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Sprunggelenk- und Vorfußtherapie in der Rheumatologie
– wie lange können wir den aufrechten Gang
erhalten? AKTUEL RHEUMATOL 2021. [DOI: 10.1055/a-1552-3007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungDie Therapie des rheumatischen Fußes ist komplex und erstreckt sich
über ein breites Spektrum von konservativen und operativen
Behandlungsmethoden. Das Ziel ist, bei guter Stabilität,
möglichst viel Beweglichkeit zu erhalten. Nebenerkrankungen wie die
Polyneuropathie mit und ohne Diabetes mellitus beeinflussen die
Behandlungsoptionen entscheidend. Aufgrund dessen, dass beim Rheumatiker
multiple Gelenke befallen sind, unterliegen die orthopädische
Schuhversorgung und die operative Therapie des rheumatischen Fußes
speziellen Anforderungen im Hinblick auf das Gewicht, die Stabilität des
Schuhs und Bettung des Fußes bzw. die Zugangswege und die
Primärstabilität der Osteosynthesen. Der aufrechte Gang kann
durch einen stadiengerechten zielgerichteten Einsatz aller Therapieoption sehr
lange erhalten bleiben. Hierfür müssen die therapeutischen
Fenster erkannt und genutzt sowie eine Übertherapie vermieden
werden.
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Outcomes of Scarf and Akin Osteotomy with Intra-Articular Stepwise Lateral Soft Tissue Release for Correcting Hallux Valgus Deformity in Rheumatoid Arthritis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182010667. [PMID: 34682415 PMCID: PMC8535323 DOI: 10.3390/ijerph182010667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/04/2021] [Accepted: 10/09/2021] [Indexed: 02/08/2023]
Abstract
Background. The effectiveness of scarf and Akin osteotomy with intra-articular lateral soft tissue release for the correction of hallux valgus (HV) in patients with rheumatoid arthritis (RA) has not been elucidated. Methods. A total of 36 feet in 28 patients with RA who had scarf and Akin osteotomy with intra-articular stepwise lateral soft tissue release between 2015 and 2020 at a single institute were investigated retrospectively, with a mean follow-up period of 32.0 ± 16.9 months. Radiographic evaluations including the HV angle, intermetatarsal angle, and sesamoid position were performed preoperatively and postoperatively. Clinical outcomes were assessed using the Japanese Society of Surgery of the Foot (JSSF) hallux scale and self-administered foot evaluation questionnaire (SAFE-Q). Results. The procedure resulted in significant HV correction, with a recurrence rate of 13.9%. The JSSF scale and all five SAFE-Q subscale scores significantly improved (p < 0.05), with no major complications. More than 90% of cases achieved adequate lateral soft tissue release without sacrificing the adductor tendon of the hallux. Conclusions. Intra-articular stepwise lateral soft tissue release in combination with scarf and Akin osteotomy provided satisfactory radiographic and patient-reported outcomes for the correction of HV in patients with RA with minimum lateral soft tissue release.
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Joint-Preserving Surgery for Forefoot Deformities in Patients with Rheumatoid Arthritis: A Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18084093. [PMID: 33924481 PMCID: PMC8068870 DOI: 10.3390/ijerph18084093] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/23/2021] [Accepted: 04/08/2021] [Indexed: 11/17/2022]
Abstract
The combination of first metatarsophalangeal joint arthrodesis and resection arthroplasty of all lesser metatarsal heads has been historically considered the golden standard treatment for rheumatoid forefoot deformities. However, as recent improved management of rheumatoid arthritis have reduced progression of joint destruction, the surgical treatments for rheumatoid forefoot deformities have gradually changed from joint-sacrificing surgery, such as arthrodesis and resection arthroplasty, to joint-preserving surgery. The aim of this literature review was to provide current evidence for joint-preserving surgery for rheumatoid forefoot deformities. We focused on the indications, specific outcomes, and postsurgical complications of joint-preserving surgery in this review.
