Modified Lapidus Procedure Research Articles

Cross-screw technique for the modified Lapidus procedure using headless compression screws

Aims: The aim was to evaluate union rates using two cross headless compression screws for the modified Lapidus procedure. This was compared to conventional fixation using solid AO screws and plates, as recorded in the published literature. Patients and methods: This is a retrospective study of the modified Lapidus procedure performed in patients with a moderate to severe hallux valgus deformity. Union time and patient demographics were retrieved from medical records. Patient demographics included age, sex, smoking habits and other comorbidities. The union rate was compared to the literature using the two-population probability test, with p<0.05 being significant. Results: Sixty-nine feet in 56 patients were assessed for radiographic union. There were three delayed unions and two non-unions. The union rate of 97% was not statistically different when compared to studies using conventional solid AO screws. Conclusion: The use of headless compression screws in the fixation of the first tarsometatarsal joint and early mobilisation was found to be comparable to conventional solid AO screws with regard to union rates. The cannulated design enhances ease of insertion and, being headless, minimises the risk of intra-operative fracture and hardware prominence requiring subsequent removal. Level of evidence: Level 4

Outcome of the modified Lapidus procedure for hallux valgus deformity during the first year following surgery: A prospective clinical and gait analysis study

BackgroundThe modified Lapidus procedure is a surgical option to treat moderate to severe hallux valgus deformity with good radio-clinical outcome. However, comprehensive biomechanical outcome evaluation of this surgery at mid-term follow-up is missing. This study assesses and compares the radio-clinical and gait outcome at 6 and 12 months following modified Lapidus procedure. MethodTen consecutive female patients with moderate to severe hallux valgus who underwent modified Lapidus procedure participated in the study. Comprehensive gait assessment was performed preoperatively, at 6 and 12 months postoperatively. Gait parameters including spatiotemporal, kinematics and plantar pressure were analyzed using pressure insoles and 3-dimensional inertial sensors. Outcome was evaluated using two clinical questionnaires, i.e. the American Orthopaedic Foot and Ankle Score and the Foot and Ankle Ability Measure, and X-rays. FindingsThree spatiotemporal, two kinematics, and seven plantar pressure parameters significantly improved between 6 months and 12 months postoperatively. Significant improvement in radiological and clinical outcome was reported at 6 and 12 months. The Foot and Ankle Ability Measure showed non-significant improvement at 12 months. InterpretationThe outcome of this study is consistent with the previously reported good clinical and radiological results at one year following Lapidus for moderate to severe hallux valgus. Twelve gait parameters demonstrated that outcome improves from 6 months to 12 months postoperative with room for further improvement at long term. The gait outcome in this study confirms the longer rehabilitation period following modified Lapidus procedure. Studies with a larger sample size are required to confirm these findings.

Structures at Risk From an Intermetatarsal Screw for Lapidus Bunionectomy: A Cadaveric Study

The Lapidus bunionectomy is performed to treat hallux valgus. Recurrence of the deformity remains a concern. A transverse intermetatarsal screw spanning the base of the first metatarsal to the base of the second can increase stability. The neurovascular bundle is located within the proximity of this screw. In this study, we assessed the structures at risks with the use of this technique. In 10 specimens, a guide wire was placed, and a 4.0-mm cannulated screw was inserted. The neurovascular bundle was dissected and inspected for direct trauma to the neurovascular bundle, and the proximity of the screw was measured using a digital caliper. Ten cadaveric specimens were used. The dorsalis pedis artery and deep peroneal nerve were free from injury in 9 of 10 specimens. In those 9 specimens, the neurovascular bundle was located dorsal in relation to the screw. The mean distance of the screw to the neurovascular bundle was 7.1 ± 3.3 mm. The mean distance from the screw to the first tarsometatarsal joint (TMTJ) was 14.7 ± 4.3 mm. The mean distance from the screw as it entered the second metatarsal to the second TMTJ was 18.0 ± 7.2 mm. In 1 specimen, the screw was found to be traversing through the neurovascular bundle. The distance from the screw to the first TMTJ was 15.0 mm. The distance of the screw from where it entered the second metatarsal to the second TMTJ was 24.0 mm. Although the intermetatarsal screw avoided the neurovascular cases in most instances, there is some anatomic risk to the neurovascular bundle. Further study is warranted to evaluate clinical results using the intermetatarsal screw for the modified Lapidus procedure.

