SLR - July 2018 - Sagar A. Shah

Modified Scarf Osteotomy with Medial Capsule Interposition for Hallux Valgus in Rheumatoid Arthritis: A Study of Cases Including Severe First Metatarsophalangeal Joint Destruction

Reference: Kushioka J, Hirao M, Tsuboi H, Ebina K, Noguchi T, Nampei A, Tsuji S, Akita S, Hashimoto J, Yoshikawa H. Modified Scarf Osteotomy with Medial Capsule Interposition for Hallux Valgus in Rheumatoid Arthritis: A Study of Cases Including Severe First Metatarsophalangeal Joint Destruction. J Bone Joint Surg Am. 2018 May 2; 100(9):765–776.

Scientific Literature Review

Reviewed By: Sagar A. Shah, DPM
Residency Program: Larkin Community Hospital, South Miami, Florida

Podiatric Relevance:
Hallux valgus with concomitant first metatarsophalangeal (MTP) joint destruction in a rheumatoid arthritis (RA) patient has traditionally been addressed via Keller arthroplasty, first MTP joint fusion, or in some cases, MTP joint replacement. Some studies indicate good results with joint sparing procedures for the rheumatoid patient but included patients with less severe hallux valgus deformity. This article investigates clinical outcomes of an RA patient with moderate to severe hallux valgus and severe joint destruction surgically addressed with a modified scarf osteotomy and interposition of the capsule to serve as a soft-tissue spacer in the decompressed joint. The authors retrospectively reviewed clinical and radiographic outcomes of the modified scarf osteotomy with medial capsule interposition and determined risk factors associated with recurrence.

Methods: A retrospective observational study of 76 feet (60 patients) who met the inclusion criteria were included, and all of the patients’ RA disease was controlled via medications. All patients underwent the same surgical procedure and postoperative course. Pre- and postoperative clinical assessment scores were obtained via the RA foot and ankle scale and the hallux scale along with the SAFE-Q at final follow-up. RA disease activity was monitored via the DAS29-CRP, CRP level and MMP3. Weightbearing radiographs were reviewed pre and post op to determine the HVA and the IM angles of the first and second metatarsals (M1M2A) along with the first and fifth metatarsals (M1M5A). Recurrence was defined as a HVA of >20 degrees postoperatively.

Results: The mean follow-up was 35.3 months with no significant differences in DAS28-CRP, CRP or the MMP3 levels, which was indicative of no disease progression throughout the follow-up. The mean RA foot and ankle scores and hallux scale scores improved significantly from 52.2 to 76.9 points and 38.2 to 74.5 points, respectively. The HVA, M1M2A and M1M5A decreased significantly along with the sesamoid position at three months postop and at final follow-up in most patients. There was a significant difference in the recurrence group in the measured preoperative values of DAS28-CRP, M1M2A, M1M5A and the three months after surgery values of HVA, M1M2A, M1M5A and Hardy grade. A significant negative correlation between preoperative DAS28-CRP score and the RA foot and ankle score, and a significant positive correlation between preoperative DAS28-CRP score and HVA was noted at the final follow-up, implying that higher disease activity was associated with both clinical and radiographic outcomes.

Conclusions: The authors concluded that joint-preserving surgery (modified scar osteotomy with medial capsule interposition) for hallux valgus improved both clinical and radiographic outcomes in patients with RA, even those with severe first MTP joint destruction. There was not a significant improvement in mean motion index of the first MTP according to the RA foot and ankle score. I believe this surgical procedure is a viable option for a low-demand patient who cannot be NWB for six to eight weeks for a Lapidus bunionectomy. This procedure and the overall positive outcomes outlined in the study should give the surgeon confidence that this is an alternative procedure to keep in mind.

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