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Cychosz CC, Mizher R, Digiovanni GM, Jones AC, Conti MS, Ellis SJ. Correlation of Clinical Outcomes and Relative Position of the First Metatarsal After the Modified Lapidus Procedure. Foot Ankle Int 2024; 45:979-987. [PMID: 38872316 DOI: 10.1177/10711007241255378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
BACKGROUND Hallux valgus is a complex 3-dimensional deformity, and the modified Lapidus is a commonly used procedure to correct moderate to severe cases. Shortening and elevation of the first ray can occur with this procedure, which may result in increased pressure on the lesser metatarsal heads. However, there is currently no consensus regarding an accepted length and elevation of the first ray following the modified Lapidus. Therefore, the purpose of this study is to evaluate the impact of the position of the first ray on patient-reported outcome measures. METHODS This retrospective study identified 68 patients (72 feet) who underwent the modified Lapidus bunionectomy over a 4-year period at a single institution with a median follow-up of 24 months (range, 11-35.6 months). Patients were included if they were over 18 years of age, had pre- and postoperative weightbearing computed tomography (WBCT) scans, and preoperative and minimum 1-year postoperative Patient-Reported Outcome Measurement Information System (PROMIS) scores. PROMIS scores from 6 domains including physical function, pain interference, pain intensity, global physical health, global mental health, and depression were evaluated and compared pre- and postoperatively. Radiographic parameters were measured and compared before and after surgery. Paired t tests were used to evaluate the significance of pre- to postoperative changes. Differences between cohorts were compared using Mann-Whitney U test for continuous variables or Fisher exact test for categorical variables. Correlation between radiographic measurements and patient-reported outcomes were assessed using the Spearman rank rho estimate and visualized with scatterplots with a linear regression. RESULTS PROMIS physical function, pain interference, pain intensity, and global physical health improved significantly following the modified Lapidus (all P < .001); however, scores did not show any significant correlation with shortening of the first ray up to a maximum shortening of 4.8 mm. The length of the first metatarsal relative to the second decreased by an average of 2.7 mm following the procedure when measured on WBCT (P < .001), and 2.6 mm when measured on plain radiographs (P < .001). No significant elevation of the first ray was observed postoperatively. CONCLUSION This study revealed that the Lapidus bunionectomy resulted in significantly improved pain and physical function at short-term follow-up. The amount of first ray shortening and elevation that occurred in this cohort did not adversely affect patient-reported outcomes.
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Affiliation(s)
- Chris C Cychosz
- Slocum Center for Orthopedics and Sports Medicine, Foot and Ankle, Eugene, OR, USA
| | - Rami Mizher
- Hospital for Special Surgery, New York, NY, USA
| | | | | | - Matthew S Conti
- Hospital for Special Surgery, Foot & Ankle, New York, NY, USA
| | - Scott J Ellis
- Hospital for Special Surgery, Foot & Ankle, New York, NY, USA
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2
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Kane LA, Weintraub MLR, Mitchell L, Parker M, King CM, Pollard JD. Secondary Surgery Following Lapidus Bunionectomy. J Foot Ankle Surg 2024:S1067-2516(24)00114-5. [PMID: 38914154 DOI: 10.1053/j.jfas.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/22/2024] [Accepted: 05/25/2024] [Indexed: 06/26/2024]
Abstract
While the Lapidus bunionectomy is a common procedure utilized to address hallux valgus, the incidence of secondary surgery is not well established. Our primary goal was to determine the incidence of revision surgery and hardware removal following the Lapidus bunionectomy in addition to the risk factors associated with each. A retrospective nested case-control study of adult patients who underwent a Lapidus bunionectomy for symptomatic hallux valgus over a 9-year period was performed. The incidence rates and 95% confidence intervals (CI) of secondary surgery in the 3 years following the procedure along with the estimated independent associations and odds ratios between baseline demographic, clinical, and radiographic characteristics were calculated. Of the original cohort of 2540 patients, 127 were identified (5.0%; CI: 4.1%, 5.8%) who underwent revision surgery and 165 (6.5%; CI: 5.5%, 7.5%) who underwent hardware removal following Lapidus bunionectomy. Initially, the hallux valgus angle, intermetatarsal angle, and tibial sesamoid position were risk factors for revision surgery. However, in adjusted analyses for revision surgery, using a screw for third point of fixation emerged as the only independent risk factor (odds ratio [OR] = 3.01; CI: 1.59, 5.69). In adjusted analyses for hardware removal, female sex (OR = 2.33; CI: 1.08, 5.00) and third point of fixation (OR = 2.92; CI: 1.82, 4.69) emerged as independent risk factors. While the overall risks associated with Lapidus bunionectomy are low and the need for revision surgery are low, this study helps to identify specific risk factors for secondary surgery and hardware removal to help in evaluation and discussion with patients.
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Affiliation(s)
- Lewis A Kane
- Department of Podiatric Surgery, Kaiser Permanente Diablo Service Area, Walnut Creek, CA
| | | | - Logan Mitchell
- Department of Podiatric Surgery, Sutter Medical Foundation, Yuba City, CA
| | | | - Christy M King
- Department of Podiatric Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Jason D Pollard
- Department of Podiatric Surgery, Kaiser Permanente Oakland, Oakland, CA.
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3
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Adebayo T, Koroneos Z, Özdemir E, Herrin A, El Akkari S, Lewis G, Aydogan U. Cannulated screws versus nitinol staple for tarsometatarsal fusion: A cadaveric biomechanical comparison model. Foot Ankle Surg 2024:S1268-7731(24)00115-2. [PMID: 38839459 DOI: 10.1016/j.fas.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 03/17/2024] [Accepted: 05/21/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The objective of this study was to evaluate the biomechanical stability of a medially placed nitinol staple compared to two crossed-screws in the first TMT-1 joint fusion in a cadaveric cyclic loading model. METHODS Seven matched pairs (N = 7) of lower limb cadaveric specimens were utilized. TMT-1 joints from each donor were fixed with a medially placed nitinol staple or dorsally placed two 3.5 mm partially threaded cannulated crossed-screws. Specimens were tested in a 4-point bending setting with increasing cyclic forces. RESULTS The mean plantar gapping was not significantly different between the two groups at any loading stage below 200 N. Specimens fixed with a nitinol staple failed at a mean load of 305 ± 57 N. Conversely, those fixed with crossed-screws failed at 373 ± 86 N. (P = .09). CONCLUSION There was no statistical difference between a medially placed nitinol staple and dorsally placed crossed-screws in failure loads and plantar gapping under cyclic loads at the TMT-1 joint, however, the staple fixation was much more variable. LEVEL OF EVIDENCE Level V, basic science study, biomechanics.