Hallux Valgus

Category: Bunion Introduction/Purpose: Abnormal motion of the first tarsometatarsal (TMT) joint disrupts the anatomic alignment of the metatarsal head, sesamoid complex and proximal first phalanx. This anatomic disruption combined with the deforming forces of the extensor hallucis longus, adductor tendons, and extensor hallucis brevis result in a hallux valgus deformity. First TMT arthrodesis or the Lapidus procedure has been described as treatment for moderate to severe hallux valgus deformities by correcting hypermobility and restoring anatomic alignment of the first ray. The aim of this study was to evaluate the safety of a percutaneous approach to the Lapidus procedure and its relation to anatomic structures. Methods: A percutaneous, modified Lapidus procedure was performed on 19 embalmed cadaveric feet under fluoroscopic guidance. The specimens were then dissected to identify the extensor hallucis longus (EHL), extensor hallucis brevis (EHB), tibialis anterior (TA), median branch of the superficial peroneal nerve (MBSPN), intermediate branch of the superficial peroneal nerve (IBSPN), deep peroneal neurovascular bundle (DPNVB) and saphenous vein (SV). The structures were localized with reference to percutaneous burr and screw placement during the procedure. Results: The tibialis anterior and intermediate branch of the superficial peroneal nerve were a mean of 3.75 millimeters (mm) and 5.08 mm from the closest burr or screw placement. The extensor hallucis longus and extensor hallucis brevis were at greatest risk under the new approach with mean distances of .92 to 4.08 mm to nearby instrumentation. The extensor hallucis longus or extensor hallucis brevis were either directly pierced or &lt;2 mm from instrumentation on 26 occasions. A terminal branch of the saphenous vein was also either pierced or within 2 mm of instrumentation on 4 occasions. The deep peroneal neurovascular bundle and median branch of superficial peroneal nerve were relatively safe, coming within 2 mm of percutaneous burr or screw placement on only 2 occasions each. Conclusion: The minimally invasive percutaneous Lapidus arthrodesis provides a safe alternative to the traditional, open approach for patients with moderate to severe hallux valgus deformities. This may be a beneficial alternative to conventional open Lapidus procedures by minimizing soft tissue dissection. Further clinical studies must be performed to compare deformity correction, fusion rate, and complications with the modified percutaneous Lapidus procedure.

Comparison of postoperative outcomes between modified Mann procedure and modified Lapidus procedure for hallux valgus

Category: Bunion Introduction/Purpose: Surgery for hallux valgus (HV) includes a variety of techniques based on the osteotomy site. We use the modified Mann technique in cases with deformity ranging from 30° to 40° and the modified Lapidus procedure in HV cases with deformity of over 40° or with metatarsalgia. Methods: Here we report our investigation of the appropriateness of the modified Mann technique and the modified Lapidus procedure based on a comparison of postoperative outcomes. In total, 73 feet of 58 cases who underwent surgery for HV with subsequent follow-up observation for at least 1 year were included in the study. The modified Mann technique was performed on 31 feet of 26 cases (M Group), and the modified Lapidus procedure was performed on 42 feet of 32 cases (L Group). Six cases in the M Group and 39 cases in the L Group also underwent concurrent surgery for metatarsalgia. The outcome measures were changes in the HV angle, the angle between the M1M2, the Japanese Society for Surgery of the Foot (JSSF) hallux scale, complications, and HV recurrence. These outcome measures were compared using the unpaired t-test on standing anteroposterior X-ray of the feet. Results: In the M Group, comparison of pre- and postoperative radiological changes indicated that the HV angle improved from 38.2° to 11.4°, M1M2 angle improved from 14.5° to 5.0° respectively. JSSF hallux score improved from 53.3 to 89.6. Postoperative hallux varus was confirmed in four cases, Osteoarthrosis of the MTP joint in six, and HV recurrence in two. In the L Group, comparison of pre- and postoperative radiological changes indicated that the HV angle improved from 46.0° to 16.9°, M1M2 angle improved from 15.2° to 6.6°respectivelty. JSSF hallux score improved from 47.8 to 94.7. Postoperative hallux varus was confirmed in two cases, Osteoarthrosis of the MTP in four, and HV recurrence in four. In both groups, only preoperative HV angle exhibited significant differences (p &lt; 0.0001). Conclusion: Surgical technique was selected based on HV severity and metatarsalgia whether were present; however, both groups showed satisfactory results. In cases of severe HV or in cases accompanied by metatarsalgia, we performed the modified Lapidus procedure that reduced pronation and valgus of first metatarsal. The X-ray and clinical findings of the present study showed that the results of the L Group were not inferior when compared to those of the M Group. Surgical technique should be selected based on both HV severity and lessor toe symptoms.

