リウマチ足趾に対する骨頭温存手術の成績は良好

少し前まではリウマチ足趾の手術というと、切除関節形成術resection arthroplastyがほとんどだったように思いますが、疾患活動性コントロール改善とともに、中足骨頭を温存した短縮骨切り術が（少なくとも日本では）主流となってきました。東京女子医科大学の矢野紘一郎先生らは、関節リウマチ53足に行った骨頭温存型手術の成績を後方視的に検討し、Self-Administered Foot Evaluation Questionnaire (SAFE-Q)の5 subscalesいずれも有意な改善が見られ、7年後の生存率（再手術不要）は89.5%という良好な成績を示したことを報告しています。創治癒遅延（すべて治癒）が20.0%、外反母趾再発が10.5%、内反母趾変形が3.8%、lesser MTPJの脱臼再発が7.7%に見られました。また再手術が不要だった症例の17.0%に有痛性胼胝再発あるいは残存が見られ、このような症例では胼胝無例と比較してSAFE-Qのうち3/5項目 (pain and pain-related, social functioning, shoe-related)で有意に低値でした。今後①術後の疾患活動性や使用薬物と再発との関係、②切除関節形成術との比較、などについても研究が進むことが期待されます。

Yano K et al., Patient-Reported and Radiographic Outcomes of Joint-Preserving Surgery for Rheumatoid Forefoot Deformities

A Retrospective Case Series with Mean Follow-up of 6 Years. J Bone Joint Surg Am. 2021 Mar 17;103(6):506-516.

Patient-Reported and Radiographic Outcomes of... : JBJS

lated forefoot deformities have gradually changed from joint-sacrificing to joint-preserving. The aim of this study was to assess the long-term outcomes, including patient-reported outcomes, of joint-preserving surgery for forefoot deformities associated with RA. Methods: This retrospective study included 105 feet in 89 patients with RA who were treated during the period of January 2012 to May 2015 and had a minimum of 5 years of follow-up (mean, 6.0 ± 0.9 years). The patient-reported outcome measure used was the Self-Administered Foot Evaluation Questionnaire (SAFE-Q), which was completed preoperatively and at the latest follow-up (n = 53 feet). The hallux valgus angle (HVA), the intermetatarsal angle (IMA), and the position of the medial sesamoid were measured preoperatively, at 3 months postoperatively, and at the latest follow-up. Cases of delayed wound-healing, hallux valgus recurrence, nonunion at the osteotomy sites, and reoperation were recorded. Kaplan-Meier survival curves were used to determine the estimated survivorship, with reoperation as the end point. Results: Scores of all 5 subscales of the SAFE-Q demonstrated significant improvement at the latest follow-up. The average HVA and IMA decreased significantly 3 months postoperatively, and these measurements remained significantly lower than the preoperative values (p < 0.01). The position of the medial sesamoid at the latest follow-up improved significantly (p < 0.01). Delayed wound-healing was found at the site of surgery in 21 (20.0%) of the 105 feet. Recurrence of hallux valgus was observed in 11 (10.5%) of the feet. There was no case of nonunion at any osteotomy site. Eleven (10.5%) of the feet required reoperation. The estimated survivorship of the studied joint-preserving surgery at 7 years, with reoperation as the end point, was 89.5%. Conclusions: Satisfactory long-term patient-reported and radiographic outcomes after joint-preserving surgery for forefoot deformities associated with RA can be achieved. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence....

Patient-Reported and Radiographic Outcomes of... : JBJS