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Affiliation(s)
- Temitope Adebayo
- Department of Orthopaedics & Rehabilitation, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Zachary Koroneos
- Department of Orthopaedics & Rehabilitation, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Erdi Özdemir
- Department of Orthopaedics & Rehabilitation, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA, USA.
| | - Alex Herrin
- Department of Orthopaedics & Rehabilitation, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Sherif El Akkari
- Department of Orthopaedics & Rehabilitation, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Gregory Lewis
- Department of Orthopaedics & Rehabilitation, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Umur Aydogan
- Department of Orthopaedics & Rehabilitation, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA, USA
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Rigby RB, McWilliam JR, Jenkins BT. Tension Side Fixation for Lapidus Arthrodesis: A Retrospective Analysis. J Foot Ankle Surg 2024; 63:372-375. [PMID: 38266808 DOI: 10.1053/j.jfas.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 11/19/2023] [Accepted: 01/13/2024] [Indexed: 01/26/2024]
Abstract
Moderate to severe hallux valgus deformity often requires a Lapidus procedure (first-tarsometatarsal arthrodesis). Traditional methods include a dorsal approach with dorsal or medial fixation. However, studies demonstrate plantar/tension-side fixation, provides superior load to failure and fixation strength. This could improve outcomes, address comorbidities, and accelerate postoperative protocols; however, a paucity exists for patient outcomes in the literature regarding tension-side-fixation. The purpose of this study is to report the outcomes for tension-side Lapidus fixation. A retrospective analysis was performed of 81 patients who underwent tension-side-fixation Lapidus. Data collection consisted of: time to weight-bear, time to return to regular shoegear, hardware removal rate, revision rate, recurrence rate, relative metatarsal shortening, and nonunion rates. Mean patient age was 44 years old (range: 16-82). There were 65 females, and 16 males. The average time to weightbearing was 10.4 days. Time to return to regular shoegear was a mean of 6 weeks (ranging 2-10 weeks). Hardware removal rate was 1.2%. The recurrence rate was 8.6% (7 of 81 patients) and 5 of those 7 patients experienced recurrence before frontal-plane-correction was adopted by the surgeon. The revision rate was 0% and despite 8.6% recurrence, no patients were dissatisfied or requested a revisional procedure. The first-metatarsal shortening was a mean of 0.42 mm. The complications were as follows: 7% superficial dehiscence, 1.2% superficial wound infection, 0% deep infection, and 1.2% asymptomatic nonunion. This study suggests tension-side-fixation for Lapidus arthrodesis may allow for safe early return to weightbearing, early return to regular shoegear, low hardware removal rate, low revision rate, low metatarsal shortening, and low nonunion rate.
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Affiliation(s)
- Ryan B Rigby
- Logan Regional Orthopedics, Intermountain Healthcare, Logan, UT; Attending, Intermountain Medical Center Podiatry Residency Program, Logan, UT
| | - James R McWilliam
- White Plains Hospital Physicians Associates, White Plains, NY; Assistant Clinical Professor of Orthopaedic Surgery, New York Medical College, Valhalla, NY
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Patel S, Dionisopoulos SB, Schmalhaus MJ. Early Functional Rehabilitation in Foot and Ankle Surgery. Clin Podiatr Med Surg 2024; 41:59-71. [PMID: 37951679 DOI: 10.1016/j.cpm.2023.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
The traditional postoperative management of common foot and ankle procedures has involved a prolonged period of immobilization and nonweight bearing. The concern was loss of correction and fixation failure. However, it has been shown that a prolonged period of nonweight bearing can predispose patients possible deep vein thrombosis, disuse osteopenia, cardiovascular complications, and generalized deconditioning. The authors' institution has published studies reviewing the efficacy of early weight bearing after first metatarsophalangeal joint arthrodesis, modified Lapidus bunionectomy, and open reduction and internal fixation of ankle fractures. This article highlights the literature and rationale supporting the safety of early weight-bearing protocols.
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Affiliation(s)
- Sandeep Patel
- San Francisco Bay Area Foot and Ankle Residency, The Permanente Medical Group, Diablo Service Area, 1425 South Main Street, Walnut Creek, CA 94596, USA.
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Paranjape CS, Zhang J, Lalli T, Lin FC, Tennant JN. Radiographic and Patient-Reported Outcomes of a Low-Cost Modified Lapidus Bunion Correction Technique. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231200482. [PMID: 37786608 PMCID: PMC10541767 DOI: 10.1177/24730114231200482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
Background The modified Lapidus (ML) is a powerful procedure for correction of hallux valgus (HV) with emerging techniques. Studies considering patient-reported outcomes, radiographic measures, complications, and implant costs are currently limited. Methods Retrospective cohort with prospectively collected Patient Reported Outcome Information System Physical Function (PROMIS-PF) Computerized Adaptive Test (CAT) scores, radiographic parameters (intermetatarsal angle, IMA; hallux valgus angle, HVA; and tibial sesamoid position, TSP), complications, and total operative time and implant costs were reviewed from 2014 to 2019. Results Seventy-three feet (68 patients) underwent bunion correction by ML with lag-screw fixation. Median age was 55.8 years (IQR 45.6, 53.9), 4 of 73 (5.5%) were male, 11 of 73 (15.1%) were smokers, and 15 of 73 (20.6%) were diabetic (median HbA1c 6.4% [IQR 6.0, 7.4], none insulin dependent, 5 of 15 with neuropathy). Complications included 6 of 73 (8.2%) wound issues resolved with topical or oral treatment, 9 of 73 (12.3%) painful or broken hardware requiring hardware removal. Two of 73 (2.7%) had persistent pain despite union. One of 73 (1.4%) was overcorrected and required first MTP arthrodesis. Of 3 nonunions (2.7%), 1 resolved with corrected hypothyroidism, 1 was asymptomatic and required no treatment, 1 had a hallux valgus recurrence and sought revision surgery elsewhere. Preoperative radiographic angles were HVA 35 degrees, IMA 14 degrees which improved at final postoperative follow up to HVA 10 degrees, IMA 6 degrees. Tibial sesamoid position improved from 6.05 ± 1.00 to 2.22 ± 1.38. Thirty-two patients had preoperative and 42 had 1-year postoperative outcomes. PROMIS-PF (51% collection rate) was 43 (IQR 37,52) preoperatively, 37 (31, 39) at 6 weeks, 46 (42, 51) at 3 months, and 49 (41, 53) at >360 days postoperatively. The drop in PROMIS-PF between preoperative and 6 weeks and the rise from 6 weeks to 3 months were statistically significant. Pre- and postoperative PROMIS-PF scores were not significantly different. Implant cost averaged US$146. Discussion/Conclusion We report low complication rates and costs with high patient postoperative functional and radiographic outcomes. PROMIS-PF decreased acutely postoperatively but recovered and maintained high levels by 3 months postoperatively. Level of Evidence Level IV, case series.
