Modern Rheumatology
ISSN: 1439-7595 (Print) 1439-7609 (Online) Journal homepage: http://www.tandfonline.com/loi/imor20
Longer operative time is the risk for delayed wound healing after forefoot surgery in patients with rheumatoid arthritis Koichiro Yano, Katsunori Ikari, Yoshihito Takatsuki, Atsuo Taniguchi, Hisashi Yamanaka & Shigeki Momohara To cite this article: Koichiro Yano, Katsunori Ikari, Yoshihito Takatsuki, Atsuo Taniguchi, Hisashi Yamanaka & Shigeki Momohara (2015): Longer operative time is the risk for delayed wound healing after forefoot surgery in patients with rheumatoid arthritis, Modern Rheumatology, DOI: 10.3109/14397595.2015.1071456 To link to this article: http://dx.doi.org/10.3109/14397595.2015.1071456
Published online: 07 Sep 2015.
Submit your article to this journal
Article views: 37
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imor20 Download by: [Chinese University of Hong Kong]
Date: 11 November 2015, At: 03:01
http://informahealthcare.com/mor ISSN 1439-7595 (print), 1439-7609 (online) Mod Rheumatol, 2015; Early Online: 1–5 © 2015 Japan College of Rheumatology DOI: 10.3109/14397595.2015.1071456
ORIGINAL ARTICLE
Longer operative time is the risk for delayed wound healing after forefoot surgery in patients with rheumatoid arthritis Koichiro Yano1, Katsunori Ikari1,2, Yoshihito Takatsuki1, Atsuo Taniguchi1, Hisashi Yamanaka1, and Shigeki Momohara1
Downloaded by [Chinese University of Hong Kong] at 03:01 11 November 2015
1Institute of Rheumatology, Tokyo Women’s Medical University, Shinjuku, Tokyo Japan and 2CREST, JST, Shinjuku, Tokyo Japan
Abstract
Keywords
Objectives. Forefoot deformities are common in patients with rheumatoid arthritis (RA) and often require operative treatment. There is a high rate of delayed wound healing after foot surgery, especially among patients with RA. The aim of this study was to identify risk factors of delayed wound healing in RA patients who had undergone forefoot surgery. Methods. This study was a retrospective observational study designed to analyze the outcomes of all consecutive RA patients who had undergone toe arthroplasty from April 2010 through May 2014 at a single institute. Putative risk factors for delayed wound healing were assessed using univariate logistic regression analysis. Variables with α ⫽ 0.1 were then subjected to stepwise multivariate logistic regression analysis. Results. A total of 192 RA patients (192 feet) were included in this study. Delayed wound healing was seen in 40 feet (40/192 [20.8%]). A stepwise multivariate logistic regression analysis revealed that longer operative time was the risk factor associated with delayed wound healing in RA patients undergoing forefoot surgery (p ⫽ 0.028, odds ratio ⫽ 1.19 [per 10 min], 95% confidence interval [CI]: 1.07–1.32). Conclusions. This finding emphasizes the importance of preventing operative complications during forefoot surgery.
Delayed wound healing, Forefoot surgery, Operative time, Rheumatoid arthritis History Received 16 February 2015 Accepted 5 July 2015)
Introduction
Patients and methods
Rheumatoid arthritis (RA) is a major chronic inflammatory disease that is characterized by destruction of multiple joints. Most patients with RA have painful symptoms associated with the foot and ankle [1], and forefoot deformity is a common problem. Although powerful antirheumatic drugs, including biologic agents, have reduced disease activity [2], conflicting results on the recent trend of the number of foot surgeries for RA patients have been reported [3–5]. Since these powerful antirheumatic medications cause immunosuppression, postoperative adverse events such as delayed wound healing are of concern [6]. In particular, there is a high rate of delayed wound healing after foot surgery, because the procedures are performed on joints lined with thin soft tissue, which occasionally has impaired circulation. These reconstructive procedures often require multiple incisions and soft tissue dissections without the luxury of large bridges of undisturbed planes of soft tissue [7]. Moreover, RA patients often require a number of simultaneous operative procedures to correct their foot deformities, which may also cause wound-healing problems. Therefore, rheumatoid forefoot deformities present a difficult challenge to surgeons. The aim of this study was to identify the risk factors of delayed wound healing after forefoot surgery in patients with RA.
This was a retrospective observational study designed to analyze the outcomes of patients who had undergone primary forefoot surgery at a single institute from April 2010 to May 2014. This study was a part of Institute of Rheumatology, Rheumatoid Arthritis cohort (IORRA), a large prospective observational cohort study of RA patients. The Ethics Committee of the institute approved this study.
Correspondence to: Katsunori Ikari, MD, PhD, Institute of Rheumatology, Tokyo Women’s Medical University, 10-22 Kawada, Shinjuku, Tokyo 162-0054, Japan. Tel: ⫹ 81-3-5269-1725. Fax: ⫹ 81-3-5269-1726. E-mail: [email protected]
Patients The study included patients with RA in whom conservative nonoperative treatment for moderate-to-severe symptomatic forefoot deformity failed and who then underwent toe arthroplasty (e.g., hallux valgus osteotomy, first metatarsal–phalangeal joint arthrodesis, metatarsal shortening osteotomy, and/or resection arthroplasty). All patients who underwent toe arthroplasty fulfilled the 1987 American College of Rheumatology revised criteria for RA [8]. There were no patients with other concomitant autoimmune diseases (e.g., systemic lupus erythematosus, scleroderma, polymyositis, dermatomyositis, and mixed connective tissue disease) except concomitant Sjögren’s syndrome in some patients. Only primary surgery was included if a patient had undergone forefoot surgeries many times in one side of feet. The first surgery in the study duration was included if a patient had undergone elective surgeries in both feet separately. Patients who were operated on both feet at the same time were excluded. RA patients stopped taking biologic disease-modifying antirheumatic drugs (DMARDs) during the perioperative period. In
2
K. Yano et al.
Mod Rheumatol, 2015; Early Online: 1–5
Downloaded by [Chinese University of Hong Kong] at 03:01 11 November 2015
Table 1. Demographic and clinical characteristics of patients at the surgery (n ⫽ 192). Age at surgery, years Gender, female BMI Disease duration, years DAS28 Hyperglycemia Smoking history, ever PSL dose, mg/day MTX dose, mg/week Use of biologic DMARDs Infliximab Etanercept Adalimumab Golimumab Tocilizumab Abatacept Operative time, minutes Tourniquet time, minutes Number of toes operated on Number of surgical wounds
60.6 (28 to 85) 180 (93.8) 20.8 19.3 (0 to 47) 3.28 (1.14 to 5.56) 5 (2.6) 55 (29.4) 2.06 (0 to 10) 7.23 (0 to 16) 42 (21.9) 8 (4.2) 23 (12.0) 5 (2.6) 2 (1.0) 1 (0.5) 3 (1.6) 108.6 (45 to 227) 100.8 (47 to 207) 4.1 (1 to 5) 2.5 (1 to 4)
BMI body mass index, DAS28 disease activity score with 28-joint counts, PSL prednisolone, MTX methotrexate, DMARDs disease-modifying anti-rheumatic drugs. Data are presented as mean (range) or n (%).
