal (MTP) joint. Indications & Contraindications Step 1: Preoperative Planning On a standing anteroposterior radiograph, plan the resection of the first metatarsal as the amount equal to the overlap of the first metatarsal and the base of the proximal phalanx, and plan to resect enough length of the lesser metatarsals to allow reduction of the MTP joints while keeping these metatarsals longer than the first. Step 2: Operating Room Setup (Fig.2) With the patient supine, and a fluoroscope in place to later check alignment and correction, ensure that full knee joint flexion is possible so that the foot can be placed parallel to the operating table. Step 3: Incisions (Fig. 3) Make the incisions. Step 4: Approach Approach the lesser toes through the lateral 2 dorsal toe incisions and the great toe through the dorsal first web space incision. Step 5: Osteotomy and Reduction Resect a sufficient amount of each lesser metatarsal neck to allow reduction of the respective MTP joint (Fig. 5-A); to correct the hallux valgus deformity, perform sufficient shortening and translation of the first metatarsal shaft through a horizontal longitudinal osteotomy (Fig. 5-B). Step 6: Fixation Lock the distal fragment (metatarsal head) of the lesser metatarsals into 3-mm-deep grooves in the cortical bone of the proximal fragment and then secure it to the proximal fragment with a 1.2-mm Kirschner wire (Fig. 6-A); shift the distal bone fragment of the first metatarsal laterally and securely fix it with screws (Fig. 6-B). Step 7: Medial Capsular Interposition and Closure After correction of the hallux valgus deformity using the modified Scarf osteotomy, interpose the 10-mm-wide capsular flap into the first MTP joint (Fig. 7). Results In our series of 76 cases in 60 patients, sufficient reduction of the hallux valgus deformity was achieved consistently even in cases with severe destruction (Larsen grade 4 or 5) of the first MTP joint due to rheumatoid arthritis2. Pitfalls & Challenges, Background: Arthrodesis of the first metatarsophalangeal (MTP) joint has been recommended for severe hallux valgus deformity in patients with rheumatoid arthritis. We developed an alternative procedure that preserves motion of the first MTP joint while restoring alignment and balance to the forefoot. This procedure was shown to be effective in a series of 60 patients with a 3-year follow-up. Description: We perform a modified Scarf osteotomy, with the longitudinal first metatarsal cut parallel to the sole of the foot and with shortening of the metatarsal to realign the first ray. This is combined with an interpositional capsular arthroplasty of the first MTP joint and shortening offset osteotomies of the lesser metatarsals. Alternatives: Alternatives include arthrodesis of the first MTP joint combined with resection arthroplasty of the lesser MTP joints, or of all 5 MTP joints, or perhaps interpositional (total) joint arthroplasty for severe rheumatoid forefoot deformity/destruction. Rationale: The purpose of the modified Scarf osteotomy is preservation of motion of the first MTP joint and protection against destruction of the rheumatoid joint. The metatarsal shortening offset osteotomy provides rigid stabilization at the site of osteotomy after dynamic correction to make the transverse arch.

Outcomes after total ankle arthroplasty (TAA) combined with additive techniques (augmentation of bone strength, control of soft-tissue balance, adjustment of the loading axis) for the treatment of rheumatoid arthritis were evaluated after intermediate to long-term follow-up. The influences of biologic treatment on the outcomes after TAA were also evaluated.We performed a retrospective observational study involving 50 ankles (44 patients) that underwent TAA for the treatment of rheumatoid arthritis. The mean duration of follow-up was 7.1 years. Clinical outcomes were evaluated with use of the Japanese Society for Surgery of the Foot (JSSF) scale score and a postoperative self-administered foot-evaluation questionnaire (SAFE-Q). Radiographic findings were evaluated as well. These parameters also were compared between patients managed with and without biologic treatment.This procedure significantly improved the clinical scores of the JSSF rheumatoid arthritis foot and ankle scale (p0.0001). Forty-eight of the 50 ankles had no revision TAA surgery. Subsidence of the talar component was seen in 8 ankles (6 in the biologic treatment group and 2 in the non-biologic treatment group); 2 of these ankles (both in the biologic treatment group) underwent revision TAA. The social functioning score of the SAFE-Q scale at the time of the latest follow-up was significantly higher in the biologic treatment group (p = 0.0079). The dosage of prednisolone (p = 0.0003), rate of usage of prednisolone (p = 0.0001), and disease-activity score (p0.01) at the time of the latest follow-up were all significantly lower in the biologic treatment group.TAA is recommended for the treatment of rheumatoid arthritis if disease control, augmentation of bone strength, control of soft-tissue balance, and adjustment of the loading axis are taken into account. The prevention of talar component subsidence remains a challenge in patients with the combination of subtalar fusion, rheumatoid arthritis, and higher social activity levels.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.