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Affiliation(s)
| | - Jingru Zhang
- University of North Carolina, Chapel Hill, NC, USA
| | - Trapper Lalli
- University of North Carolina System, Chapel Hill, NC, USA
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Jones JM, Schleunes SD, Vacketta VG, Philp FH, Hentges MJ, McMillen RL, Saltrick KR, Catanzariti AR. First Tarsometatarsal Joint Arthrodesis for Hallux Valgus With and Without Intermetatarsal Screw Fixation: A Comparison of Correction and Maintenance of Correction. J Foot Ankle Surg 2022; 61:1255-1262. [PMID: 35346576 DOI: 10.1053/j.jfas.2022.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 02/03/2023]
Abstract
Tarsometatarsal joint arthrodesis is a commonly accepted procedure for hallux valgus associated with severe deformity and first ray hypermobility or medial column instability. This study evaluates the correction of hallux valgus deformity and the maintenance of correction with and without the use of a stabilization screw between the first and second metatarsal bases. Through retrospective review of first tarsometatarsal joint arthrodesis within our institution we evaluated 63 patients. Twenty-seven patients did not have a first to second metatarsal base screw and were placed into the no screw cohort. Thirty-six patients did have a first to second metatarsal base screw and were placed into the screw cohort. This study population had an osseous union rate of 95%. Clinical and radiographic recurrence occurred in 5 of 63 patients (8%). At 1-y postop the measurements demonstrated that the screw cohort had an average intermetatarsal angle correction of 11.6 degrees while the no screw cohort had an average correction of 7.8 degrees. Additionally, at 1-y postop the screw cohort had greater maintenance of the intermetatarsal angle correction with an average change of 0.5 degrees compared to 2.3 degrees in the no screw cohort. We conclude that the addition of the stabilization screw improves the first tarsometatarsal joint arthrodesis construct resulting in a greater degree of realignment and maintenance of correction.
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Affiliation(s)
- Jacob M Jones
- Resident, Postgraduate Year 3, Division of Foot and Ankle Surgery, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA
| | - Scott D Schleunes
- Resident, Postgraduate Year 2, Division of Foot and Ankle Surgery, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA
| | - Vincent G Vacketta
- Resident, Postgraduate Year 3, Division of Foot and Ankle Surgery, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA
| | - Frances Hite Philp
- Health Outcomes Researcher, AHN Research and Orthopaedic Institutes, Allegheny Health Network, Pittsburgh, PA
| | - Matthew J Hentges
- Attending Faculty of Residency Training Division of Foot and Ankle Surgery, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA
| | - Ryan L McMillen
- Attending Faculty of Residency Training Division of Foot and Ankle Surgery, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA
| | - Karl R Saltrick
- Vice Chair, Division of Foot and Ankle Surgery, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA
| | - Alan R Catanzariti
- Director of Residency Training Division of Foot and Ankle Surgery, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA.
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8
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Do DH, Sun JJ, Wukich DK. Modified Lapidus Procedure and Hallux Valgus: A Systematic Review and Update on Triplanar Correction. Orthop Clin North Am 2022; 53:499-508. [PMID: 36208892 DOI: 10.1016/j.ocl.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This review article examines contemporary methods and assesses radiographic outcomes and postoperative complications following the modified Lapidus procedure. A systematic review demonstrated significant improvements in intermetatarsal angle, hallux valgus angle, and tibial sesamoid position. We are updating a modified Lapidus technique for achieving triplanar correction of hallux valgus. Two cases of hallux valgus, one primary and one recurrent, are presented. As demonstrated in the systematic review, outcomes of Lapidus procedures create future opportunities. Surprisingly, only 78% of the studies assessed for this review reported on the hallux valgus angle and only 33% reported on tibial sesamoid position.
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Affiliation(s)
- Dang-Huy Do
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390-8883, USA
| | - Joshua Jian Sun
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390-8883, USA
| | - Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390-8883, USA.
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Kasparek MF, Benca E, Hirtler L, Willegger M, Boettner F, Zandieh S, Holinka J, Windhager R, Schuh R. Biomechanical evaluation of the proximal chevron osteotomy in comparison to the Lapidus arthrodesis for the correction of hallux valgus deformities. INTERNATIONAL ORTHOPAEDICS 2022; 46:2257-2264. [PMID: 35844015 PMCID: PMC9492599 DOI: 10.1007/s00264-022-05514-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/08/2022] [Indexed: 11/12/2022]
Abstract
PURPOSE The proximal chevron osteotomy and the modified Lapidus arthrodesis are both procedures utilized for deformity correction in patients with severe symptomatic hallux valgus. The aim of the current study was to compare their biomechanical stability when using locking plate fixation. METHODS Twelve matched pairs of human anatomical lower leg specimens underwent on one side a proximal chevron osteotomy with a medial locking plate and on the other side a modified Lapidus arthrodesis with a plantar locking plate utilizing an interfragmentary compression screw. All specimens underwent bone mineral density (BMD) assessment and were tested in a servohydraulic load frame which applied a load on the centre of the metatarsal head over 1000 loading cycles with subsequently ultimate load testing. Displacement of the proximal and distal bone segment, ultimate load, and bending stiffness were analyzed. RESULTS Mean displacement of both procedures showed no statistically significant difference throughout all the loading cycles (0.213 ≤ p ≤ 0.834). The mean ultimate load of the proximal chevron osteotomy was 227.9 N (± 232.4) and of the modified Lapidus arthrodesis 162.9 N (± 74.6) (p = 0.754). The proximal chevron osteotomy (38.2 N/mm (± 24.9)) had a significantly higher bending stiffness compared to the modified Lapidus arthrodesis (17.3 N/mm (± 9.9)) (p = 0.009). There was no correlation between BMD and displacement in all loading cycles, ultimate load, and bending stiffness of either procedure (p > 0.05). CONCLUSION Although the bending stiffness of the chevron osteotomy was higher, there was no statistically significant difference between the surgical techniques in mean displacement and ultimate load. The BMD did not influence the overall stability of either reconstruction. Locking plate fixation increases the clinical value of the modified Lapidus arthrodesis by outweighing most of the biomechanical disadvantages in comparison to the proximal chevron osteotomy.