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Nash WJ, Al-Nammari S, Khan WS, Pengas IP. Surgical management of the forefoot in patients with rheumatoid arthritis - a review article. Open Orthop J 2015; 9:78-83. [PMID: 25861409 PMCID: PMC4384227 DOI: 10.2174/1874325001509010078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 01/25/2015] [Accepted: 02/03/2015] [Indexed: 11/22/2022] Open
Abstract
Foot and ankle pathologies cause a significant disease burden on rheumatoid patients. Forefoot pathologies causes pain, callosities and possibly ulceration, and can cause problems with footwear. Forefoot correction in rheumatoid patients has historically comprised of excision of diseased joints. While satisfaction was high with this procedure, complications, changing expectations and improvement in medical therapy have raised expectation of patients, physicians and surgeons alike. This review assesses the role of joint preserving osteotomies and arthrodesis, as well as associated complications. It also describes the role of the multidisciplinary team in the management of these patients.
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Affiliation(s)
- W J Nash
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, UK
| | - S Al-Nammari
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, UK
| | - W S Khan
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, UK
| | - I P Pengas
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, UK
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Correction power and complications of first tarsometatarsal joint arthrodesis for hallux valgus deformity. INTERNATIONAL ORTHOPAEDICS 2014; 39:467-76. [DOI: 10.1007/s00264-014-2601-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 11/06/2014] [Indexed: 11/25/2022]
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Abstract
Rheumatoid arthritis (RA) manifests itself in a variety of ways, with its effect being seen in around 90 % of sufferers' feet. The foot has been found to be the most common reason for incapacity in patients with RA, with the forefoot the most common area. The foot is second, behind only the hand, as the most common place for manifestation of RA. Pain in the foot is commonly the most debilitating condition, which causes the patient to seek specialist help. As well as pain, foot deformities such as hallux valgus and claw toes are common complaints. These symptoms often arise as a result of continued walking on an unstable foot, leading to painful callosities and dislocation of the metatarsophalangeal joints. Other conditions, such as pannus formation and Morton's neuroma, can be related to RA. This review sets out what we believe to be a successful approach to the rheumatoid forefoot, which aims at the relief of pain and the preservation of ambulation. Key to a successful outcome is appropriate medical control with a multidisciplinary approach that enables close liaison between orthopaedic surgeons, orthotists, and rheumatologists. Combined clinics provide this multidisciplinary care. Those treating RA need to be aware of the high incidence of foot involvement and how early intervention may benefit the patient. The aim of this article is to present current evidence to enable people to develop a treatment algorithm for this condition.
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Louwerens JWK, Schrier JCM. Rheumatoid forefoot deformity: pathophysiology, evaluation and operative treatment options. INTERNATIONAL ORTHOPAEDICS 2013; 37:1719-29. [PMID: 23892468 PMCID: PMC3764283 DOI: 10.1007/s00264-013-2014-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 06/25/2013] [Indexed: 10/26/2022]
Abstract
Despite recent advances in pharmacological management of rheumatoid arthritis, forefoot deformity, with its symptoms, remains a common problem, often requiring operative treatment. Typical deformities in these patients comprise hallux valgus and deformity of the lesser metatarsophalangeal (MTP) joints and toes. With regard to the lesser rays the standard operative procedure, advocated for the disabling forefoot pain in these patients, remains metatarsal head resection. It should be considered that with increasing success of pharmacological treatment the degree of forefoot deformity in these patients is becoming less and that resection of the lesser MTP joints is becoming more and more superfluous. This supports a trend towards metatarsal head-preserving surgery. The optimal treatment of the hallux deformity remains unclear. Fusion of the first MTP joint is, generally, recommended. This article will discuss the current surgical options in rheumatoid forefoot pathology.
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Affiliation(s)
- Jan Willem K Louwerens
- Department of Orthopaedic Surgery, Foot and Ankle Reconstruction Unit, St Maartenskliniek, Nijmegen, The Netherlands.