general, biologic DMARDs are withheld for 2–4 weeks prior to elective surgeries and are restarted two weeks postoperatively. All conventional synthetic DMARDs, including methotrexate (MTX), were continued throughout the perioperative period. Routine perioperative prophylactic antibiotics were administered twice, immediately before the incision and immediately after the surgery. Cefazolin was the agent of choice and fosfomycin was administered instead to patients allergic to penicillin and penicillin-like antibiotics. All patients in this study underwent elective forefoot surgery performed by or under the supervision of three stuff surgeons
who had extensive experience in the rheumatoid foot surgeries. A tourniquet was used routinely. It was deflated for at least 10 min if the tourniquet time was more than 120 min. Patients were allowed to walk, bearing weight on the heel, starting the day after surgery. Delayed wound healing was defined as wounds that were not healed more than two weeks after the procedure (sutures are removed two weeks after joint surgeries), though it may be rather aggressive in people with bad skin, decreased blood flow, and other medical co-morbidities. Information on the clinical characteristics of the patients was obtained in part from the observational cohort database, and the following perioperative data were obtained from medical records: biologic and synthetic DMARDs, operative procedures, medical history, and laboratory tests. Statistical analysis The significance of differences in frequencies of delayed wound healing across the surgeons was tested by the Fisher’s exact test. Putative risk factors for delayed wound healing were assessed using univariate logistic regression analysis (univariate-based feature selection). Each variable with α ⫽ 0.1 was subjected to stepwise multivariate logistic regression analysis to evaluate its relationship with the dependent variable, delayed wound healing. The putative risk factors tested by univariate analysis were as follows: age at surgery, gender, body mass index (BMI)-based weight classification (underweight [BMI ⬍ 18.5], normal weight [BMI ⫽ 18.5–24.9], overweight [BMI ⫽ 25.0–29.9], and obesity [BMI ⱖ 30]) [9], disease duration, disease activity score with 28-joint counts (DAS28), use of biologic DMARDs, dose of MTX, dose of prednisolone (PSL), history of smoking, hyperglycemia (HbA1c ⱖ 6.5%), operative time (per 10 min), tourniquet time (per 10 min), number of toes operated on, number of surgical wounds, hemoglobin level (Hb), serum total protein (TP), and C-reactive protein level (CRP). The significance level was set at 0.05. When the continuous variables were detected as the risk for delayed
Table 2. Operative procedures for first toe and lessor toes performed for the patients (n ⫽ 192).
Operative procedures for first toe Proximal rotational closing-wedge osteotomy [16] Proximal rotational closing-wedge osteotomy [16] and arthrodesis of metatarsophalangeal joint Proximal rotational closing-wedge osteotomy [16] and arthrodesis of interphalangeal joint Resection arthroplasty Mitchell osteotomy [17] Arthrodesis of interphalangeal joint Arthrodesis of metatarsophalangeal joint Modified McBride procedure [18] Crescentic proximal metatarsal osteotomy [19] Chevron osteotomy [20] No operative procedure on first toe Operative procedures for lesser toes Distal shortening oblique osteotomies of lesser metatarsals Distal shortening oblique osteotomies of lesser metatarsals and arthroplasty of fifth metatarsophalangeal joint Distal shortening oblique osteotomies and resection arthroplasty of lesser metatarsals Distal shortening oblique osteotomies of lesser metatarsals and arthrodesis of proximal interphalangeal joints Distal shortening oblique osteotomy of lesser metatarsals and incision of capsules of metatarsophalangeal joints Incision of capsule of metatarsophalangeal joints Arthrodesis of proximal interphalangeal joints Z-lengthening of extensor digitorum longus Resection arthroplasties of lesser metatarsals No operative procedure on lesser toes NA not applicable. The counts for delayed wound healings were overlapped for the first toes and lesser toes. *For key to incision numbers see Figure 1.
Count
Delayed wound healing
Skin incision*
112 2 3 22 17 11 7 2 2 1 13
25 0 1 6 4 1 1 0 0 0 2
1, 2 1, 2 1, 2, 3 1 1 3 1 1 1, 2 1 NA
133 3
31 1
4 and/or 5 4 and 5
5 4
0 0
4 and/or 5 4 and/or 5 and 6
4
1
4 and/or 5
2 1 1 25 14
0 1 0 6 0
4 and/or 5 6 4 7 NA
Longer operative time is the risk for delayed wound healing 3
DOI 10.3109/14397595.2015.1071456
Downloaded by [Chinese University of Hong Kong] at 03:01 11 November 2015
Figure 1. The skin incision positions shown in Table 2. 1, 2) A straight midline dorsal incision over the first MTP joint (1) or to the TMT joint (2). 3) A straight midline dorsal incision over the first IP joint. 4) A lazy S-shaped dorsal incision that began from the second MTP joint, passed over the third metatarsal and ended at the base of the fourth metatarsal. 5) A vertical incision at the lateral aspect of the fifth metatarsal. 6) A straight midline dorsal incision over the PIP joint. 7) A curved plantar incision over the heads of the metatarsals.
wound healing, receiver operating characteristic (ROC) curves were then generated to determine a cutoff value for each risk factor. All analyses were performed using the R Statistical Package, version 2.14.2 (http://www.r-project.org/).