Retrospective Analysis of Non-Union Rate Associated with Immediate Weightbearing Following A Modified Lapidus Arthrodesis

Category: Bunion Introduction/Purpose: A 6-8 week non-weightbearing period post modified lapidus arthrodesis has traditionally been universally accepted. A review of the literature reports nonunion rates between 5-33% after modified lapidus with 6-8 weeks of non- weightbearing. There are only a few reports in the literature that discuss immediate weightbearing after the modified lapidus procedure. In this retrospective review, we examine the nonunion rate among patients undergoing the modified lapidus arthrodesis who were immediately weightbearing in a controlled ankle motion (CAM) boot. It is our hypothesis that the non- union rate will be comparable to the traditional post-operative protocol nonunion rate. Methods: In this retrospective study, we evaluated chart data on patients who underwent a modified Lapidus arthrodesis with immediate weight- bearing in a CAM boot. The goal of the study was to determine if a modified Lapidus surgical technique in conjunction with rigid internal fixation produces the necessary stability post-operatively in order to allow bony consolidation while being stressed with immediate weight bearing forces. Patients who underwent a modified Lapidus arthrodesis using either a 3 screw construct or a medially placed locking plate with an interfragmentary screw were included in the study. Patients with other adjunctive procedures that would prevent early weight bearing were not included in the investigation. Results: A total of 376 patients were identified with 74 patients meeting inclusion criteria. 4 patients had bilateral procedures performed at separate times for a total of 78 Lapidus procedures. 31 patients had a 3 screw construct while 43 patients had a medial locking plate with an interfragmentary screw. 15 patients admitted to using nicotine. Additionally, 7 patients had type II Diabetes Mellitus. Autogenous shear- strain relief bone graft was used in 75 of the 79 procedures.Three patients (3.8%) experienced a post-operative non-union. Interestingly, none of the patients with non-unions were smokers and only one patient was diabetic. Conclusion: The results of this study found a 3.8% nonunion rate. Based on these results we conclude that a modified Lapidus procedure using a long, solid interfragmentary screw with either additional screw support or a locking plate, we may permit patients to ambulate safely in a CAM boot immediately post- operative period without affecting surgical outcome.

Comparison of postoperative outcomes between modified Mann procedure and modified Lapidus procedure

Comparison of postoperative outcomes between modified Mann procedure and modified Lapidus procedure

