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Friday, February 15, 2002

Hallux MP joint fusion best option for rheumatoid arthritis

About 90% of patients with rheumatoid arthritis (RA) eventually develop symptoms related to the foot or ankle, including hallux valgus and deformities of the lesser toes. Whether the hallux metatarsophalangeal (MP) joint can be preserved by preemptive surgery is the question examined in poster exhibit 205.

Eight female patients with severe rheumatoid arthritis in the forefoot underwent surgery to resect the lesser MP joints and preserve the hallux MP joint. The hallux MP joint space on all of the patients was normal on preoperative radiographs. The average age of the patients was 47 years, and all were on medication for active rheumatoid arthritis. Surgery was performed on a total of 13 feet.

The contralateral foot in two of these patients had a hallux MP fusion with resectional arthroplasty of the lesser MP joint. In addition to a resectional arthroplasty of the second through fifth MP joints, eight feet underwent a distal Chevron osteotomy with medial capsular imbrication, two feet underwent an interphalangeal (IP) fusion, one foot underwent a Chevron osteotomy with Akin procedure, and two feet had no surgery on a well-aligned first ray.

Most preemptive surgeries fail

Researchers found that despite the surgeries, 11 of the13 hallux MP joints developed a valgus deformity or inflammatory erosions. The average time to failure was 24 months (range: 6 to 36 months). The Chevron/Akin procedure remained successful at one year after surgery and one IP fusion was successful at six years after surgery. A salvage hallux MP fusion was later performed on five of the failures. Recurrent valgus deformities also necessitated revisions of the lesser MP resectional arthroplasty/ realignment on three feet.

Although patients with rheumatoid arthritis may, on occasion, have a well-preserved hallux MP joint with minimal or no deformity, the researchers concluded that most of these will fail a surgical procedure that does not result in fusion of the hallux MP joint. Patients with less severe deformities or a normal-appearing hallux MP joint should be advised that other types of surgery have a high-risk of failure. When hallux valgus begins to develop after lesser MP resectional arthroplasty, a hallux MP joint fusion should be performed to prevent lesser MP recurrent deformity.

Co-authors of the study are David B. Thordarson, MD, Soheil Aval, MD, and Lauren E. Krieger, MD, all of Los Angeles, Calif.

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Last modified 08/February/2002