Results A total of 306 primary forefoot surgeries (218 patients) were performed during the study period. Of these, 62 patients received forefoot surgeries on both feet separately and 26 patients received the surgeries on both feet at the same time. Finally, 192 RA patients with a total of 192 feet were included in this study. Most of the operative procedures (n ⫽ 159) were performed by three stuff surgeons with subspecialty training in foot and ankle surgery and the others (n ⫽ 33) were performed by ten other board certified orthopedic surgeons under the supervision of the three stuff
surgeons. All the patients were followed until their wounds healed after surgery. The baseline characteristics of the patients are shown in Table 1. The average age at surgery was 60.6 (28–85) years, average duration of RA was 19.3 (0–47) years, and the average operative time was 108.6 (45–227) min. The operative procedures performed for the patients including skin incision positions are listed in Table 2. Delayed wound healing was found at the site of surgery in 40 of 192 feet (20.8%). All of these wounds healed after conservative treatment. There were no significant differences in frequencies of delayed wound healing across the surgeons (p ⫽ 0.30). Univariate logistic regression analysis found that hyperglycemia (p ⫽ 0.07, odds ratio [OR] ⫽ 5.47, 95% confidence interval [CI]: 0.88–34.0), longer operative time (p ⫽ 0.002, OR ⫽ 1.18 [per 10 min], 95% CI: 1.06–1.31), longer tourniquet time (p ⫽ 0.009, OR ⫽ 1.26 [per 10 min], 95% CI: 1.06–1.49), high number of toes
Table 3. Univariate logistic regression analysis of putative risk factors for delayed wound healing after forefoot surgery in patients with RA. Putative risk Age at surgery, years Gender, female BMI-underweight* BMI-overweight* Disease duration, years DAS28 Hyperglycemia Smoking history (ever) PSL dose, mg/day MTX dose, mg/week Use of biologic DMARDs Operative time, 10 min Tourniquet time, 10 min Number of toes operated on Number of surgical wounds Serum CRP level, mg/dl Serum TP level, g/dl Serum Hb level, g/dl
Standardized regression coefficients 0.03 ⫺ 0.41 0.30 0.10 ⫺ 0.17 0.90 0.67 0.36 0.42 0.29 ⫺ 0.36 1.41 1.31 1.34 0.86 0.40 0.17 ⫺ 0.65
OR (95% CI) 1.00 (0.97–1.04) 0.50 (0.14–1.77) 1.21 (0.51–2.89) 1.07 (0.28–4.12) 0.99 (0.95–1.03) 1.44 (0.80–2.57) 5.47 (0.88–34.0) 1.38 (0.66–2.90) 1.07 (0.94–1.22) 1.03 (0.94–1.12) 0.70 (0.29–1.73) 1.18 (1.06–1.31) 1.26 (1.06–1.49) 1.54 (1.07–2.23) 1.59 (0.98–2.58) 1.21 (0.84–1.75) 1.15 (0.58–2.25) 0.84 (0.67–1.05)
p 0.95 0.28 0.66 0.92 0.70 0.23 0.07† 0.40 0.32 0.54 0.44 0.002† 0.009† 0.02† 0.06† 0.30 0.69 0.13
OR odds ratio, 95% CI 95% confidence interval, BMI body mass index, DAS28 disease activity score with 28-joint counts, DMARDs disease-modifying anti-rheumatic drugs, MTX methotrexate, PSL prednisolone, CRP C-reactive protein, TP total protein, Hb hemoglobin. *BMI-normal weight as the referent category. There were no obese patients. †p ⬍ 0.10.
4
K. Yano et al.
Mod Rheumatol, 2015; Early Online: 1–5
Table 4. Stepwise multivariate logistic regression analysis of risk factors for delayed wound healing after forefoot surgery in patients with RA.
Risk factors Hyperglycemia Operative time, 10 min Number of toes operated on
Standardized regression coefficients 0.70 1.10 0.89
Adjusted OR (95% CI) 5.72 (0.79–41.4) 1.14 (1.02–1.29) 1.34 (0.89–2.01)
p 0.09 0.028* 0.16
Downloaded by [Chinese University of Hong Kong] at 03:01 11 November 2015
OR odds ratio, 95% CI 95% confidence interval. *p ⬍ 0.05.
operated on (p ⫽ 0.02, OR ⫽ 1.54, 95% CI: 1.07–2.23), and high number of surgical wounds (p ⫽ 0.06, OR ⫽ 1.59, 95% CI: 0.98– 2.58) satisfied our entry criterion (Table 3). Variables excluded by the stepwise procedure were tourniquet time and the number of surgical wounds. Finally, multivariate logistic regression analysis showed that longer operative time (p ⫽ 0.028) was an independent risk factor for delayed healing (Table 4). The ROC curve was generated to determine a cutoff value of operative time for the risk of delayed wound healing; however, the area under the ROC curve (AUC) showed low accuracy for prediction (cutoff ⫽ 89.0 min with a specificity of 30.7% and sensitivity of 92.3%, AUC ⫽ 0.646).
Discussion There are conflicting reports on the trend in the number of elective orthopedic surgical procedures performed on patients with RA. While some investigators have surmised that the number has been decreasing [5], there were some reports that the number of foot and ankle procedures performed on RA patients has been increasing in the past several years [3,4]. Since delayed wound healing is one of the most common complications of foot and ankle surgeries for patients with RA, the identification of risk factors for delayed wound healing is important for surgeons. Ishie et al. studied the systemic and local risk factors and the effect of surgical procedures after forefoot surgery in patients with RA and reported delayed rate of wound healing as 18.0% [10]. Their rate of delayed wound healing was similar to the rate found in the present study (20.8%), although they defined delayed wound healing as wounds healing more than three weeks after surgery, as opposed to more than two weeks after surgery in our study. Although surgeons aim to reduce postoperative adverse events, eliminating operative complications from foot surgeries is difficult, especially for patients with RA. The combination of poor peripheral circulation and weak, friable skin impedes wound healing [11]; concomitant diabetes mellitus (DM) [12], protein malnutrition, tobacco smoking [13,14], steroids, and immunosuppressants [6] have also been reported to be associated with delayed wound healing. In the present study, longer operative time was shown to be the risk factor for delayed wound healing after forefoot surgery in RA patients. Since the operative time, the tourniquet time, the number of toes operated on, and the number of surgical wounds are associated with each other (Pearson’s product-moment correlation coefficient between the operative time and three other variables from our data were 0.89, 0.48, and 0.63, respectively), it is difficult to identify the true determinants of the delayed wound healing among them. However, the results of this study showed that the operative time was the major determinant for the operative complication. Longer operative time may be associated with local ischemia, which leads to delayed wound healing. Surgery on the rheumatoid forefoot is rather complex. Correction of a rheumatoid forefoot deformity may involve hallux valgus osteotomy, metatarsal shortening osteotomies of the lesser toes, and lengthening of the extensor digitorum longus and/or extensor
hallucis longus tendons, all during the same operative procedure on occasion. Therefore, surgical procedures for the rheumatoid forefoot tend to require prolonged operative time. The key to shortening the operative time for the rheumatoid forefoot is for surgeons and the operative staff to increase their operative skill. A study of 4762 patients with RA, who underwent total hip arthroplasties (THA, n ⫽ 1515) or total knee arthroplasties (TKA, n ⫽ 3247), found that increased operative experience performing total joint arthroplasty (TJA) in patients with RA was associated with a decreased risk of operative complications, irrespective of the surgeons’ overall experience performing TJA [15]. Since the number of foot surgeries for patients with RA is smaller than the number of THA or TKA, surgeons would rather obtain training at a high-volume institution treating patients with rheumatoid forefoot deformities. Though concomitant DM has frequently been linked to complications associated with soft-tissue healing [12], hyperglycemia was not associated with delayed wound healing significantly in this study. Considering the fact that delayed wound healing had occurred in three of five hyperglycemic patients (60%), which was far higher than in non-hyperglycemic patients (19.8%, 37/187), a statistical power might not be enough to detect significant difference. This study has some limitations. Since the study design was retrospective, we were unable to obtain all the relevant clinical data for the study patients. Though not all delayed healed wounds are infected, any surgical site infection (SSI) may cause delayed healing. On the other hand, since the skin is the major barrier between our tissues and the environment to prevent infection, delayed healed wounds resulted in a higher susceptibility to secondary infections. We could not analyze the relationship between delayed wound healing and SSI in this study, because we did not collect the detailed data of SSI in detail including bacterial wound culture. One of our study strengths, however, is the relatively large number of study participants compared with other studies of delayed wound healing after rheumatoid forefoot surgeries. Since there were no cases missed during the study period, the selection bias was minimized. In conclusion, longer operative time was a risk of delayed wound healing after surgery for rheumatoid forefoot deformities. Surgeons performing these surgeries should attempt to shorten operative times in order to reduce the risk of delayed wound healing. For prolonged rheumatoid forefoot surgery, the surgeon must take care to provide treatment that takes into consideration the possibility of delayed wound healing.
