SLR - April 2014 - Zachary G. Jagmin
Reference: Chao JC, Charlick D, Tocci S, Brodsky JW. Radiographic and Clinical Outcomes of Joint-preserving Procedures for Hallux Valgus in Rheumatoid Arthritis. Foot and Ankle International. 2013 Dec; 34(12):1638-44
Scientific Literature Review
Reviewed By: Zachary G. Jagmin, DPM
Residency Program: Massachusetts General Hospital, Boston MA.
Podiatric Relevance: Although there is no current consensus regarding the standard treatment of hallux valgus (HV) deformity associated with rheumatoid arthritis (RA), the most commonly performed procedure is 1st metatarsal-phalangeal joint (MTPJ) arthrodesis. As relatively new disease-modifying drugs (DMARDs) may reduce the incidence and progression of joint destruction, the authors hypothesized that joint-preserving osteotomy/bunionectomy procedures may be used to successfully treat this deformity.
Methods: This is a retrospective case study of twenty-seven female patients (37 feet) with RA who underwent joint preserving 1st ray surgical procedures, performed over an 11-year period by two surgeons. The procedures included: Ludloff (20 feet), Scarf (15 feet) and Chevron (two feet), each with ancillary MTPJ soft tissue realignment. The average patient age was 58 years. Weight-bearing (WB) radiographs were performed on all feet, both pre- and post-operatively.
Results: The average hallux valgus angle (HVA) decreased from 36 degrees preoperatively to 12 degrees at the first postoperative visit, and the average 1st intermetatarsal angle (IMA) decreased from 14 degrees to 3 degrees. Although there was radiographic progression of 1st MTP and hallux interphalangeal (IP) joint space narrowing in some patients, it did not progress in the majority. All 1st MTPJs demonstrated < 50 percent joint narrowing preoperatively. Radiographic progression of IP joint space narrowing occurred in only two feet (5.6 percent). Clinical outcomes showed statistically significant improvement in both AOFAS (45.2, 82.6) and VAS scores (4.8, 1.5). The 1st MTPJ passive range of motion (PROM) remained relatively unchanged in the majority. Five patients (seven feet) required a second surgery: I&D (three feet), 1st MTPJ arthrodesis (two feet, due to recurrent hallux valgus or iatrogenic hallux varus, initially treated by Ludloff), revisional bunionectomy (one foot treated, initially by Ludloff and subsequently treated by Scarf) or hardware removal (one foot).
Conclusions: First MTP joint-preserving surgery for HV may be effective treatment in patients with RA and taking antirheumatic drugs. Post-operative complications, requiring additional surgery, may be due to procedure selection, surgical risks associated with RA, or effects of antirheumatic drugs on healing.