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Affiliation(s)
- Maximilian F. Kasparek
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Emir Benca
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Lena Hirtler
- Center of Anatomy and Cell Biology, Medical University of Vienna, Waehringer Strasse 13, 1090 Vienna, Austria
| | - Madeleine Willegger
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Friedrich Boettner
- Adult Reconstruction & Joint Replacement Division, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Shahin Zandieh
- Department of Radiology, Hanusch Krankenhaus, Heinrich-Collin-Strasse 20, 1140 Vienna, Austria
| | - Johannes Holinka
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Reinhard Schuh
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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Wang B, Manchanda K, Lalli T, Wukich DK, Liu GT, Raspovic K, VanPelt M, Nakonezny PA, Johnson MJ. Identifying Risk Factors for Nonunion of the Modified Lapidus Procedure for the Correction of Hallux Valgus. J Foot Ankle Surg 2022; 61:1001-1006. [PMID: 35221219 DOI: 10.1053/j.jfas.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 01/03/2022] [Accepted: 01/06/2022] [Indexed: 02/03/2023]
Abstract
There is a paucity of literature characterizing risk factors for nonunion associated with the modified Lapidus procedure for correction of hallux valgus. The purpose of this study was to evaluate risk factors associated with nonunion for Lapidus bunionectomies. Patients who underwent modified Lapidus procedure from 2009 to 2018 were retrospectively reviewed. Patient's age, sex, body mass index, prior bunionectomy, history of tobacco use, presence of diabetes mellitus or hypothyroidism, and fixation method were recorded along with pre- and postoperative radiographic parameters. A multiple logistic regression analysis was implemented to estimate the odds of nonunion. Of the 222 patients who met inclusion criteria, nonunion with modified Lapidus procedure was observed in 20 patients (9.01%). Odds of nonunion with modified Lapidus procedure were greater for patients who had undergone previous bunionectomy (odds ratio [OR] = 3.957, 95% confidence interval [CI]: 1.021-15.338), as body mass index increased (OR = 1.091, 95% CI: 1.018-1.170), and as preoperative HV angle increased (OR = 1.108, 95% CI: 1.020-1.203). Odds of nonunion were lower for patients as preoperative intermetatarsal angle increased (OR = 0.739, 95% CI: 0.580-0.941). No significant increased odds of nonunion were found between fixation methods.
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Affiliation(s)
- Benjamin Wang
- University of Texas Southwestern Medical School, Dallas, TX
| | - Kshitij Manchanda
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Trapper Lalli
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - George Tye Liu
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Katherine Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael VanPelt
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Paul A Nakonezny
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Matthew J Johnson
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
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11
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King CM, Doyle MD, Castellucci-Garza FM, Lyon L, Richey J, Patel S, Collman DR. Addressing Transverse Plane Instability in the Modified Lapidus Arthrodesis: A Comparative Study of Screw Versus Suture and Button Fixation Device Technique. J Foot Ankle Surg 2022; 61:979-985. [PMID: 35491340 DOI: 10.1053/j.jfas.2021.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/02/2021] [Accepted: 12/13/2021] [Indexed: 02/03/2023]
Abstract
The Lapidus arthrodesis is a powerful procedure for the correction of hallux valgus with metatarsus primus varus. Yet, first ray instability may persist despite correction of the primary deformity with 2 crossed screw fixation. A third screw is often utilized as the additional point of fixation for noteworthy residual transverse plane motion, but it is not without potential complications. The suture and button fixation device may be an appropriate alternative to the third screw construct. This retrospective cohort study identified clinical / radiographic outcomes and complication rates following a third point of fixation with either a screw or suture and button fixation device in patients undergoing a modified Lapidus arthrodesis. One surgeon performed all of the Lapidus procedure with a third screw while the other surgeon performed all with a suture and button fixation device. Of 136 consecutive patients who underwent a modified Lapidus arthrodesis, 83 (61%) patients required a third point of fixation for satisfactory stabilization of the first ray. Surgical technique was similar between the 2 surgeons; however, one utilized the suture and button fixation device method (n = 36), while the other used a third screw for fixation (n = 47). Many of the clinical outcomes, radiographic results, and the union rate were similar between the 2 methods. Nineteen (40%) complications occurred in the third screw group compared to 6 (17%) in the suture and button fixation device group. However, the third screw group demonstrated 100% maintenance of deformity correction at 1 year versus 95% in the suture and button fixation device group. Although fixation with a suture and button fixation device was associated with fewer complications, a larger study is necessary to determine if these variations are statistically significant.
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Affiliation(s)
- Christy M King
- Residency Director and Attending Staff, Department of Orthopedics, Kaiser San Francisco Bay Area Foot and Ankle Residency Program Kaiser Foundation Hospital, Oakland, CA.
| | - Matthew D Doyle
- Foot and Ankle Surgeon, Silicon Valley Reconstructive Foot and Ankle Fellowship, Palo Alto Medical Foundation, Mountain View, CA
| | - Francesca M Castellucci-Garza
- Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics, Kaiser Foundation Hospital, Antioch, CA
| | - Liisa Lyon
- Senior Data Consultant, Division of Research, Kaiser Permanente, Oakland, CA
| | | | - Sandeep Patel
- Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics, Kaiser Foundation Hospital, Antioch, CA
| | - David R Collman
- Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics, Kaiser Foundation Hospital, San Francisco, CA
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Meyr AJ, Doyle MD, King CM, Kwaadu KY, Nasser EM, Ramdass R, Theodoulou MH, Zarick CS. The American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Hallux Valgus. J Foot Ankle Surg 2022; 61:369-383. [PMID: 34706857 DOI: 10.1053/j.jfas.2021.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/24/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Andrew J Meyr
- Clinical Professor, Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
| | - Matthew D Doyle
- Silicon Valley Reconstructive Foot and Ankle Fellowship - Palo Alto Medical Foundation, Mountain View, CA
| | - Christy M King
- Residency Director, Kaiser San Francisco Bay Area Foot & Ankle Residency Program and Attending Surgeon, Kaiser Foundation Hospital, Oakland, CA
| | - Kwasi Y Kwaadu
- Clinical Associate Professor, Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA
| | | | - Roland Ramdass
- Residency Training Committee, INOVA Fairfax Medical Campus, Fairfax, VA
| | - Michael H Theodoulou
- Chief Division of Podiatric Surgery, Cambridge Health Alliance, and Instructor of Surgery, Harvard Medical School, Boston, MA
| | - Caitlin S Zarick
- Assistant Professor, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
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13
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Is first metatarsal shortening correlated with clinical and functional outcomes following the Lapidus procedure? INTERNATIONAL ORTHOPAEDICS 2021; 45:2927-2931. [PMID: 34448926 DOI: 10.1007/s00264-021-05199-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To correlate first metatarsal (M1) shortening with transfer metatarsalgia, and clinical and functional outcomes in patients who underwent the Lapidus procedure (LP). MATERIALS AND METHODS A retrospective review of 29 patients who were submitted to the LP for HV correction. The average follow-up was 20 months. M1 length was analyzed using the Relative First Metatarsal Length (RML) measurement. Intermetatarsal angle (IMA) and hallux valgus angle (HVA) were also measured. Clinical and functional analyses were based on the visual analogue scale (VAS), Lower Extremity Functional Scale (LEFS), and Short-form 12 (SF-12) health survey. SF-12 is divided into physical (PCS-12) and mental health (MCS-12) composite scales. Transfer metatarsalgia was diagnosed by the clinical exam. Radiographic, clinical, and functional outcomes were compared using paired Wilcoxon's and Student's t tests. Inter-observer reliability of RML measures was calculated using Intraclass Correlation Coefficients (ICC). The correlation between RML and the clinical and functional questionnaires was assessed with the Spearman's Rho test. RESULTS There was a significant M1 shortening of 2.3 mm (p < 0.05), with mean preoperative RML of 3 mm and mean post-operative of 5.3 mm. None of the patients evolved with transfer metatarsalgia. ICC of the RML measures presented excellent reliability. IMA and HVA showed improvements (p < 0.05). Clinical and functional improvements were observed in all questionnaires applied, except in the MCS-12. In the linear regression, RML was inversely correlated to LEFS (p < 0.05), which means that LEFS scores increased as RML measurements decreased. CONCLUSION The present study demonstrated that M1 shortening led to a decreased LEFS following the LP.