Acknowledgments We appreciate the members of Institute of Rheumatology, Tokyo Women’s Medical University for their effort on IORRA cohort study.
Conflict of interest K. Y. received honorarium for the lecture from Janssen Pharmaceutical K.K., Mitsubishi Tanabe Pharma Co., Santen Pharmaceutical Co., Ltd., and Takeda Pharmaceutical Co., Ltd. K. I. received honorarium for the lecture and/or unrestricted research grants from AbbVie, Inc., Asahi Kasei Pharma Corp., Astellas Pharma Inc., Bristol-Myers Squibb Co., Chugai Pharmaceutical Co., Eisai Co., Ltd., Hisamitsu Pharmaceutical Co. Inc., Janssen Pharmaceutical K.K., Kaken Pharmaceutical Co. Ltd., Mitsubishi Tanabe Pharma Co., Santen Pharmaceutical Co., Ltd., Taisho Toyama Pharmaceutical Co. Ltd., and Takeda Pharmaceutical Co., Ltd. H. Y. received honorarium for the lecture or consultancy from AbbVie, Inc., Astellas Pharma Inc., Bristol-Myers Squibb Co., Chugai Pharmaceutical Co., Daiichi Sankyo Co. Ltd., Mitsubishi Tanabe Pharma
DOI 10.3109/14397595.2015.1071456
Co., Nippon Kayaku Co. Ltd., Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., Teijin Pharma Ltd., and UCB Japan Co. Ltd. A. T. received honorarium for the lecture and/or unrestricted research grants from AbbVie, Inc., Eisai Co., Ltd., Mitsubishi Tanabe Pharma Co., Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., and Teijin Pharma Ltd. S. M. received honorarium for the lecture and/or unrestricted research grants from AbbVie, Inc., Asahi Kasei Pharma Corp., Bristol-Myers Squibb Co., Chugai Pharmaceutical Co., Daiichi Sankyo Co. Ltd., Eisai Co. Ltd., Mitsubishi Tanabe Pharma Co., Nakashima Medical Co. Ltd., Santen Pharmaceutical Co. Ltd., Taisho Toyama Pharmaceutical Co. Ltd., and Takeda Pharmaceutical Co. Ltd. The sponsors were not involved in the study design; collection, analysis, and interpretation of data; writing of the paper; and/or decision to submit for publication. For the remaining author, no conflict of interest is declared.
Downloaded by [Chinese University of Hong Kong] at 03:01 11 November 2015
References 1. Michelson J, Easley M, Wigley FM, Hellmann D. Foot and ankle problems in rheumatoid arthritis. Foot ankle Int. 1994;15(11): 608–13. 2. Yamanaka H, Seto Y, Tanaka E, Furuya T, Nakajima A, Ikari K, et al. Management of rheumatoid arthritis: the 2012 perspective. Mod Rheumatol. 2013;23(1):1–7. 3. Momohara S, Inoue E, Ikari K, Ochi K, Ishida O, Yano K, et al. Recent Trends in Orthopedic Surgery Aiming to Improve Quality of Life for Those with Rheumatoid Arthritis: Data from a Large Observational Cohort. J Rheumatol. 2014;41(5):862–6. 4. Momohara S, Tanaka S, Nakamura H, Mibe J, Iwamoto T, Ikari K, et al. Recent trends in orthopedic surgery performed in Japan for rheumatoid arthritis. Mod Rheumatol. 2011;21(4):337–42. 5. Nikiphorou E, Carpenter L, Morris S, Macgregor AJ, Dixey J, Kiely P, et al. Hand and foot surgery rates in rheumatoid arthritis have declined from 1986 to 2011, but large-joint replacement rates remain unchanged: results from two UK inception cohorts. Arthritis Rheumatol (Hoboken, NJ). 2014;66(5):1081–9. 6. Reeves CL, Peaden AJ, Shane AM. The complications encountered with the rheumatoid surgical foot and ankle. Clin Podiatr Med Surg. 2010;27(2):313–25. 7. Bibbo C, Anderson RB, Davis WH, Norton J. The influence of rheumatoid chemotherapy, age, and presence of rheumatoid nodules
Longer operative time is the risk for delayed wound healing 5
8.
9.
10. 11. 12. 13. 14. 15.
16.
17. 18. 19. 20.
on postoperative complications in rheumatoid foot and ankle surgery: analysis of 725 procedures in 104 patients. Foot Ankle Int. 2003; 24(1):40–4. Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988;31(3):315–24. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults–The Evidence Report. National Institutes of Health. Obes Res. 1998;6 Suppl 2: 51S–209S. Ishie S, Ito H, Azukizawa M, Furu M, Ishikawa M, Ogino H, et al. Delayed wound healing after forefoot surgery in patients with rheumatoid arthritis. Mod Rheumatol. 2015;25(3):367–72. Jeng C, Campbell J. Current concepts review: the rheumatoid forefoot. Foot Ankle Int. 2008;29(9):959–68. Chaudhary SB, Liporace FA, Gandhi A, Donley BG, Pinzur MS, Lin SS. Complications of ankle fracture in patients with diabetes. J Am Acad Orthop Surg. 2008;16(3):159–70. Janis JE, Harrison B. Wound healing: part I. Basic science. Plast Reconstr Surg. 2014;133(2):199e–207e. Bibbo C, Jaffe L, Goldkind A. Complications of digital and lesser metatarsal surgery. Clin Podiatr Med Surg Elsevier Ltd. 2010;27(4):485–507. Ravi B, Croxford R, Austin PC, Hollands S, Paterson JM, Bogoch E, et al. Increased surgeon experience with rheumatoid arthritis reduces the risk of complications following total joint arthroplasty. Arthritis Rheumatol (Hoboken, NJ). 2014;66(3):488–96. Yano K, Ikari K, Iwamoto T, Saito A, Naito Y, Kawakami K, et al. Proximal rotational closing-wedge osteotomy of the first metatarsal in rheumatoid arthritis: clinical and radiographic evaluation of a continuous series of 35 cases. Mod Rheumatol. 2013;23(5):953–8. Mitchell CL, Fleming JL, Allen R, Glenney C, Ssanford GA. Osteotomy-bunionectomy for hallux valgus. J Bone Joint Surg Am. 1958;40-A(1):41–58; discussion 59–60. McBride ED. A conservative operation for bunions. 1928. J Bone Joint Surg Am. 2002;84-A(11):2101. Mann RA, Rudicel S, Graves SC. Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy. A long-term follow-up. J Bone Joint Surg Am. 1992;74(1):124–9. Austin DW, Leventen EO. A new osteotomy for hallux valgus: a horizontally directed “V” displacement osteotomy of the metatarsal head for hallux valgus and primus varus. Clin Orthop Relat Res. 1981;(157):25–30.
