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Médecine et chirurgie du pied

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Hallux Valgus Combined with Osteoarthritis: Value of Conservative Surgery
Preliminary Study at Four Months Follow-up. A Report of 36 Cases of Hallux Valgus Associated with First Metatarsophalangeal Joint Osteoarthritis Volume 35, issue 3, Septembre 2019

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Authors

In case of proven arthritis of the first metatarsophalangeal joint (MTPJ) combined with hallux valgus, many authors propose a first metatarsophalangeal joint arthrodesis. In the series of patients undergoing conservative surgical correction of hallux valgus published in the literature, there is a lack of reviews investigating specifically the results of patients with hallux valgus combined with first metatarsophalangeal joint arthritis. The present study aims to assess the results of conservative surgery in patients with hallux valgus combined with proven arthritis of the first MTPJ. Diagnostic criteria were: firstly, a first metatarsophalangeal angle superior to 20° on weight-bearing dorsoplantar foot radiograph; secondly, a stage 2 (Regnauld classification) arthritis of the first metatarsophalangeal joint; and thirdly, a follow-up period of at least four months. In total, 36 feet were operated on and followed-up. Osteotomy of the first metatarsal was carried out either by Scarf osteotomy or distal chevron osteotomy. Results were evaluated based on three groups of criteria: clinically, radiographically and surgically. 36 feet were included in the study: 100% female patients, mean age: 67 years. 36 feet presented arthritis of the first metatarsophalangeal joint, stage 2 on the Regnauld classification. There was neither major stiffness nor any metatarsus primus elevatus. We carried out 31 Scarf osteotomies and 5 distal chevron osteotomies. In 100% of the cases, we shortened the first metatarsal to achieve decompression and carried out a basal osteotomy with shortening of the first phalanx. At four month follow-up, the mean American Orthopedic Foot and Ankle Society (AOFAS) score was 94.3. Ranges of motion of the first metatarsophalangeal joint were 77°. 23 feet had a widened joint space compared to the preoperative status. 13 feet had an unchanged joint space. No foot presented a worsening of the arthritic joint space narrowing. Our series shows that the question of conservative surgery in case of association (HV + stage 2 arthritis) comes up in almost one out of ten patients. In our opinion, classifications specifically dedicated to the study of HV are not suitable to the description of arthritis encountered in case of HV. Regnauld classification refers to morphologic changes that we seldom encounter in our series. Coughlin classification takes into account the progressive horizontalization of the first metatarsal (metatarsus primus elevatus) that we did not find in our series. According to Coughlin, the association (HV + hallux rigidus) is rare. We have found that the association (HV with osteoarthritis without hallux rigidus) affects about 10% of patients who underwent surgery for hallux valgus. The presence of a preoperative arthritis of the first metatarsophalangeal joint in hallux valgus does not affect the satisfaction of the patient who underwent conservative surgery. At four-month follow-up, there is no pain due to osteoarthritis. We attribute this good outcome to two factors: the shortening which decompresses the joint and thus relieves the cartilage and the change in the joint relation. The results obtained at four-month follow-up in our patients who underwent a surgical procedure for hallux valgus combined with a stage 2 osteoarthritis of the first metatarsophalangeal joint by surgery preserving the first MTP are as follows: 100% have an unlimited walking perimeter, 94.5% have very good results in pain relief, 100% have no postoperative worsening of stiffness. In case of hallux valgus combined with osteoarthritis of the first metatarsophalangeal joint, conservative surgery can be proposed to patients when osteoarthritis does not exceed stage 2 (Regnauld classification). Results are similar to those obtained in series of patients who underwent surgical procedure for hallux valgus without arthritis. Limit of our study is a follow-up period of four months.