Immediate Weight Bearing after Bi-planar Plantar Fixation of Lapidus

Category: Bunion Introduction/Purpose: There are many options when choosing to repair HAV (hallux abducto-valgus) deformity of the foot. The Lapidus procedure and its modifications are often selected to correct these deformities due to multiplanar correction at the CORA (center of rotational angulation). As with any surgical procedure, there are advantages and disadvantages when selecting the correct technique. One drawback often identified with the Lapidus procedure is the need for extended immobilization and the inability to weight bear for an extended period of time. The objectives of this study were to demonstrate a new, novel construct that can allow for immediate weight bearing after Lapidus arthrodesis with predictable outcomes. Methods: This IRB approved study was comprised of 4 centers that performed a specific modification of the Lapidus procedure with an identical fixation construct. The construct consisted of 2 mini-plates that were applied across the first tarsometatarsal (TMT) joint. The plates were applied while the joint was held in compression. The plates were oriented dorsal and plantar-medial allowing for a greater than 90° spread between plates for appropriate distribution of the forces and a true multi-planar construct. This concept takes into account biplanar stability as described by Kolner[1] and micromotion to stimulate secondary bone healing as described by Perren[2]. All patients were placed into a protective, cushioned dressing with a rigid bottom shoe or boot depending on surgeon preference. The patients were allowed weight-bear as tolerated with walker or crutches for safety as soon as the regional anesthesia dissipated to allow for complete sensation in the operative limb. Results: Twelve months of consecutive cases with immediate weight bearing and minimum follow-up of 6 months were included in the study. All cases that met inclusion criteria were included in the analysis; inclusion criteria were primary corrections of a HAV deformity with correction done via the described technique performed within the approved date range. Procedures not utilizing the described technique, revision procedures and procedures that extended the arthrodesis outside of the first TMT joint were excluded. Conclusion: Preoperative and postoperative measurements of 50 patients were obtained in this study. Radiographic evaluation of the fusion site was used to determine if the arthrodesis demonstrated healing at a minimum of 6 months. Other studies have shown early weight bearing (&lt;3 weeks) is possible after the Lapidus procedure [3], this study demonstrated that immediate weight bearing after a modified Lapidus procedure is possible with a decreased reported nonunion rate (4.0%). This modified procedure did not result in a recurrence of the deformity. We expect continuation of the study to demonstrate that there are no long-term issues.

Management of Hallux Valgus Deformity in Patients with Metatarsus Adductus

Category: Bunion Introduction/Purpose: Metatarsus adductus (MA) is a congenital condition in which there is persistent adduction of the metatarsals, which has been shown to increase the risk of recurrence of hallux valgus in patients undergoing surgery. The rate of recurrence varies with the magnitude of the adductus, perhaps correlating with the type of surgery performed, ie. the treatment of the adductus deformity and not just the hallux valgus. The goal of this study was to further analyze a cohort of patients with severe MA and identify clinical/surgical factors that are associated with a lower rate of recurrent deformity. Methods: An IRB approved retrospective review between 2002-2012 was completed. All patients undergoing hallux valgus surgery were identified. Patients were included if adequate radiographic information /clinical records were available and if the MAA was greater than 31° (normal values for the MA angle are &lt; 20°). Clinical information collected included associated diagnoses, the presence of arthritis of the tarsometatarsal joints, the presence and degree of lesser toe valgus deformities and surgical procedures completed. Radiographic recurrence was defined as a postoperative HVA &gt; 20° (at most recent follow up). Results: A total of 19 patients with severe MA/hallux valgus were identified. The average age of patients in this group was 55 years (51-60). Eight patients had associated tarsometatarsal arthritis and ten patients had severe valgus lesser toe deformities. Nine patients were treated with a modified Lapidus procedure and 10 patients underwent a distal first metatarsal osteotomy. Of the 9 patients who were treated with a modified Lapidus procedure, 5 patients underwent simultaneous realignment arthrodesis of the 2nd/3rd TMT joints for management of simultaneous midfoot arthritis. One of these patients had radiographic recurrence of deformity. Of the 7 patients who underwent a distal first metatarsal osteotomy without realignment arthrodesis of the 5 had recurrence of deformity. When evaluating patients for treatment of lesser toe deformity, 11 patients who were treated with simultaneous distal metatarsal realignment osteotomies, did not have recurrence of hallux valgus. Conclusion: Based on our findings, the use of a modified Lapidus arthrodesis led to a lower rate of HV deformity recurrence in comparison to isolated distal first metatarsal osteotomies but only when performed in conjunction with realignment arthrodesis of the 2nd/3rd TMT joints and distal lesser metatarsal osteotomies. If the patient does not have arthritis of the lesser TMT joints proximal metatarsal osteotomies are sufficient for correction. Treatment of lesser toe deformity with distal osteotomies was associated with lower recurrence of HV deformity and should be included as part of the treatment algorithm.