ISSN: 1439-7595 (Print) 1439-7609 (Online) Journal homepage: http://www.tandfonline.com/loi/imor20
Longer operative time is the risk for delayed wound healing after forefoot surgery in patients with rheumatoid arthritis Koichiro Yano, Katsunori Ikari, Yoshihito Takatsuki, Atsuo Taniguchi, Hisashi Yamanaka & Shigeki Momohara To cite this article: Koichiro Yano, Katsunori Ikari, Yoshihito Takatsuki, Atsuo Taniguchi, Hisashi Yamanaka & Shigeki Momohara (2015): Longer operative time is the risk for delayed wound healing after forefoot surgery in patients with rheumatoid arthritis, Modern Rheumatology, DOI: 10.3109/14397595.2015.1071456 To link to this article: http://dx.doi.org/10.3109/14397595.2015.1071456
Published online: 07 Sep 2015.
Submit your article to this journal
Article views: 37
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imor20 Download by: [Chinese University of Hong Kong]
Date: 11 November 2015, At: 03:01
http://informahealthcare.com/mor ISSN 1439-7595 (print), 1439-7609 (online) Mod Rheumatol, 2015; Early Online: 1–5 © 2015 Japan College of Rheumatology DOI: 10.3109/14397595.2015.1071456
ORIGINAL ARTICLE
Longer operative time is the risk for delayed wound healing after forefoot surgery in patients with rheumatoid arthritis Koichiro Yano1, Katsunori Ikari1,2, Yoshihito Takatsuki1, Atsuo Taniguchi1, Hisashi Yamanaka1, and Shigeki Momohara1
Downloaded by [Chinese University of Hong Kong] at 03:01 11 November 2015
1Institute of Rheumatology, Tokyo Women’s Medical University, Shinjuku, Tokyo Japan and 2CREST, JST, Shinjuku, Tokyo Japan
Abstract
Keywords
Objectives. Forefoot deformities are common in patients with rheumatoid arthritis (RA) and often require operative treatment. There is a high rate of delayed wound healing after foot surgery, especially among patients with RA. The aim of this study was to identify risk factors of delayed wound healing in RA patients who had undergone forefoot surgery. Methods. This study was a retrospective observational study designed to analyze the outcomes of all consecutive RA patients who had undergone toe arthroplasty from April 2010 through May 2014 at a single institute. Putative risk factors for delayed wound healing were assessed using univariate logistic regression analysis. Variables with α ⫽ 0.1 were then subjected to stepwise multivariate logistic regression analysis. Results. A total of 192 RA patients (192 feet) were included in this study. Delayed wound healing was seen in 40 feet (40/192 [20.8%]). A stepwise multivariate logistic regression analysis revealed that longer operative time was the risk factor associated with delayed wound healing in RA patients undergoing forefoot surgery (p ⫽ 0.028, odds ratio ⫽ 1.19 [per 10 min], 95% confidence interval [CI]: 1.07–1.32). Conclusions. This finding emphasizes the importance of preventing operative complications during forefoot surgery.
Delayed wound healing, Forefoot surgery, Operative time, Rheumatoid arthritis History Received 16 February 2015 Accepted 5 July 2015)
Introduction
Patients and methods
Rheumatoid arthritis (RA) is a major chronic inflammatory disease that is characterized by destruction of multiple joints. Most patients with RA have painful symptoms associated with the foot and ankle [1], and forefoot deformity is a common problem. Although powerful antirheumatic drugs, including biologic agents, have reduced disease activity [2], conflicting results on the recent trend of the number of foot surgeries for RA patients have been reported [3–5]. Since these powerful antirheumatic medications cause immunosuppression, postoperative adverse events such as delayed wound healing are of concern [6]. In particular, there is a high rate of delayed wound healing after foot surgery, because the procedures are performed on joints lined with thin soft tissue, which occasionally has impaired circulation. These reconstructive procedures often require multiple incisions and soft tissue dissections without the luxury of large bridges of undisturbed planes of soft tissue [7]. Moreover, RA patients often require a number of simultaneous operative procedures to correct their foot deformities, which may also cause wound-healing problems. Therefore, rheumatoid forefoot deformities present a difficult challenge to surgeons. The aim of this study was to identify the risk factors of delayed wound healing after forefoot surgery in patients with RA.
This was a retrospective observational study designed to analyze the outcomes of patients who had undergone primary forefoot surgery at a single institute from April 2010 to May 2014. This study was a part of Institute of Rheumatology, Rheumatoid Arthritis cohort (IORRA), a large prospective observational cohort study of RA patients. The Ethics Committee of the institute approved this study.
Correspondence to: Katsunori Ikari, MD, PhD, Institute of Rheumatology, Tokyo Women’s Medical University, 10-22 Kawada, Shinjuku, Tokyo 162-0054, Japan. Tel: ⫹ 81-3-5269-1725. Fax: ⫹ 81-3-5269-1726. E-mail: [email protected]
Patients The study included patients with RA in whom conservative nonoperative treatment for moderate-to-severe symptomatic forefoot deformity failed and who then underwent toe arthroplasty (e.g., hallux valgus osteotomy, first metatarsal–phalangeal joint arthrodesis, metatarsal shortening osteotomy, and/or resection arthroplasty). All patients who underwent toe arthroplasty fulfilled the 1987 American College of Rheumatology revised criteria for RA [8]. There were no patients with other concomitant autoimmune diseases (e.g., systemic lupus erythematosus, scleroderma, polymyositis, dermatomyositis, and mixed connective tissue disease) except concomitant Sjögren’s syndrome in some patients. Only primary surgery was included if a patient had undergone forefoot surgeries many times in one side of feet. The first surgery in the study duration was included if a patient had undergone elective surgeries in both feet separately. Patients who were operated on both feet at the same time were excluded. RA patients stopped taking biologic disease-modifying antirheumatic drugs (DMARDs) during the perioperative period. In
2
K. Yano et al.
Mod Rheumatol, 2015; Early Online: 1–5
Downloaded by [Chinese University of Hong Kong] at 03:01 11 November 2015
Table 1. Demographic and clinical characteristics of patients at the surgery (n ⫽ 192). Age at surgery, years Gender, female BMI Disease duration, years DAS28 Hyperglycemia Smoking history, ever PSL dose, mg/day MTX dose, mg/week Use of biologic DMARDs Infliximab Etanercept Adalimumab Golimumab Tocilizumab Abatacept Operative time, minutes Tourniquet time, minutes Number of toes operated on Number of surgical wounds
60.6 (28 to 85) 180 (93.8) 20.8 19.3 (0 to 47) 3.28 (1.14 to 5.56) 5 (2.6) 55 (29.4) 2.06 (0 to 10) 7.23 (0 to 16) 42 (21.9) 8 (4.2) 23 (12.0) 5 (2.6) 2 (1.0) 1 (0.5) 3 (1.6) 108.6 (45 to 227) 100.8 (47 to 207) 4.1 (1 to 5) 2.5 (1 to 4)
BMI body mass index, DAS28 disease activity score with 28-joint counts, PSL prednisolone, MTX methotrexate, DMARDs disease-modifying anti-rheumatic drugs. Data are presented as mean (range) or n (%).