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Anatomy of hallux valgus in rheumatoid arthritis: radiographic analysis using a two-dimensional coordinate system. Mod Rheumatol 2012; 23:774-81. [PMID: 22930442 DOI: 10.1007/s10165-012-0739-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 08/01/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The purpose of this study is to compare the anatomy of rheumatoid hallux valgus with that of idiopathic hallux valgus from the standpoint of joint-preserving surgery. METHODS One hundred forty-eight feet of 81 rheumatoid patients were included. Feet with idiopathic hallux valgus and normal feet were compared as controls. Weight-bearing dorsoplantar radiographs of the feet were taken of each patient. A two-dimensional coordinate system was defined on the radiographic image, and 19 anatomic points of the forefoot were measured. RESULTS In rheumatoid hallux valgus, the first metatarsal head shifted medially as hallux valgus angle increased, which was similar to the deformity of idiopathic hallux valgus. Proximal deviation of the tips of the lesser toes, caused by clawing and dislocations of the metatarsophalangeal joints, occurred in rheumatoid hallux valgus. Specifically the tips of the second toes in rheumatoid hallux valgus were located more proximally than those in idiopathic hallux valgus irrespective of the severity of hallux valgus. CONCLUSIONS Corrective osteotomy of the first metatarsal is a reasonable procedure for rheumatoid hallux valgus. Additionally, correction of the second toe deformity to make a stable lateral support on the hallux may be another important factor for successful joint-preserving surgery.
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Popelka S, Hromádka R, Vavřík P, Barták V, Popelka S, Sosna A. Hypermobility of the first metatarsal bone in patients with rheumatoid arthritis treated by Lapidus procedure. BMC Musculoskelet Disord 2012; 13:148. [PMID: 22906022 PMCID: PMC3517407 DOI: 10.1186/1471-2474-13-148] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 07/13/2012] [Indexed: 01/18/2023] Open
Abstract
Background Foot deformities and related problems of the forefoot are very common in patients with rheumatoid arthritis. The laxity of the medial cuneometatarsal joint and its synovitis are important factors in the development of forefoot deformity. The impaired joint causes the first metatarsal bone to become unstable in the frontal and sagittal planes. In this retrospective study we evaluated data of patients with rheumatoid arthritis who underwent Lapidus procedure. We evaluated the role of the instability in a group of patients, focusing mainly on the clinical symptoms and X-ray signs of the instability. Methods The study group included 125 patients with rheumatoid arthritis. The indications of the Lapidus procedure were a hallux valgus deformity greater than 15 degrees and varus deformity of the first metatarsal bone with the intermetatarsal angle greater than 15 degrees on anterio-posterior weight-bearing X-ray. Results Data of 143 Lapidus procedures of 125 patients with rheumatoid arthritis, who underwent surgery between 2004 and 2010 was evaluated. Signs and symptoms of the first metatarsal bone instability was found in 92 feet (64.3%) in our group. The AOFAS score was 48.6 before and 87.6 six months after the foot reconstruction. Nonunion of the medial cuneometatarsal joint arthrodesis on X-rays occurred in seven feet (4.9%). Conclusion The Lapidus procedure provides the possibility to correct the first metatarsal bone varus position and its instability, as well as providing the possibility to achieve a painless foot for walking. We recommend using the procedure as a preventive surgery in poorly symptomatic patients with rheumatoid arthritis in case of the first metatarsal bone hypermobility.
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Affiliation(s)
- Stanislav Popelka
- 1st Orthopaedic Clinic, 1st Faculty of Medicine, Charles University in Prague, V Úvalu 84, Prague 5, 150 06, Czech Republic.
