Arthrodesis indications for hallux valgus include failed MTP joint replacement and RA

Consider fusion for post-traumatic hallux valgus cases where contractures have become rigid.

Issue: April 2009

At the American Orthopaedic Foot and Ankle Society 24th Annual Meeting, Vincent James Sammarco, MD, discussed the top reasons for surgeons to treat hallux valgus with arthrodesis.

“This is an excellent choice for revision of failed bunion surgeries,” he said. “It can restore the length and the alignment. It is durable. The deformity will not recur and you can fix your own failures, as well as others.”

Indications for fusion of hallux valgus include the treatment of neuromuscular diseases with spasticity. “This has a relatively high recurrence rate for more standard procedures even if you have balance the soft tissue envelope properly,” Sammarco said. “Spasticity tends to increase with time in patients with neuromuscular disease and surgeons should consider fusions for patients with cerebral palsy or those who have had strokes.”

Arthrodesis can also be used to treat conditions which are associated with significant bone loss such as failed metatarsophalangeal (MTP) joint replacement, infected bunion surgeries and trauma.

A 42-year-old woman seen 5 years following bunion surgery. Preoperative X-rays show recurrence of deformity and significant shortening of the first metatarsal. There is also arthritis of the first MTP joint.

Clinical photograph of the preoperative deformity.

Images: Sammarco VJ

“Fusion for hallux valgus associated with severe forefoot trauma is indicated not only for bone loss, but also due to the severe and rigid soft tissue contractures that often develop,” Sammarco told Orthopedics Today. “I think that you really should pay special attention to traumatic bunion deformity because these tend to be rigid and are often very difficult to correct,” he said.

Hallux valgus with arthritis

Other indications for arthrodesis include hallux valgus associated with osteoarthritis. “It is a durable procedure with good pain relief for arthritis,” Sammarco said.

In addition, fusion can be beneficial for bunion patients with rheumatoid arthritis. “The cartilage is often destroyed by this disease and inflammation makes reconstruction of the soft tissue envelope difficult or impossible,” he said.

Postoperative radiograph showing correction of hallux valgus angle
Postoperative radiograph showing correction of hallux valgus angle and intermetatarsal angle with fusion. Length has been corrected and the weight-bearing function of the hallux restored.

Severe deformity

The procedure can also be used to treat severe bunion deformities with multiple lesser MTP joint deformities.

“Fusion is indicated for severe deformity in elderly individuals where osteoporosis may prevent stable fixation of osteotomies,” Sammarco said. “I would consider a fusion for HVA (hallux valgus angles) greater than 40°, age greater than 65, and in patients who have poor bone quality or are anticipated [to have] poor compliance with weight-bearing restrictions.”

“One of my favorite advantages of fusion over more standard bunion surgery is that the postoperative care is a lot easier,” he said. “There are no fussy dressing changes and the number of post-operative visits necessary is greatly diminished.” He added, “Most bunions can and should be successfully treated by more standard joint sparing procedures, but fusion works well where other operations will not. In my opinion, some conditions are simply more predictably managed with arthrodesis.”

For more information:

Vincent James Sammarco, MD, can be reached at the Cincinnati Sports Medicine and Orthopaedic Center, 10663 Montgomery Road, Cincinnati, OH 45242; 513-891-3200; e-mail: vjsammarco@csmoc.com. He receives miscellaneous non-income support from DePuy.

Reference:

Sammarco VJ. Arthrodesis for hallux valgus. Presented at the American Orthopaedic Foot and Ankle Society 24th Annual Summer Meeting. June 26-28, 2008. Denver.