general, biologic DMARDs are withheld for 2–4 weeks prior to elective surgeries and are restarted two weeks postoperatively. All conventional synthetic DMARDs, including methotrexate (MTX), were continued throughout the perioperative period. Routine perioperative prophylactic antibiotics were administered twice, immediately before the incision and immediately after the surgery. Cefazolin was the agent of choice and fosfomycin was administered instead to patients allergic to penicillin and penicillin-like antibiotics. All patients in this study underwent elective forefoot surgery performed by or under the supervision of three stuff surgeons
who had extensive experience in the rheumatoid foot surgeries. A tourniquet was used routinely. It was deflated for at least 10 min if the tourniquet time was more than 120 min. Patients were allowed to walk, bearing weight on the heel, starting the day after surgery. Delayed wound healing was defined as wounds that were not healed more than two weeks after the procedure (sutures are removed two weeks after joint surgeries), though it may be rather aggressive in people with bad skin, decreased blood flow, and other medical co-morbidities. Information on the clinical characteristics of the patients was obtained in part from the observational cohort database, and the following perioperative data were obtained from medical records: biologic and synthetic DMARDs, operative procedures, medical history, and laboratory tests. Statistical analysis The significance of differences in frequencies of delayed wound healing across the surgeons was tested by the Fisher’s exact test. Putative risk factors for delayed wound healing were assessed using univariate logistic regression analysis (univariate-based feature selection). Each variable with α ⫽ 0.1 was subjected to stepwise multivariate logistic regression analysis to evaluate its relationship with the dependent variable, delayed wound healing. The putative risk factors tested by univariate analysis were as follows: age at surgery, gender, body mass index (BMI)-based weight classification (underweight [BMI ⬍ 18.5], normal weight [BMI ⫽ 18.5–24.9], overweight [BMI ⫽ 25.0–29.9], and obesity [BMI ⱖ 30]) [9], disease duration, disease activity score with 28-joint counts (DAS28), use of biologic DMARDs, dose of MTX, dose of prednisolone (PSL), history of smoking, hyperglycemia (HbA1c ⱖ 6.5%), operative time (per 10 min), tourniquet time (per 10 min), number of toes operated on, number of surgical wounds, hemoglobin level (Hb), serum total protein (TP), and C-reactive protein level (CRP). The significance level was set at 0.05. When the continuous variables were detected as the risk for delayed
Table 2. Operative procedures for first toe and lessor toes performed for the patients (n ⫽ 192).
Operative procedures for first toe Proximal rotational closing-wedge osteotomy [16] Proximal rotational closing-wedge osteotomy [16] and arthrodesis of metatarsophalangeal joint Proximal rotational closing-wedge osteotomy [16] and arthrodesis of interphalangeal joint Resection arthroplasty Mitchell osteotomy [17] Arthrodesis of interphalangeal joint Arthrodesis of metatarsophalangeal joint Modified McBride procedure [18] Crescentic proximal metatarsal osteotomy [19] Chevron osteotomy [20] No operative procedure on first toe Operative procedures for lesser toes Distal shortening oblique osteotomies of lesser metatarsals Distal shortening oblique osteotomies of lesser metatarsals and arthroplasty of fifth metatarsophalangeal joint Distal shortening oblique osteotomies and resection arthroplasty of lesser metatarsals Distal shortening oblique osteotomies of lesser metatarsals and arthrodesis of proximal interphalangeal joints Distal shortening oblique osteotomy of lesser metatarsals and incision of capsules of metatarsophalangeal joints Incision of capsule of metatarsophalangeal joints Arthrodesis of proximal interphalangeal joints Z-lengthening of extensor digitorum longus Resection arthroplasties of lesser metatarsals No operative procedure on lesser toes NA not applicable. The counts for delayed wound healings were overlapped for the first toes and lesser toes. *For key to incision numbers see Figure 1.
Count
Delayed wound healing
Skin incision*
112 2 3 22 17 11 7 2 2 1 13
25 0 1 6 4 1 1 0 0 0 2
1, 2 1, 2 1, 2, 3 1 1 3 1 1 1, 2 1 NA
133 3
31 1
4 and/or 5 4 and 5
5 4
0 0
4 and/or 5 4 and/or 5 and 6
4
1
4 and/or 5
2 1 1 25 14
0 1 0 6 0
4 and/or 5 6 4 7 NA
Longer operative time is the risk for delayed wound healing 3
DOI 10.3109/14397595.2015.1071456
Downloaded by [Chinese University of Hong Kong] at 03:01 11 November 2015
Figure 1. The skin incision positions shown in Table 2. 1, 2) A straight midline dorsal incision over the first MTP joint (1) or to the TMT joint (2). 3) A straight midline dorsal incision over the first IP joint. 4) A lazy S-shaped dorsal incision that began from the second MTP joint, passed over the third metatarsal and ended at the base of the fourth metatarsal. 5) A vertical incision at the lateral aspect of the fifth metatarsal. 6) A straight midline dorsal incision over the PIP joint. 7) A curved plantar incision over the heads of the metatarsals.
wound healing, receiver operating characteristic (ROC) curves were then generated to determine a cutoff value for each risk factor. All analyses were performed using the R Statistical Package, version 2.14.2 (http://www.r-project.org/).