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Jay Groves M. The Realign-Resect Arthrodesis Technique. J Foot Ankle Surg 2021; 60:807-813. [PMID: 33685765 DOI: 10.1053/j.jfas.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/11/2020] [Accepted: 02/07/2021] [Indexed: 02/03/2023]
Abstract
During traditional fusion procedures surgeons initially perform a joint resection and then the structures are realigned for correction of deformity. The procedure described herein by the author reverses this traditional surgical approach by first realigning the joint to correct deformity, then after achieving a corrected alignment, joint resection is performed in parallel without wedging. Realigning deformity as an initial step creates the conditions for an in-situ fusion wherein the deformity is corrected simultaneously with parallel bone resection. The purpose of this paper is to review the advantages and technical aspects of a realignment arthrodesis technique in which joint resection begins with the foot in the corrected position. This approach to joint fusion has been shown to simplify bone resection, eliminate post-resection adjustments, create full apposition of fusion surfaces, reliably correct deformity, and result in solid arthrodesis. The technique provides for immediate correction of deformity and is amenable for conditions that require either minimal or significant segmental shortening. There are many areas where the "Realign-resect" approach to joint fusion would be well suited. Full implementation of this technique may be particularly useful to the surgeon who does not have seasoned assistants in the operating room.
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Affiliation(s)
- Mack Jay Groves
- Private practice, Groves Foot & Ankle, Covington, LA; Faculty, The Podiatry Institute, Covington, LA.
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15
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Foran IM, Lin J, Hamid KS, Lee S. Technical Tip Kerfing for Lapidus Arthrodesis: Deformity Correction With Minimal Bone Resection. J Foot Ankle Surg 2021; 60:424-427. [PMID: 33187899 DOI: 10.1053/j.jfas.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 10/01/2020] [Accepted: 10/01/2020] [Indexed: 02/03/2023]
Abstract
The Lapidus arthrodesis can be a powerful but technically challenging procedure. Common pitfalls include gapping at the arthrodesis site, shortening, and residual malalignment. Herein is described a simple and reproducible technique to obtain a congruent arthrodesis site with excellent deformity correction and minimal bone loss by the use of joint kerfing.
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Affiliation(s)
- Ian M Foran
- Assistant Professor of Orthopaedic Surgery, University of California San Diego, La Jolla, CA.
| | - Johnny Lin
- Assistant Professor of Orthopaedic Surgery, Rush University Medical Center, Midwest Orthopedics at Rush, Chicago, IL
| | - Kamran S Hamid
- Assistant Professor of Orthopaedic Surgery, Rush University Medical Center, Midwest Orthopedics at Rush, Chicago, IL
| | - Simon Lee
- Associate Professor of Orthopaedic Surgery, Rush University Medical Center, Midwest Orthopedics at Rush, Chicago, IL
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16
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Jagadale VS, Thomas RL. A Clinicoradiological and Functional Evaluation of Lapidus Surgery for Moderate to Severe Bunion Deformity Shows Excellent Stable Correction and High Long-Term Patient Satisfaction. Foot Ankle Spec 2020; 13:488-493. [PMID: 31793348 DOI: 10.1177/1938640019890716] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Lapidus surgery involving arthrodesis of the first metatarsocuneiform (MTC) joint is an effective procedure for the correction of moderate to severe hallux valgus. The aim of this study was to collect and analyze radiographic data from our institution and determine the extent of first metatarsal shortening associated with the Lapidus procedure. Materials and Methods. A total of 53 patients (54 feet) who underwent arthrodesis of the first MTC joint combined with modified McBride bunionectomy for correction of moderate to severe hallux valgus deformity, between 2010 and 2015 were included in this study. Complete radiographic evaluation and AOFAS (American Orthopaedic Foot and Ankle Surgery) scoring was available for 54 feet. The average preoperative hallux valgus angulation (HVA) was 32° and the average intermetatarsal angle (IMA) was 16°. Results. Excluding 2 patients with postoperative hallux varus the average postoperative HVA correction at last follow-up was 14°. Average postoperative IMA was 9°. Although there was minimal bone resection during preparation of the MTC joint, no significant shortening of the first metatarsal was observed with this procedure. The relative length of the first metatarsal to the second metatarsal changed only 1.3%. Nonunion of the first MTC joint occurred in 10.3%, but only 1 foot was symptomatic requiring revision. The average postoperative hallux AOFAS score was 80.8. In sum, 63% of patients were very satisfied, 27% satisfied with reservations, and 10% were dissatisfied. Conclusion. The Lapidus bunion procedure offers excellent stable correction of moderate to severe hallux valgus deformity with minimal shortening of the first metatarsal and thereby higher patient satisfaction.Levels of Evidence: Level IV: Retrospective case series.