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Donnenwerth MP, Borkosky SL, Abicht BP, Plovanich EJ, Roukis TS. Rate of nonunion after first metatarsal-cuneiform arthrodesis using joint curettage and two crossed compression screw fixation: a systematic review. J Foot Ankle Surg 2011; 50:707-9. [PMID: 21908206 DOI: 10.1053/j.jfas.2011.08.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Indexed: 02/03/2023]
Abstract
First metatarsal-cuneiform joint arthrodesis is a commonly performed procedure to correct first ray pathology. The most widely accepted approach is curettage and 2 crossed compression screw fixation followed by a period of non-weight-bearing. Despite adequate joint preparation and stable internal fixation, nonunion has been cited as a known complication. This can lead to the need for revision surgery, which is undesirable and drives healthcare costs. To further investigate this topic, we conducted a systematic review to determine the rate of nonunion after the first metatarsal-cuneiform joint arthrodesis using curettage and 2 crossed compression screw fixation. Studies were eligible for inclusion only if they involved the following: arthrodesis of the first metatarsal-cuneiform joint with curettage and 2 crossed compression screw fixation, a minimum of 25 feet, with a mean follow-up of at least 6 months, and a period of postoperative non-weight-bearing. After considering all the potentially eligible references, 1 (1.8%) evidence-based medicine level I and 4 (7.3%) evidence-based medicine level IV studies met our inclusion criteria. A total of 537 patients (599 feet), 54 (10%) males and 483 (90%) females, with a weighted mean age of 49.4 years, were included. For those studies that specified the exact follow-up, the weighted mean was 30.9 months. A total of 30 nonunions (5%) were reported, with 17 (56.7%) symptomatic. The results of our systematic review revealed a relatively high rate of nonunion for first metatarsal-cuneiform joint arthrodesis with curettage and 2 crossed compression screw fixation, even when performed by experienced surgeons. Therefore, given the available data, additional prospective investigations are warranted, especially in the evaluation and comparison of fixation constructs and postoperative management.
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Affiliation(s)
- Michael P Donnenwerth
- Podiatric Medicine and Surgery Resident (PGY-II), Gundersen Lutheran Medical Foundation, La Crosse, WI 54601, USA
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Ellington JK, Myerson MS, Coetzee JC, Stone RM. The use of the Lapidus procedure for recurrent hallux valgus. Foot Ankle Int 2011; 32:674-80. [PMID: 21972761 DOI: 10.3113/fai.2011.0674] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The objective of this study was to evaluate the Lapidus procedure or it's modifications for treatment of recurrent hallux valgus (HV). Our hypothesis was that the Lapidus procedure would achieve good correction of recurrent HV and patients would be satisfied. MATERIALS AND METHODS A retrospective review of 32 feet (30 patients) treated with the Lapidus procedure for recurrent HV with at least 1-year followup was performed. Evaluation included radiographs, examination, and chart review. Outcomes were assessed with a pain visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, SF-12, Revised Foot Function Index (RFFI), and a survey. Twenty-three of 30 patients (25 feet) met the criteria for inclusion in the study and were available for followup evaluation. The average followup was 31.6 months. RESULTS Arthrodesis was present in 24 out of 25 feet (96%). The time from initial HV correction to revision surgery was 91 months. The initial surgery performed was a distal osteotomy (15), proximal osteotomy (five), exostectomy (two), diaphyseal osteotomy (two), and proximal/distal osteotomy (one). Preoperative evaluation revealed 96% of patients had clinical hypermobility of the first TMT joint and 52% had radiographic findings of instability. The average postoperative AOFAS hallux score was 82.8, SF-12 score was 94.5, and RFFI was 101. The average preoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) were 36.2, 13.6, 18.6 degrees, respectively, which corrected to an average of 15.2, 7.5, 11.7 degrees postoperatively (p < 0.001). The average shortening of the first ray was 2.9 mm. Average pain VAS was 2.4. Eighty-seven percent reported good to excellent results. Using a multivariable linear regression analysis, postoperative HVA along with change in length of the first ray were significant predictors of quality of life based on SF-12 (p < 0.05). CONCLUSION The Lapidus procedure corrected recurrent HV with a low nonunion rate and excellent radiographic correction and patients were satisfied with their outcome. LEVEL OF EVIDENCE IV, Retrospective Case Series
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Affiliation(s)
- J Kent Ellington
- Institute for Foot and Ankle Reconstruction, Mercy Medical Center, Baltimore, MD, USA.
