Bunion (Hallux Valgus) Surgery in Rheumatoid Arthritis: What a New Study Reveals
Ever wondered whether bunion surgery can preserve your big toe’s movement, especially if you live with rheumatoid arthritis (RA)? As clinicians, we’re often asked if there’s an alternative to fusing the joint. A recent peer‑reviewed study offers compelling evidence that joint-preserving bunion surgery—specifically distal chevron metatarsal osteotomy (DCMO)—can deliver excellent correction and comfort in RA, while keeping the joint mobile.
Key Takeaway: Joint-Preserving Surgery Can Work in RA
Traditionally, severe bunions in RA are treated with first metatarsophalangeal (MTP) joint fusion (arthrodesis). It’s reliable, but you lose motion. This 2024 study in Clinical Orthopaedics and Surgery assessed DCMO—a joint-preserving technique—and found significant, lasting correction with good functional outcomes in patients with RA-related hallux valgus. Source: 38827764 | PMC11130625 | 10.4055/cios23184.
What Is Distal Chevron Metatarsal Osteotomy (DCMO)?
DCMO is a well-established bunion (hallux valgus) surgery that reshapes and shifts the first metatarsal bone to realign the big toe. Unlike fusion, it aims to correct deformity while preserving joint motion. For people with RA—where forefoot deformities and pain are common—maintaining mobility can be a game-changer for gait and daily activities.
Study at a Glance: Patients, Methods, and Measures
The researchers reviewed 24 feet in 18 consecutive RA patients treated with DCMO between 2000 and 2018. They measured:
- Hallux valgus angle (HVA) and intermetatarsal angle (IMA) on X-rays.
- RA-related joint damage using the Sharp/van der Heijde score (erosion and joint space narrowing).
- Pain via visual analogue scale (VAS) and function via the American Orthopaedic Foot & Ankle Society (AOFAS) forefoot score.
Results: Meaningful Correction and Symptom Relief
DCMO delivered substantial radiographic correction that was maintained at final follow-up:
- HVA improved from an average 38.0° (25°–65°) to 3.5° (0°–17°), p < 0.05.
- IMA improved from an average 14.9° (5°–22°) to 4.3° (2°–11°), p < 0.05.
Importantly, RA erosion scores (Sharp/van der Heijde, 0–10) were stable over time: 3.83 pre-op to 3.54 at follow-up (p = 0.12), suggesting no accelerated joint damage signal from the procedure in this cohort.
Complications and Recurrence: What to Expect
Complications were relatively infrequent:
- Recurrent hallux valgus: 1 patient.
- Postoperative hallux varus: 2 feet.
- Spontaneous MTP fusion: 1 case.
For context, recurrence and overcorrection (varus) are recognised risks in bunion surgery generally. Here, the low recurrence and manageable complication rates are reassuring, particularly given the RA population.
How Does This Compare with Fusion?
Fusion remains a gold standard for severe deformity, instability, or significant joint destruction in RA, offering powerful pain relief and durable alignment—but at the cost of MTP motion. This study supports DCMO as a viable alternative in appropriately selected RA patients who value joint preservation and have sufficient bone quality and soft-tissue balance.
Who Might Benefit from DCMO?
Based on these data and our clinical experience, candidates may include RA patients with:
- Moderate to severe hallux valgus without end-stage MTP destruction.
- Desire to maintain big toe motion for gait efficiency and footwear comfort.
- Manageable lesser toe pathology (often addressed concurrently).
Clinical Pearls for Patients Considering Bunion (Hallux Valgus) Surgery
- Ask about joint-preserving options if your MTP joint is not severely destroyed.
- Expect meaningful angle correction and pain relief with DCMO when appropriately indicated.
- Understand the trade-offs: preserving motion vs the durability of fusion in very severe cases.
- Discuss recurrence risks, postoperative protocols, and footwear modifications.
Why This Matters for People Living with RA
RA commonly affects the forefoot, altering gait and quality of life. A surgery that both corrects deformity and preserves motion can help you walk more naturally and wear a broader range of shoes—small wins that add up. As ever, success hinges on patient selection, surgical technique, and postoperative rehabilitation.
Evidence and Sources
The summary above is based on: Clin Orthop Surg. 2024;16(3):461–469. PubMed | PMC | DOI. While the cohort is modest (24 feet), the results align with broader bunion literature showing that chevron-type osteotomies can produce strong correction with careful technique.
Bottom Line: Our Take on Bunion (Hallux Valgus) Surgery in RA
For selected RA patients, distal chevron metatarsal osteotomy offers excellent correction with the prized benefit of preserving MTP motion. Fusion still has a clear role in severe joint destruction or instability, but it’s not the only path. A personalised surgical plan—grounded in imaging, RA disease control, and your functional goals—will yield the best outcome. If you’re weighing options for bunion (hallux valgus) surgery, we can help you decide whether DCMO or fusion makes most sense for your feet and lifestyle.
Clin Orthop Surg. 2024 Jun;16(3):461-469. doi: 10.4055/cios23184. Epub 2024 Apr 25.
ABSTRACT
BACKGROUND: Rheumatoid arthritis (RA) is a chronic autoimmune disorder that frequently causes forefoot deformities. Arthrodesis of the first metatarsophalangeal joint is a common surgery for severe hallux valgus. However, joint-preserving surgery can maintain the mobility of the joint. This study aimed to investigate the clinical and radiographic outcomes of distal chevron metatarsal osteotomy (DCMO) for correcting hallux valgus deformity associated with RA.
METHODS: Between August 2000 and December 2018, 18 consecutive patients with rheumatoid forefoot deformities (24 feet) underwent DCMO for hallux valgus with/without lesser toe surgery. Radiological evaluations were conducted, assessing the hallux valgus angle, the intermetatarsal angle between the first and second metatarsals, and the Sharp/van der Heijde score for erosion and joint space narrowing. Clinical outcomes were quantified using a visual analog scale for pain and the American Orthopaedic Foot and Ankle Society forefoot scores to measure function and alignment.
RESULTS: The mean hallux valgus angle decreased from 38.0° (range, 25°-65°) preoperatively to 3.5° (range, 0°-17°) at the final follow-up (p < 0.05). The mean intermetatarsal angle decreased from 14.9° (range, 5°-22°) preoperatively to 4.3° (range, 2°-11°) at the final follow-up. (p < 0.05). Regarding the Sharp/van der Heijde score, the mean erosion score (0-10) showed no significant change, decreasing from 3.83 (range, 0-6) preoperatively to 3.54 (range, 0-4) at the final follow-up (p = 0.12). Recurrent hallux valgus was observed in 1 patient and postoperative hallux varus deformity was observed in 2 feet. Spontaneous fusion of the metatarsophalangeal joint developed in 1 case.
CONCLUSIONS: DCMO resulted in satisfactory clinical and radiographic outcomes for correcting RA-associated hallux valgus deformity.
PMID:38827764 | PMC:PMC11130625 | DOI:10.4055/cios23184