Early Weight Bearing Following First TMT Arthrodesis

Category: Midfoot/Forefoot Introduction/Purpose: The modified Lapidus arthrodesis is an accepted method of correcting varying degrees of hallux valgus with or without associated first ray insufficiency. Improved operative techniques have led to more reliable outcomes and lower incidence of nonunion. As a result, the modified Lapidus procedure has increased in popularity. Historically, surgeons have followed cautious postoperative protocols, initially restricting weight bearing until bone consolidation is confirmed radiographically. More recently, an alternative approach to postoperative management has been proposed, allowing patients to bear weight as tolerated two weeks after surgery with the goal of improving patient compliance while minimizing postoperative disability. The purpose of this study is to compare outcomes of patients randomized to either early weight bearing or standard non-weight bearing postoperative course following modified Lapidus arthrodesis. Methods: We determined that at least 130 patients would need to be enrolled in this study to achieve statistical significance (p &lt; 0.05). Beginning in 2012, patients with hallux valgus indicated for modified Lapidus arthrodesis were assigned to either the investigational Group A (early weight bearing) or to the control Group B (standard of care) by a random number generator. All patients underwent modified Lapidus arthrodesis by one of the three senior authors (JGA, DRB, JDM). Specific demographic, clinical, patient-centered, and radiographic data were collected during the preoperative visit, the operative procedure, and at defined intervals during the postoperative period. The primary outcome variable was defined as first tarsometatarsal joint fusion at six months. Results: To date, 100 subjects have been enrolled, 57 of whom (40 patients in Group A, 17 patients in Group B) have completed one year of follow up. At six months, 38/40 patients in Group A had achieved radiographic union, compared to 17/17 patients in Group B (p = 0.495). Smoking status, BMI, and age at surgery were not found to be significantly associated with rate of union in either group. Patients in Group A required less time to reach full weight bearing status (p &lt; 0.001). At six weeks after surgery, Group A reported significantly higher levels of physical function and overall composite scores on the SF-36 questionnaire. The rate of adverse events was not significantly different between the two groups at any postoperative timepoint. Conclusion: Though data collection is ongoing, our results indicate that clinical, patient-centered, and radiographic outcomes were comparable following modified Lapidus arthrodesis in both the early weight bearing and standard of care patient groups. Early weight bearing does not appear to increase the rate of adverse events or significantly slow rate of fusion, and also reduces postoperative disability.

Results of percutaneous modified Lapidus procedure for severe hallux valgus deformities

Results of percutaneous modified Lapidus procedure for severe hallux valgus deformities

Subjective versus objective assessment in early clinical outcome of modified Lapidus procedure for hallux valgus deformity

BackgroundStudies have assessed the outcome of hallux valgus surgeries based on subjective questionnaires, usually the American Orthopaedic Foot and Ankle Society Score, and radiographic results reporting good to excellent outcome at 6–12months postoperatively. However, contrasting results were reported by gait studies at 12–24months postoperatively. In a previous study, we found nine gait parameters which can describe the altered gait in hallux valgus deformity. This study aimed, to assess the outcome of modified Lapidus at 6months postoperatively, using gait assessment method, to determine if the nine specified gait parameters effectively relates with the clinical scores and the radiological results or add information missed by these commonly used clinical assessments. MethodWe assessed 21 participants including 11 controls and 10 patients with moderate to severe hallux valgus deformity. The patient group was followed 6months postoperatively. The ambulatory gait assessment was performed utilizing pressure insoles and inertial sensors. Clinical assessment includes foot and ankle questionnaires along with radiographic results. Comparison was made using non parametric tests, P<0.05. FindingsAltered gait patterns, similar to the preoperative outcome, persisted at 6months postoperatively when compared to controls. The foot and ankle ability measure score showed an outcome comparable to the gait results. In contrast, the American Orthopaedic Foot and Ankle Society Score and radiographic results showed significant improvement. InterpretationStudy supports the reliability of nine defined gait parameters in assessing the outcome of hallux valgus surgeries. The existing clinical assessment overestimates the functional outcome at the early postoperative phase.