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Affiliation(s)
- Vivek S Jagadale
- Department of Orthopedic Surgery, Central Arkansas Veterans Healthcare System, University of Arkansas College of Medicine, Little Rock, Arkansas
| | - Ruth L Thomas
- Department of Orthopedic Surgery, Central Arkansas Veterans Healthcare System, University of Arkansas College of Medicine, Little Rock, Arkansas
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17
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Hatch DJ, Dayton P, DeCarbo W, McAleer JP, Ray JJ, Santrock RD, Smith WB. Analysis of Shortening and Elevation of the First Ray With Instrumented Triplane First Tarsometatarsal Arthrodesis. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420960678. [PMID: 35097411 PMCID: PMC8702970 DOI: 10.1177/2473011420960678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The Lapidus procedure using planar saw resection has often been criticized for complications related to excessive shortening and elevation of the first ray. The goal of this study was to assess the amount of shortening that occurs when using a cutting guide for controlled saw resection of the first tarsometatarsal (TMT) joint surfaces, along with assessment of deformity correction in all 3 anatomic planes. METHODS A prospective multicenter study with IRB approval included 35 hallux valgus subjects evaluated at baseline and 6 months following instrumented triplane first TMT arthrodesis without lesser metatarsal osteotomies. RESULTS The average first ray bone segment length loss was 3.1 mm (95% confidence interval [CI] 2.4-3.7) in the anteroposterior (AP) radiographic assessment and 2.4 mm (95% CI 1.7-3.1) in the sagittal plane. The mean preoperative radiographic measurements were 1.7 degrees (dorsiflexion) for sagittal plane angle, 13.8 degrees for intermetatarsal angle (IMA), and 5.1 for tibial sesamoid position (TSP). Improvements were seen postoperatively for all measures with a mean difference of -0.2 degrees (95% CI -1.0 to 0.6) for sagittal plane angle, -9.2 degrees (95% CI -10.1 to -8.3 degrees) for IMA, and -3.5 (95% CI -4.0 to -3.1) for TSP. Five of the patients reported lesser metatarsal pain preoperatively, and no patients complained of lesser metatarsalgia at 6-month follow-up. CONCLUSIONS Minimal length loss of the first ray can be expected following instrumented triplane TMT arthrodesis while achieving full 3-dimensional deformity correction and reducing the risk of lesser metatarsalgia. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Affiliation(s)
- Daniel J. Hatch
- Foot and Ankle Center of Northern Colorado, Greeley, CO, USA
| | - Paul Dayton
- Foot & Ankle Center of Iowa, Midwest Bunion Center, Ankeny, IA, USA
| | | | - Jody P. McAleer
- Jefferson City Medical Group, Department of Podiatry, Jefferson City, MO, USA
| | - Justin J. Ray
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | - Robert D. Santrock
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | - W. Bret Smith
- Mercy Orthopedic Associates, Mercy Regional Medical Center, Durango, CO, USA
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18
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First tarsometatarsal fusion using saw preparation vs. standard preparation of the joint: A cadaver study. Foot Ankle Surg 2020; 26:703-707. [PMID: 31548149 DOI: 10.1016/j.fas.2019.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 06/27/2019] [Accepted: 08/28/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND First tarsometatarsal (TMT) joint fusion is effective for treatment of arthritis and some first ray deformities. To prepare the articular surfaces, cartilage should be carefully but completely denuded. Inadequate preparation may result in non-union, while excessive preparation may cause ray shortening and consequential transfer metatarsalgia. Preparation can be performed with an osteotome or a saw. The purpose of this study was to investigate whether utilization of an osteotome or saw would minimize shortening of the first ray in TMT arthrodesis. METHODS Ten fresh-frozen cadaver specimens were randomly assigned to undergo joint preparation using either an osteotome (n=5) or saw (n=5). Sample size was determined by cadaver availability. Fusion was performed using a cross-screw construct through the dorsal aspect of the proximal phalanx and the medial cuneiform. Pre- and post-operative X-rays were taken with a radiopaque ruler in the field, and changes in length in the first metatarsal and first cuneiform were compared between osteotome and sawblade groups. RESULTS The average change in metatarsal length was significantly smaller in the osteotome group (1.6mm) as compared to the saw group (4.4mm) (p=0.031). The average percent change in metatarsal length was also significantly smaller in the osteotome group (3.0%) compared to the saw group (8.4%) (p=0.025). There was no significant difference between the two groups with respect to change in cuneiform length. The osteotome group demonstrated a significantly smaller average measured change (3.0mm vs. 6.9mm, p=0.001) and percent change (4.1% vs. 9.3%, p<0.001) in total length (cuneiform plus metatarsal) in comparison to the saw group. CONCLUSIONS In first TMT fusion, joint preparation with an osteotome may prevent over-shortening of the first ray in comparison to preparation with a saw.
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19
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Foran IM, Mehraban N, Jacobsen SK, Bohl DD, Lin J, Lee S, Holmes GB, Hamid KS. Radiographic Impact of Lapidus, Proximal Lateral Closing Wedge Osteotomy, and Suture Button Procedures on First Ray Length and Dorsiflexion for Hallux Valgus. Foot Ankle Int 2020; 41:964-971. [PMID: 32517537 DOI: 10.1177/1071100720925438] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Shortening and dorsiflexion of the first metatarsal are known potential side effects of metatarsal osteotomies for hallux valgus (HV) with the potential to cause transfer metatarsalgia. We compared the effect of the first tarsometatarsal joint arthrodesis (Lapidus procedure), proximal lateral closing wedge osteotomy (PLCWO), and intermetatarsal suture button fixation procedures on the length and dorsiflexion of the first ray. METHODS We retrospectively evaluated 105 feet in 99 patients with 30 weeks of follow-up. The average age was 54 years. Seventy-four feet had a Lapidus procedure, 12 had a PLCWO, and 19 had intermetatarsal suture button fixation. Digital radiographic measurements were made for the pre- and postoperative hallux valgus angle (HVA) and intermetatarsal angle (IMA), absolute and relative shortening of the first ray, and dorsiflexion. RESULTS Preoperative HVA and IMA did not differ between treatment groups (P > .05 for each). Similar corrections of HVA (30.5-13.5 degrees) were achieved between all groups (P > .05). The IMA was improved more in the Lapidus group (14.3-6.5 degrees) compared with the suture button fixation group (14.2-8.1 degrees) (P = .045). There were significant differences in the change in absolute first cuneiform-metatarsal length (FCML) between the Lapidus (-1.6 mm), PLCWO (-2.3 mm), and intermetatarsal suture button fixation (+1.9 mm) procedure (P = .004). There were also significant differences in relative first metatarsal shortening between the Lapidus (0.1 mm relative shortening), PLCWO (1.1 mm relative shortening), and intermetatarsal suture button fixation (1.3 mm lengthening) procedure (P < .001). The average dorsiflexion differed between the Lapidus (1.8 degrees) and suture button fixation (0.4 degrees) groups (P = .004). CONCLUSION Intermetatarsal suture button fixation relatively lengthened the first ray, the Lapidus procedure maintained length, and the PLCWO relatively and absolutely shortened it. Dorsiflexion may be higher with the Lapidus and osteotomy procedures. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- Ian M Foran