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Shi K, Hayashida K, Owaki H, Kawai H. Replacement of the first metatarsophalangeal joint with a Swanson implant accompanied by open-wedge osteotomy of the first metatarsal bone for hallux valgus in rheumatoid arthritis. Mod Rheumatol 2007; 17:110-4. [PMID: 17437165 DOI: 10.1007/s10165-006-0551-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2006] [Accepted: 12/15/2006] [Indexed: 10/23/2022]
Abstract
Hallux valgus is very common in rheumatoid arthritis (RA) and mostly accompanied by varus deformity of the first metatarsal bone, which is often corrected in surgeries for hallux valgus in nonarthritic condition, but rarely in RA. We performed the replacement of the first metatarsophalangeal (MTP) joint with a Swanson hinge toe implant accompanied with open-wedge osteotomy of the first metatarsal bone, aiming at reconstruction of a functioning first MTP joint without recurrence of hallux valgus. Fifteen feet of 11 patients with RA were studied with a mean follow-up period of 45.1 months. The American Orthopaedic Foot and Ankle Society (AOFAS) scale improved significantly from 39 points preoperatively to 81.7 at the last follow-up. The hallux valgus angle (HVA), angle between the first and second metatarsal bones (M1/2), and that between the first and fifth (M1/5), measured on standing anteroposterior radiographs, decreased significantly from 49.8 degrees, 16.7 degrees, and 34.4 degrees preoperatively to 10.9 degrees, 8.7 degrees, and 22.2 degrees at the last follow-up, respectively. Union of the corrected first metatarsal bone was recognized in all cases and no such problems as infection, dislocation, or implant fracture were observed. These data suggest that replacement of the first MTP joint with a Swanson implant accompanied with open-wedge osteotomy of the first metatarsal bone can be a useful option for hallux valgus in RA.
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Affiliation(s)
- Kenrin Shi
- Department of Orthopaedic Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai 591-8025, Japan.
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Abstract
Presented here is a preliminary report of 102 patients who underwent first metatarsocuneiform joint arthrodeses performed with external fixation for the correction of hallux valgus. The advantages of using external fixation are the ability to initiate early weightbearing, predictable fusion, and removal of all of the hardware postoperatively. In the 102 patients reported here, the average time to initiation of unassisted full weightbearing was 13.1 days. The average time to fusion was 5.3 weeks, with removal of the external fixator at an average of 5.5 weeks postoperatively. There was no incidence of delayed union or nonunion. There was one case of pin-tract irritation, which resolved with appropriate pin care and a short course of oral antibiotics. External fixation is an effective alternative to traditional internal fixation techniques in metatarsocuneiform joint arthrodesis.
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Baravarian B, Briskin GB, Burns P. Lapidus bunionectomy: arthrodesis of the first metatarsocunieform joint. Clin Podiatr Med Surg 2004; 21:97-111, vi. [PMID: 15012034 DOI: 10.1016/s0891-8422(03)00112-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Fusion of the first metatarsocunieform (MC) joint allows for correction of the first metatarsal in three planes, including adduction, plantarflexion, and rotation. It also allows for decreased jamming of the great toe joint and increased medial column stability. As knowledge about other medial column procedures grows, fusion of the first MC joint will continue to grow in popularity. It is an excellent procedure for hallux limitus and also for metatarsus primus elevatus cases.
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Affiliation(s)
- Babak Baravarian
- Foot and Ankle Institute of Santa Monica, 2121 Wilshire, Suite 101, Santa Monica, CA 90403, USA.
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The Rheumatoid Hallux Valgus. Tech Orthop 2003. [DOI: 10.1097/00013611-200309000-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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