Radiographic and clinical outcomes of joint-preserving procedures for hallux valgus in rheumatoid arthritis.Foot Ankle Int. 2013 Dec; 34(12):1638-44.FA
The standard treatment for hallux valgus in rheumatoid arthritis has been arthrodesis of the first metatarsophalangeal (MTP) joint. There is limited literature regarding the results of hallux valgus procedures which preserve the first MTP joint in rheumatoid patients. We investigated the radiographic and clinical outcomes of joint-preserving surgery for hallux valgus in a series of rheumatoid patients to evaluate the result of nonarthrodesis reconstruction.
Thirty-seven feet with hallux valgus in 27 patients with RA treated with a joint-preserving procedure of the first MTP joint were analyzed radiographically and clinically. Average follow-up was 42 (range, 12-111) months. Twenty feet had Ludloff osteotomies, 15 had scarf osteotomies, and 2 had chevron osteotomies. Radiographs were evaluated preoperatively and postoperatively for hallux valgus angle, 1-2 intermetatarsal angle, and degenerative narrowing of the first MTP joint based the Sharp score and the Larsen grade. Narrowing of the first interphalangeal (IP) joint was based on a modification of the classification of Hattrup and Johnson. Operative complications and required secondary surgeries were tabulated. Clinical outcomes were measured using preoperative and postoperative Short Form-36 (SF-36), AOFAS forefoot scale, and Visual Analogue Scale (VAS) pain questionnaires.
The average hallux valgus angle improved from 37 degrees preoperatively to 15 degrees postoperatively. The average 1-2 intermetatarsal angle improved from 14 degrees preoperatively to 5 degrees postoperatively. The average Sharp score of the first MTP joint was 0.9 preoperatively and 1.6 postoperatively. The average Larsen grade of the first MTP joint was 0.6 preoperatively and 1.4 postoperatively. Range of motion of the first MTP joint was essentially unchanged between preoperative and postoperative measurements. Seven of 37 feet had progression of first IP joint space narrowing, but none were symptomatic. The AOFAS score improved from 45.2 preoperatively to 82.6 at final follow-up (P value < .01). The VAS decreased from 4.8 preoperatively to 1.5 at final follow-up (P value < .02). The SF-36 physical component score decreased from 40.3 preoperatively to 37.4 at final follow-up, and the mental component score remained unchanged, and neither was statistically significant. There were 7 feet (19%) that required a return to surgery: 3 wound infections, 2 arthrodeses for progression of deformity, and 1 each for revision for recurrence and hardware removal.
Rheumatoid arthritis patients who undergo a bunionectomy rather than arthrodesis to preserve the first MTP joint have satisfactory clinical and radiographic outcomes. This procedure appeared to be a reasonable alternative to first MTP arthrodesis in patients with relatively preserved joints.
LEVEL OF EVIDENCE
Level IV, retrospective case series.