- Rush University Medical Center, Midwest Orthopedics at Rush, Chicago, IL, USA
| | - Nasima Mehraban
- Rush University Medical Center, Midwest Orthopedics at Rush, Chicago, IL, USA
| | - Stephen K Jacobsen
- Rush University Medical Center, Midwest Orthopedics at Rush, Chicago, IL, USA
| | - Daniel D Bohl
- Rush University Medical Center, Midwest Orthopedics at Rush, Chicago, IL, USA
| | - Johnny Lin
- Rush University Medical Center, Midwest Orthopedics at Rush, Chicago, IL, USA
| | - Simon Lee
- Rush University Medical Center, Midwest Orthopedics at Rush, Chicago, IL, USA
| | - George B Holmes
- Rush University Medical Center, Midwest Orthopedics at Rush, Chicago, IL, USA
| | - Kamran S Hamid
- Rush University Medical Center, Midwest Orthopedics at Rush, Chicago, IL, USA
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20
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Greeff W, Strydom A, Saragas NP, Ferrao PNF. Radiographic Assessment of Relative First Metatarsal Length Following Modified Lapidus Procedure. Foot Ankle Int 2020; 41:972-977. [PMID: 32456466 DOI: 10.1177/1071100720924016] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The modified Lapidus is a surgical procedure for managing moderate to severe hallux valgus, especially in the presence of first tarsometatarsal joint arthritis or hypermobility. It has good long-term results but reportedly can lead to transfer metatarsalgia due to inherent shortening of the first metatarsal. METHODS A retrospective analysis of all adult patients who underwent a modified Lapidus procedure during a 3-year period was performed. Clinical notes were evaluated to look for nonunion or any other complications related to the surgery. Pre- and postoperative standard weightbearing radiographs were used to establish the relative metatarsal length (RML), intermetatarsal angle (IMA), hallux valgus angle (HVA), and distal metatarsal articular angle (DMMA). A total of 69 modified Lapidus procedures were identified, with 32 included in the study. RESULTS The mean pre- and postoperative RMLs were -0.8 and -4.9 mm, respectively. The average RML shortening due to the procedure was -4.1 (P < .0001). The mean pre- and postoperative IMAs were 15 and 5 degrees, respectively (P < .0001). The mean pre- and postoperative HVAs were 33 and 9 degrees, respectively (P < .0001). One patient reported transfer metatarsalgia, which was attributed to elevation of the first metatarsal. CONCLUSION We found a statistically significant degree of shortening of the relative length of the first metatarsal without any clinically significant metatarsalgia. The low rate of transfer metatarsalgia following the modified Lapidus procedure could be attributed to the sagittal plane correction and stability obtained by performing a first tarsometatarsal fusion. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Wessel Greeff
- The Orthopaedic Foot and Ankle Unit, Department of Orthopaedic Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Strydom
- The Orthopaedic Foot and Ankle Unit, Department of Orthopaedic Surgery, University of the Witwatersrand, Johannesburg, South Africa.,Netcare Sunninghill Hospital, Johannesburg, South Africa
| | - Nikiforos Pandelis Saragas
- The Orthopaedic Foot and Ankle Unit, Department of Orthopaedic Surgery, University of the Witwatersrand, Johannesburg, South Africa.,The Orthopaedic Foot and Ankle Unit, Netcare Linksfield Hospital, Johannesburg, South Africa
| | - Paulo Norberto Faria Ferrao
- The Orthopaedic Foot and Ankle Unit, Department of Orthopaedic Surgery, University of the Witwatersrand, Johannesburg, South Africa.,The Orthopaedic Foot and Ankle Unit, Netcare Linksfield Hospital, Johannesburg, South Africa
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Abstract
"Lapidus arthrodesis is becoming more of a common procedure for treatment of hallux valgus deformities. Like other procedures, complications are possible. The common complications associated with Lapidus arthrodesis procedures include nonunion and malunion. Malunion is typically broken down into recurrence, elevated first ray, shortened first ray, or plantarflexed first ray. This article discusses these common complications after Lapidus arthrodesis.
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Affiliation(s)
| | - Eric R Reese
- Unitypoint Health - Iowa Methodist Medical Center, 1200 Pleasant Street, Des Moines, IA 50309, USA
| | - Ryan D Prusa
- Unitypoint Health - Iowa Methodist Medical Center, 1200 Pleasant Street, Des Moines, IA 50309, USA
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Abstract
The evolution of Lapidus fixation has been strongly associated with the understanding of the anatomy and function of the first tarsometatarsal joint, the mechanism of hypermobility of the first tarsometatarsal joint, and cause of the hallux valgus deformity in 3 dimensions. Some methods, such as plantar plating, nitinol staples, and intramedullary fixation, have proven to be stronger biomechanically in cadaveric testing. Theoretically, stable fixation will reduce the rate of complications, in particular, that of nonunion and allow for early postoperative weight-bearing. Further clinical studies are needed to examine whether current biomechanical studies will translate to relevant clinical outcomes.
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Affiliation(s)
- Shuyuan Li
- Steps2Walk, 1209 Harbor Island Walk, Baltimore, MD 21230, USA.
| | - Mark S Myerson
- Steps2Walk, 1209 Harbor Island Walk, Baltimore, MD 21230, USA
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Abstract
Postoperative management of hallux valgus varies widely. Setting preoperative expectations is an important aspect of attaining a successful outcome, but this is not routinely reviewed in the literature. This chapter offers suggestions on successfully navigating this area of patient care. Current concepts focus on pain control, immobilization, and return to activities. This chapter also reviews the current literature in these areas and sets out the authors' preferred management in the postoperative setting.
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Affiliation(s)
- William A Hester
- Sidney Kimmel Medical College, Thomas Jefferson University, The Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107, USA
| | - David I Pedowitz
- Foot & Ankle Fellowship, Sidney Kimmel Medical College, Thomas Jefferson University, The Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107, USA.
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Chan F, Bowlby MA, Christensen JC. Medial Column Biomechanics: Nonsurgical and Surgical Implications. Clin Podiatr Med Surg 2020; 37:39-51. [PMID: 31735268 DOI: 10.1016/j.cpm.2019.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Understanding of medial column biomechanics is paramount to a successful outcome in both conservative and surgical treatment. Dysfunctions of the dynamic stabilizers as well as the static stabilizers of the medial column play a role in pathomechanics. Conservative options for addressing the medial column include custom foot orthotics and bracing. Options for addressing the medial column surgically with the goal to restore a stable tripod configuration, include first tarsometatarsal joint arthrodesis, opening plantarflexory medial cuneiform osteotomy, and naviculocuneiform arthrodesis.
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Affiliation(s)
- Francis Chan
- Private Practice, 5000 Kingsway, Suite #320, Burnaby, BC V5H 2E4, Canada.