Placement of Plantar Plates for Lapidus Arthrodesis: Anatomical Considerations.

The modified Lapidus procedure is an accepted treatment option for patients with moderate to severe hallux valgus. Placing a plate plantar on the tension side of the arthrodesis has been shown to be biomechanically superior and has provided good clinical results. There is some concern about interference of the plantar placed plates on the tendon insertions. The purpose of this study was to determine a "safe zone" for plantar plate placement without irritation of the tendons. Twenty-nine embalmed right feet were used for this study. The anatomy of the insertion of the peroneus longus (PL) tendon and tibialis anterior (TA) tendon on the medial cuneiform and first metatarsal were analyzed. Six different plate designs for plantar plating of the first tarsometatarsal fusion were included. The fit to the bone and contact to tendon insertion were analyzed. The PL showed a main insertion to the first metatarsal and a lesser insertion to the medial cuneiform. The TA inserted onto the medial cuneiform and first metatarsal in all cases in our series. There was a "safe zone" between the TA and PL insertion areas for plate placement. Straight, Y- and U-shaped plates could be placed without compromising the tendon insertion. Depending on the design, even preshaped plates may have to be bent to allow a good fit to the plantar side of the first tarsometatarsal joint. Plantar plating for modified Lapidus arthrodesis can be safely performed, without damaging the plantar tendon insertion area of the PL and TA. The exact knowledge of the anatomy of the plantar region of the tarsometatarsal joint can help to improve plate placement.

Return to Sports and Physical Activities After the Modified Lapidus Procedure for Hallux Valgus in Young Patients.

The modified Lapidus procedure has successfully relieved pain and corrected deformity in patients with hallux valgus, but its effect on participation in specific sports and physical activities remains unclear. Our goals were to assess sports and physical activities in young patients following the modified Lapidus procedure and to compare these with clinical outcomes. Fifty-eight eligible patients were identified from a retrospective registry review. Of these, 48 (83%) were reached for follow-up at a mean of 2.8 (range, 1.0 to 6.1) years and had a mean age at surgery of 37.3 (range, 14.1 to 49.3) years. Physical activity participation was evaluated with a new sports-specific, patient-administered questionnaire. Clinical outcomes were evaluated with the Foot and Ankle Outcome Score (FAOS) and compared to sports outcomes. Patients participated in 26 different physical activities, consisting of 212 total physical activities preoperatively and 209 total postoperatively. The most common were walking, running, bicycling, and swimming. Compared to preoperatively, patients rated 29% of activities as less difficult, 52% as the same, and 19% as more difficult and rated participation levels as improved in 40%, the same in 41%, and impaired in 19%. Eighty-one percent of patients were satisfied with their operative outcome in regard to return to physical activity. Changes in the FAOS Pain subscore were significantly associated with improvements in physical activity difficulty (P < .05), and changes in the Pain, Sports, and QOL subscores were significantly associated with changes in physical activity participation levels (P < .05). Four in 5 patients were able to participate in previous sports and physical activities, including high-impact activities, at their preoperative participation level or better after the modified Lapidus procedure, and were satisfied with surgery in regard to return to previous activity. However, several patients had increased difficulty and impaired participation in physical activity postoperatively. Altogether, this suggests that the procedure is a viable treatment option for hallux valgus in young, active patients. Level IV, retrospective case series.

Modified Lapidus Procedure with Joint Compression, Meticulous Surface Preparation, and Shear-Strain-Relieved Bone Graft Yields Low Nonunion Rate.