Results A total of 306 primary forefoot surgeries (218 patients) were performed during the study period. Of these, 62 patients received forefoot surgeries on both feet separately and 26 patients received the surgeries on both feet at the same time. Finally, 192 RA patients with a total of 192 feet were included in this study. Most of the operative procedures (n ⫽ 159) were performed by three stuff surgeons with subspecialty training in foot and ankle surgery and the others (n ⫽ 33) were performed by ten other board certified orthopedic surgeons under the supervision of the three stuff
surgeons. All the patients were followed until their wounds healed after surgery. The baseline characteristics of the patients are shown in Table 1. The average age at surgery was 60.6 (28–85) years, average duration of RA was 19.3 (0–47) years, and the average operative time was 108.6 (45–227) min. The operative procedures performed for the patients including skin incision positions are listed in Table 2. Delayed wound healing was found at the site of surgery in 40 of 192 feet (20.8%). All of these wounds healed after conservative treatment. There were no significant differences in frequencies of delayed wound healing across the surgeons (p ⫽ 0.30). Univariate logistic regression analysis found that hyperglycemia (p ⫽ 0.07, odds ratio [OR] ⫽ 5.47, 95% confidence interval [CI]: 0.88–34.0), longer operative time (p ⫽ 0.002, OR ⫽ 1.18 [per 10 min], 95% CI: 1.06–1.31), longer tourniquet time (p ⫽ 0.009, OR ⫽ 1.26 [per 10 min], 95% CI: 1.06–1.49), high number of toes
Table 3. Univariate logistic regression analysis of putative risk factors for delayed wound healing after forefoot surgery in patients with RA. Putative risk Age at surgery, years Gender, female BMI-underweight* BMI-overweight* Disease duration, years DAS28 Hyperglycemia Smoking history (ever) PSL dose, mg/day MTX dose, mg/week Use of biologic DMARDs Operative time, 10 min Tourniquet time, 10 min Number of toes operated on Number of surgical wounds Serum CRP level, mg/dl Serum TP level, g/dl Serum Hb level, g/dl
Standardized regression coefficients 0.03 ⫺ 0.41 0.30 0.10 ⫺ 0.17 0.90 0.67 0.36 0.42 0.29 ⫺ 0.36 1.41 1.31 1.34 0.86 0.40 0.17 ⫺ 0.65
OR (95% CI) 1.00 (0.97–1.04) 0.50 (0.14–1.77) 1.21 (0.51–2.89) 1.07 (0.28–4.12) 0.99 (0.95–1.03) 1.44 (0.80–2.57) 5.47 (0.88–34.0) 1.38 (0.66–2.90) 1.07 (0.94–1.22) 1.03 (0.94–1.12) 0.70 (0.29–1.73) 1.18 (1.06–1.31) 1.26 (1.06–1.49) 1.54 (1.07–2.23) 1.59 (0.98–2.58) 1.21 (0.84–1.75) 1.15 (0.58–2.25) 0.84 (0.67–1.05)
p 0.95 0.28 0.66 0.92 0.70 0.23 0.07† 0.40 0.32 0.54 0.44 0.002† 0.009† 0.02† 0.06† 0.30 0.69 0.13
OR odds ratio, 95% CI 95% confidence interval, BMI body mass index, DAS28 disease activity score with 28-joint counts, DMARDs disease-modifying anti-rheumatic drugs, MTX methotrexate, PSL prednisolone, CRP C-reactive protein, TP total protein, Hb hemoglobin. *BMI-normal weight as the referent category. There were no obese patients. †p ⬍ 0.10.
4
K. Yano et al.
Mod Rheumatol, 2015; Early Online: 1–5
Table 4. Stepwise multivariate logistic regression analysis of risk factors for delayed wound healing after forefoot surgery in patients with RA.
Risk factors Hyperglycemia Operative time, 10 min Number of toes operated on
Standardized regression coefficients 0.70 1.10 0.89
Adjusted OR (95% CI) 5.72 (0.79–41.4) 1.14 (1.02–1.29) 1.34 (0.89–2.01)
p 0.09 0.028* 0.16
Downloaded by [Chinese University of Hong Kong] at 03:01 11 November 2015
OR odds ratio, 95% CI 95% confidence interval. *p ⬍ 0.05.
operated on (p ⫽ 0.02, OR ⫽ 1.54, 95% CI: 1.07–2.23), and high number of surgical wounds (p ⫽ 0.06, OR ⫽ 1.59, 95% CI: 0.98– 2.58) satisfied our entry criterion (Table 3). Variables excluded by the stepwise procedure were tourniquet time and the number of surgical wounds. Finally, multivariate logistic regression analysis showed that longer operative time (p ⫽ 0.028) was an independent risk factor for delayed healing (Table 4). The ROC curve was generated to determine a cutoff value of operative time for the risk of delayed wound healing; however, the area under the ROC curve (AUC) showed low accuracy for prediction (cutoff ⫽ 89.0 min with a specificity of 30.7% and sensitivity of 92.3%, AUC ⫽ 0.646).
Discussion There are conflicting reports on the trend in the number of elective orthopedic surgical procedures performed on patients with RA. While some investigators have surmised that the number has been decreasing [5], there were some reports that the number of foot and ankle procedures performed on RA patients has been increasing in the past several years [3,4]. Since delayed wound healing is one of the most common complications of foot and ankle surgeries for patients with RA, the identification of risk factors for delayed wound healing is important for surgeons. Ishie et al. studied the systemic and local risk factors and the effect of surgical procedures after forefoot surgery in patients with RA and reported delayed rate of wound healing as 18.0% [10]. Their rate of delayed wound healing was similar to the rate found in the present study (20.8%), although they defined delayed wound healing as wounds healing more than three weeks after surgery, as opposed to more than two weeks after surgery in our study. Although surgeons aim to reduce postoperative adverse events, eliminating operative complications from foot surgeries is difficult, especially for patients with RA. The combination of poor peripheral circulation and weak, friable skin impedes wound healing [11]; concomitant diabetes mellitus (DM) [12], protein malnutrition, tobacco smoking [13,14], steroids, and immunosuppressants [6] have also been reported to be associated with delayed wound healing. In the present study, longer operative time was shown to be the risk factor for delayed wound healing after forefoot surgery in RA patients. Since the operative time, the tourniquet time, the number of toes operated on, and the number of surgical wounds are associated with each other (Pearson’s product-moment correlation coefficient between the operative time and three other variables from our data were 0.89, 0.48, and 0.63, respectively), it is difficult to identify the true determinants of the delayed wound healing among them. However, the results of this study showed that the operative time was the major determinant for the operative complication. Longer operative time may be associated with local ischemia, which leads to delayed wound healing. Surgery on the rheumatoid forefoot is rather complex. Correction of a rheumatoid forefoot deformity may involve hallux valgus osteotomy, metatarsal shortening osteotomies of the lesser toes, and lengthening of the extensor digitorum longus and/or extensor
hallucis longus tendons, all during the same operative procedure on occasion. Therefore, surgical procedures for the rheumatoid forefoot tend to require prolonged operative time. The key to shortening the operative time for the rheumatoid forefoot is for surgeons and the operative staff to increase their operative skill. A study of 4762 patients with RA, who underwent total hip arthroplasties (THA, n ⫽ 1515) or total knee arthroplasties (TKA, n ⫽ 3247), found that increased operative experience performing total joint arthroplasty (TJA) in patients with RA was associated with a decreased risk of operative complications, irrespective of the surgeons’ overall experience performing TJA [15]. Since the number of foot surgeries for patients with RA is smaller than the number of THA or TKA, surgeons would rather obtain training at a high-volume institution treating patients with rheumatoid forefoot deformities. Though concomitant DM has frequently been linked to complications associated with soft-tissue healing [12], hyperglycemia was not associated with delayed wound healing significantly in this study. Considering the fact that delayed wound healing had occurred in three of five hyperglycemic patients (60%), which was far higher than in non-hyperglycemic patients (19.8%, 37/187), a statistical power might not be enough to detect significant difference. This study has some limitations. Since the study design was retrospective, we were unable to obtain all the relevant clinical data for the study patients. Though not all delayed healed wounds are infected, any surgical site infection (SSI) may cause delayed healing. On the other hand, since the skin is the major barrier between our tissues and the environment to prevent infection, delayed healed wounds resulted in a higher susceptibility to secondary infections. We could not analyze the relationship between delayed wound healing and SSI in this study, because we did not collect the detailed data of SSI in detail including bacterial wound culture. One of our study strengths, however, is the relatively large number of study participants compared with other studies of delayed wound healing after rheumatoid forefoot surgeries. Since there were no cases missed during the study period, the selection bias was minimized. In conclusion, longer operative time was a risk of delayed wound healing after surgery for rheumatoid forefoot deformities. Surgeons performing these surgeries should attempt to shorten operative times in order to reduce the risk of delayed wound healing. For prolonged rheumatoid forefoot surgery, the surgeon must take care to provide treatment that takes into consideration the possibility of delayed wound healing.
