The Rheumatoid Hallux Valgus

Abstract

Summary 

Rheumatoid hallux valgus causes disability with spreading of the forefoot, tender bunion, pressure from crossing toes, loss of strength and stability, callosities, and transfer metatarsalgia at the lesser metatarsal heads. When conservative treatment with shoes and insoles fails, surgery is indicated. In the Keller procedure, the base of the hallux is removed. As a result of poor strength and stability, the procedure is eventually unsuccessful with recurrent pain and deformity. Endoprosthetic arthroplasty with silicone rubber implants has been used with acceptable clinical outcome. Today, they are in disrepute because of fear of silicone particle-induced synovitis, bone cyst formation, and breakage. The chevron osteotomy at the neck and the scarf or Weil osteotomies of the shaft could work if the hallux deformity is limited and reducible and the joint without obvious arthritic changes. Regardless of the osteotomy technique, the level of the head must be maintained to prevent development of transfer metatarsalgia. In cases with pronounced metatarsus varus, a proximal wedge osteotomy could be used. However, resection with fusion of the first tarsometatarsal joint, the Lapidus procedure, might be safer. Fusion of the first metatarsal joint is a safe and simple way to alleviate rheumatoid hallux valgus. The preferred method is a dorsomedial or straight medial incision. With a pair of dome and socket reamers, the cartilage is removed. Both the hallux and extension angles should be 15° to 20°. Pronation of the hallux has to be reduced before fixation with 2 partially threaded screws. The patient is allowed to walk on a heel shoe with a foot plaster. After 3 weeks, the plaster is replaced for another 3 weeks by a molded orthosis in a wide shoe. The short- and long-term results are good and the fusion rate is approximately 90%. Compared with resection, a healthy or fused first metatarsal is better. After fusion, a diminished spreading of the foot has also been observed.