The modified Lapidus procedure is widely used to correct hallux valgus but has been reported with high nonunion rates. In this study, we retrospectively reviewed the nonunion rate of the modified Lapidus procedure performed with rigid cross screw fixation, meticulous joint preparation, and shear-strain-relieved calcaneal bone graft. Does the performance of the Lapidus procedure with rigid cross screw fixation, complete joint preparation, and shear-strain-relieved calcaneal bone graft achieve higher union rates than currently reported? If nonunion does occur, what is the clinical course? We reviewed both radiographic and clinical results of the modified Lapidus procedure with the above technique in 171 patients (182 feet). Evaluation included age, gender, tobacco use, diabetic status, and radiographic analysis at least 3months postoperatively. The modified Lapidus procedure described above resulted in a union rate of 97.3% (177 of 182 feet). Three of the five feet with radiographic nonunions were clinically symptomatic. The union rate of the modified Lapidus procedure is higher than previously reported when performed with rigid cross screw fixation, meticulous joint preparation, and shear-strain-relieved bone graft. Nonunion of the first tarsometatarsal joint should be considered an infrequent occurrence.

Long-term outcome of joint-preserving surgery by combination metatarsal osteotomies for shortening for forefoot deformity in patients with rheumatoid arthritis

Objectives. We report the long-term outcome of joint-preserving surgery by combining metatarsal osteotomies for shortening for forefoot deformity in patients with rheumatoid arthritis (RA).Methods. Forty-three patients (57 feet) aged 41.7–70.8 years (mean, 57.7 years) underwent a combination of first tarsometatarsal fusion and distal realignment (modified Lapidus procedure), shortening oblique osteotomies of the bases of metatarsals 2–4, and fifth ray osteotomy (modified Coughlin procedure). Patients were followed up for 64–108 months (mean, 76.6 months).Results. Average postoperative Foot Function Index scores for pain, disability, and activity were 10.3, 19.9, and 16.2, respectively. Average Japanese Society for Surgery of the Foot RA foot and ankle score improved significantly from 52.1 points preoperatively to 90.3 points postoperatively. Postoperatively, 41% of patients reported some forefoot stiffness, but showed no disability. Residual deformity and callosity were absent in all patients. Average hallux valgus and intermetatarsal angles decreased postoperatively from 48.5° to 8.6° and from 15.2° to 4.6°, respectively. Nonunion in two metatarsals, hardware breakage in three, and mild infection in one were identified during follow-up.Conclusions. With good perioperative medical management of RA, surgical repositioning of the metatarsophalangeal joints by proximal metatarsal shortening and consequent relaxing of the surrounding soft tissue shows successful long-term results.

Relationship of Frontal Plane Rotation of First Metatarsal to Proximal Articular Set Angle and Hallux Alignment in Patients Undergoing Tarsometatarsal Arthrodesis for Hallux Abducto Valgus: A Case Series and Critical Review of the Literature

Rotation of the first metatarsal, as a component of hallux abducto valgus, is rarely discussed and is not addressed as a component of most hallux valgus corrective procedures. We believe frontal plane rotation of the first metatarsal to be an integral component of hallux abducto valgus deformity (the “third plane of deformity”) and believe de-rotation is necessary for complete deformity correction. We observed the change in angular measurements commonly used in the evaluation of hallux valgus deformity in patients who underwent a modified lapidus procedure. We measured the intermetatarsal angle, hallux abductus angle, proximal articular set angle, and tibial sesamoid position on weightbearing radiographs of 25 feet in 24 patients who had undergone tarsal metatarsal corrective arthrodesis and lateral capsular release. Specific attention was given to reduction of the frontal plane rotation of the first metatarsal during correction. Our results showed a change in the angular measurements observed by 4 investigators as follows. The mean change in the intermetatarsal angle was 10.1° (p < .0001). The mean change in the hallux abductus angle was 17.8° (p < .0001). The mean change in the proximal articular set angle was 18.7° (p < .0001). The mean change in the tibial sesamoid position was 3.8 (p < .0001). Also, a consistent valgus, or everted position of the first metatarsal, was noted as a component of the hallux abducto valgus deformity in our patient population and was corrected by varus rotation or inversion of the metatarsal. We also reviewed the current literature related to anatomic changes in the first ray in the patient with hallux valgus deformity and reviewed our hypothesis regarding the reduction in the proximal articular set angle, which we believe to be related to frontal plane rotation of the first metatarsal, resulting in a radiographic artifact.