Acknowledgments We appreciate the members of Institute of Rheumatology, Tokyo Women’s Medical University for their effort on IORRA cohort study.
Conflict of interest K. Y. received honorarium for the lecture from Janssen Pharmaceutical K.K., Mitsubishi Tanabe Pharma Co., Santen Pharmaceutical Co., Ltd., and Takeda Pharmaceutical Co., Ltd. K. I. received honorarium for the lecture and/or unrestricted research grants from AbbVie, Inc., Asahi Kasei Pharma Corp., Astellas Pharma Inc., Bristol-Myers Squibb Co., Chugai Pharmaceutical Co., Eisai Co., Ltd., Hisamitsu Pharmaceutical Co. Inc., Janssen Pharmaceutical K.K., Kaken Pharmaceutical Co. Ltd., Mitsubishi Tanabe Pharma Co., Santen Pharmaceutical Co., Ltd., Taisho Toyama Pharmaceutical Co. Ltd., and Takeda Pharmaceutical Co., Ltd. H. Y. received honorarium for the lecture or consultancy from AbbVie, Inc., Astellas Pharma Inc., Bristol-Myers Squibb Co., Chugai Pharmaceutical Co., Daiichi Sankyo Co. Ltd., Mitsubishi Tanabe Pharma
DOI 10.3109/14397595.2015.1071456
Co., Nippon Kayaku Co. Ltd., Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., Teijin Pharma Ltd., and UCB Japan Co. Ltd. A. T. received honorarium for the lecture and/or unrestricted research grants from AbbVie, Inc., Eisai Co., Ltd., Mitsubishi Tanabe Pharma Co., Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., and Teijin Pharma Ltd. S. M. received honorarium for the lecture and/or unrestricted research grants from AbbVie, Inc., Asahi Kasei Pharma Corp., Bristol-Myers Squibb Co., Chugai Pharmaceutical Co., Daiichi Sankyo Co. Ltd., Eisai Co. Ltd., Mitsubishi Tanabe Pharma Co., Nakashima Medical Co. Ltd., Santen Pharmaceutical Co. Ltd., Taisho Toyama Pharmaceutical Co. Ltd., and Takeda Pharmaceutical Co. Ltd. The sponsors were not involved in the study design; collection, analysis, and interpretation of data; writing of the paper; and/or decision to submit for publication. For the remaining author, no conflict of interest is declared.
Downloaded by [Chinese University of Hong Kong] at 03:01 11 November 2015
References 1. Michelson J, Easley M, Wigley FM, Hellmann D. Foot and ankle problems in rheumatoid arthritis. Foot ankle Int. 1994;15(11): 608–13. 2. Yamanaka H, Seto Y, Tanaka E, Furuya T, Nakajima A, Ikari K, et al. Management of rheumatoid arthritis: the 2012 perspective. Mod Rheumatol. 2013;23(1):1–7. 3. Momohara S, Inoue E, Ikari K, Ochi K, Ishida O, Yano K, et al. Recent Trends in Orthopedic Surgery Aiming to Improve Quality of Life for Those with Rheumatoid Arthritis: Data from a Large Observational Cohort. J Rheumatol. 2014;41(5):862–6. 4. Momohara S, Tanaka S, Nakamura H, Mibe J, Iwamoto T, Ikari K, et al. Recent trends in orthopedic surgery performed in Japan for rheumatoid arthritis. Mod Rheumatol. 2011;21(4):337–42. 5. Nikiphorou E, Carpenter L, Morris S, Macgregor AJ, Dixey J, Kiely P, et al. Hand and foot surgery rates in rheumatoid arthritis have declined from 1986 to 2011, but large-joint replacement rates remain unchanged: results from two UK inception cohorts. Arthritis Rheumatol (Hoboken, NJ). 2014;66(5):1081–9. 6. Reeves CL, Peaden AJ, Shane AM. The complications encountered with the rheumatoid surgical foot and ankle. Clin Podiatr Med Surg. 2010;27(2):313–25. 7. Bibbo C, Anderson RB, Davis WH, Norton J. The influence of rheumatoid chemotherapy, age, and presence of rheumatoid nodules
Longer operative time is the risk for delayed wound healing 5
8.
9.
10. 11. 12. 13. 14. 15.
16.
17. 18. 19. 20.
on postoperative complications in rheumatoid foot and ankle surgery: analysis of 725 procedures in 104 patients. Foot Ankle Int. 2003; 24(1):40–4. Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988;31(3):315–24. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults–The Evidence Report. National Institutes of Health. Obes Res. 1998;6 Suppl 2: 51S–209S. Ishie S, Ito H, Azukizawa M, Furu M, Ishikawa M, Ogino H, et al. Delayed wound healing after forefoot surgery in patients with rheumatoid arthritis. Mod Rheumatol. 2015;25(3):367–72. Jeng C, Campbell J. Current concepts review: the rheumatoid forefoot. Foot Ankle Int. 2008;29(9):959–68. Chaudhary SB, Liporace FA, Gandhi A, Donley BG, Pinzur MS, Lin SS. Complications of ankle fracture in patients with diabetes. J Am Acad Orthop Surg. 2008;16(3):159–70. Janis JE, Harrison B. Wound healing: part I. Basic science. Plast Reconstr Surg. 2014;133(2):199e–207e. Bibbo C, Jaffe L, Goldkind A. Complications of digital and lesser metatarsal surgery. Clin Podiatr Med Surg Elsevier Ltd. 2010;27(4):485–507. Ravi B, Croxford R, Austin PC, Hollands S, Paterson JM, Bogoch E, et al. Increased surgeon experience with rheumatoid arthritis reduces the risk of complications following total joint arthroplasty. Arthritis Rheumatol (Hoboken, NJ). 2014;66(3):488–96. Yano K, Ikari K, Iwamoto T, Saito A, Naito Y, Kawakami K, et al. Proximal rotational closing-wedge osteotomy of the first metatarsal in rheumatoid arthritis: clinical and radiographic evaluation of a continuous series of 35 cases. Mod Rheumatol. 2013;23(5):953–8. Mitchell CL, Fleming JL, Allen R, Glenney C, Ssanford GA. Osteotomy-bunionectomy for hallux valgus. J Bone Joint Surg Am. 1958;40-A(1):41–58; discussion 59–60. McBride ED. A conservative operation for bunions. 1928. J Bone Joint Surg Am. 2002;84-A(11):2101. Mann RA, Rudicel S, Graves SC. Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy. A long-term follow-up. J Bone Joint Surg Am. 1992;74(1):124–9. Austin DW, Leventen EO. A new osteotomy for hallux valgus: a horizontally directed “V” displacement osteotomy of the metatarsal head for hallux valgus and primus varus. Clin Orthop Relat Res. 1981;(157):25–30.