Combination of First Metatarsophalangeal Joint Arthrodesis and Proximal Correction for Severe Hallux Valgus Deformity

Arthrodesis of the first metatarso-phalangeal (MTP-1) joint is a widely accepted procedure for the treatment of hallux valgus in patients with MTP-1 degeneration, severe or recurrent deformity, or inflammatory arthritis. This study aimed to evaluate if an additional more proximal correction was beneficial in cases with a severely increased intermetatarsal 1-2 angle (IMA 1-2). A consecutive series of 18 feet (4 bilateral, all females; mean age, 61 years) with severe hallux valgus and an increased IMA 1-2 treated by MTP-1 fusion and an additional more proximal correction (Mau osteotomy or modified Lapidus procedure) was evaluated. Radiographs were analyzed for IMA 1-2 and hallux valgus angles (HVA), and for the position of the tibial sesamoid according to the AOFAS guidelines. At a mean followup of 14 months, all patients were satisfied or very satisfied with the results of surgery. There were no intraoperative complications. The IMA 1-2 significantly improved from a mean of 18.8 degrees before surgery to 4.6 degrees at followup (p < 0.001) and the HVA from a mean of 49.9 degrees to 9.7 degrees (p < 0.001), respectively. Sesamoid position improved two grades on average. We found no difference between the Mau osteotomy and the modified Lapidus procedure. The present results indicate that the combination of a more proximal procedure with a MTP-1 arthrodesis in cases of hallux valgus with severely increased IMA 1-2 has a high correction capability and achieved normal HVAs as well as normal IMAs 1-2. This technique appeared to be safe and clinically successful.

Results of Modified Lapidus Arthrodesis Procedure Using Medial Eminence as an Interpositional Autograft

The Lapidus procedure has received wide acceptance as a valuable operation for correcting moderate to severe hallux valgus, especially in the presence of hypermobility. However, shortening of the first ray inherently occurs as the first metatarsocuneiform joint cartilage and subchondral bone are resected in preparation for arthrodesis. The purpose of this study was to radiographically compare the degree of shortening of the first ray with and without the use of the first metatarsal medial eminence as an interpositional autograft at the site of metatarsocuneiform fusion. Preoperative and postoperative radiographs were measured in 35 consecutive patients who underwent 37 modified Lapidus procedures for hallux valgus repair. In group A, 20 surgeries were performed without use of the interpositional autograft, and served as the control. In group B, 14 surgeries were performed using the medial eminence as an interpositional autograft. The mean amount of first ray shortening was 5.3 ± 1.66 mm in group A and 2.69 ± 1.56 mm in group B, and this difference was statistically significant ( P < .001). All patients progressed to complete union, and the median follow-up was 6 months (range, 4–60). Based on these results, the use of the medial eminence as an interpositional autograft in conjunction with Lapidus arthrodesis resulted in a 49.2% reduction in the amount of shortening of the first ray and proved to be a useful source of readily available bone graft.

Pseudotumour of the foot due to hypermobility of the first ray

A patient presenting with a chronic mass secondary to hypermobility of the first ray was successfully treated with a modified Lapidus procedure combined with a lengthening of the Achilles tendon. The association of the pseudotumour with a synovial cyst secondary to instability of the first ray was only made after appropriate weightbearing radiographs. The patient had previously been offered an amputation due to recurrence of the cystic mass after surgical excision. This case illustrates the importance of weightbearing radiographs in the assessment of the foot and the ankle disorders.