| | - Melinda A Bowlby
- Department of Orthopedics, Swedish Medical Center, Seattle, WA, USA; Department of Orthopedics, Providence Medical Center, Everett, WA, USA
| | - Jeffrey C Christensen
- Department of Orthopedics, Swedish Medical Center, Seattle, WA, USA; Department of Orthopedics, Providence Medical Center, Everett, WA, USA
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25
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Boffeli TJ, Hyllengren SB. Can We Abandon Saw Wedge Resection in Lapidus Fusion? A Comparative Study of Joint Preparation Techniques Regarding Correction of Deformity, Union Rate, and Preservation of First Ray Length. J Foot Ankle Surg 2019; 58:1118-1124. [PMID: 31562062 DOI: 10.1053/j.jfas.2019.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/30/2019] [Accepted: 02/01/2019] [Indexed: 02/03/2023]
Abstract
The traditional joint preparation technique for Lapidus fusion involves wedge resection using a saw to achieve correction of intermetatarsal angular deformity. The main drawback of this approach is undesirable shortening of the first ray, which can predispose to second ray overload that may preclude the procedure for a subset of patients or may necessitate second metatarsal shortening osteotomy. The goal of this study was to determine whether a first ray length-preserving joint preparation technique (curette and bur) achieves equivalent correction of deformity and fusion rate without first ray shortening compared with the standard saw wedge resection technique. A retrospective review of consecutive cases from January 2007 to August 2014 identified 62 patients who underwent 65 Lapidus fusions for hallux valgus correction with crossed-screw fixation. All patients treated from 2007 to 2010 had saw wedge resection, whereas all patients treated from 2011 to 2014 had curette and bur joint preparation without use of a saw. The mean intermetatarsal angle correction was 9.06° (range 5° to 14.7°) in the saw wedge resection group and 8.11° (range 2.8° to 15.5°) in the curette and bur group, a difference that was not statistically significant. The mean amount of first ray shortening was -3.14 (range -6.1 to 0) mm in the saw wedge resection group and -0.86 (range -2.3 to 4.2) mm in the curette and bur group, a result that was statistically significant. Osseous union was confirmed radiographically at 10 weeks postoperatively in all cases. These findings suggest that first ray length can be preserved using a more conservative joint preparation technique regardless of preoperative deformity, without compromising correction of deformity or union rate.
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Affiliation(s)
- Troy J Boffeli
- Director, Foot and Ankle Surgical Residency Program, Regions Hospital/HealthPartners Institute for Education and Research, St. Paul, MN
| | - Shelby B Hyllengren
- Foot and Ankle Surgeon, Allina Health Cambridge Medical Center, Cambridge, MN.
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26
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Drummond D, Motley T, Kosmopoulos V, Ernst J. Stability of Locking Plate and Compression Screws for Lapidus Arthrodesis: A Biomechanical Comparison of Plate Position. J Foot Ankle Surg 2018; 57:466-470. [PMID: 29472168 DOI: 10.1053/j.jfas.2017.10.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Indexed: 02/03/2023]
Abstract
Lapidus (first tarsometatarsal joint) arthrodesis is an established and widely used procedure for the management of moderate to severe hallux valgus, especially in cases involving hypermobility of the first tarsometatarsal joint. Multiple fixation methods are available, and several previous investigations have studied the relative strengths of these methods, including dorsomedial and plantar plating comparisons. However, these studies compared plates of varying designs and mechanical properties and used varying modes of compression and interfragmentary screw techniques. The present study mechanically investigated the resulting motion, stiffness, and strength of identical locking plate constructs fixed at various anatomic positions around the first tarsometatarsal joint. In a bench-top study, fourth-generation composite bones were divided into 3 fixation groups, each having identical interfragmentary screw applications, and randomized to 1 of 3 plate positions: dorsal, medial, or plantar. The plates applied in each case were identical locking plates, precontoured to fit the anatomy. Each construct was experimentally tested using a cantilever bending approach. The outcomes obtained were stiffness, yield force, displacement at yield, ultimate force, and displacement at ultimate force. The plantar plate position showed superior initial stiffness and force to ultimate failure. The plantar and medial plate positions exhibited superior force to yield. The medial plate position was superior regarding displacement tolerated before the yield point and catastrophic failure. The dorsal plate position was not superior for any outcome measured. Plantar and medial plating each offered biomechanical benefits. Clinical studies using similarly matched constructs are required to show whether these findings translate into improved clinical outcomes.
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Affiliation(s)
- David Drummond
- Clinical Instructor, Department of Surgery, Louisiana State University Health Science Center, Shreveport, LA.
| | - Travis Motley
- Associate Professor, Department of Orthopaedic Surgery, University of North Texas Health Science Center, Fort Worth, TX
| | - Victor Kosmopoulos
- Associate Professor, Department of Orthopaedic Surgery, University of North Texas Health Science Center, Fort Worth, TX
| | - Jordan Ernst
- Chief Resident, Foot & Ankle Surgery, Department of Orthopaedic Surgery, John Peter Smith Hospital, Fort Worth, TX
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Blackwood S, Gossett L. Hallux Valgus/Medial Column Instability and Their Relationship with Posterior Tibial Tendon Dysfunction. Foot Ankle Clin 2018; 23:297-313. [PMID: 29729803 DOI: 10.1016/j.fcl.2018.02.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Historically, bunions have focused on the coronal plane; however, there is tension and compression failure in the sagittal plane of the midfoot during arch collapse. Correction of all 3 planes of deformity, coronal, sagittal, and rotational, can be achieved in several ways. Taking a big picture of global foot mechanics by recognizing the common types of conditions associated with arch collapse, including hallux valgus deformities, can serve as a useful roadmap for navigating more complicated deformities where hallux valgus exists.
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Affiliation(s)
- Steven Blackwood
- Orthopaedic Associates of Michigan, 1111 Leffingwell Avenue NE, Grand Rapids, MI 49525, USA.
| | - Leland Gossett
- Spectrum Health - Michigan State University, 221 Michigan Street NE, Suite 402, Grand Rapids, MI 49503, USA
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Moore KR, Howell MA, Saltrick KR, Catanzariti AR. Risk Factors Associated With Nonunion After Elective Foot and Ankle Reconstruction: A Case-Control Study. J Foot Ankle Surg 2017; 56:457-462. [PMID: 28476384 DOI: 10.1053/j.jfas.2017.01.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Indexed: 02/03/2023]
Abstract
Postoperative nonunion is not uncommon in the lower extremity, and significant morbidity can be associated with nonunion of the foot and ankle after surgical reconstruction. For the purposes of the present study, we retrospectively reviewed and compared a cohort of patients who had undergone elective foot and ankle reconstruction to better assess the modifiable risk factors associated with postoperative nonunion. We hypothesized that the presence of endocrine and metabolic abnormalities are often associated with nonunion after foot and ankle surgical reconstruction. We formulated a matched case-control study that included 29 patients with nonunion and a control group of 29 patients with successful fusion to assess the prevalence of certain modifiable risk factors known to have an association with nonunion after foot and ankle arthrodesis. The modifiable risk factors assessed included body mass index, tobacco use, diabetes mellitus, vitamin D abnormality, thyroid dysfunction, and parathyroid disease. A statistically significant (p < .05) difference was found between the 2 groups for endocrine and metabolic disease diagnoses in the medical records of the 58 patients identified. Thus, 76% versus 26% (p < .05) of patients experienced nonunion in the endocrine disease group versus the nonendocrine disease group, respectively. Patients with vitamin D deficiency or insufficiency were 8.1 times more likely to experience nonunion (95% confidence interval 1.996 to 32.787). No statistically significant differences were found between the groups in terms of age, sex, tobacco use, body mass index, or procedure selection (p = .56, p = .43, p = .81, p = .28, and p = 1.0, respectively). A greater prevalence of endocrine abnormalities, in particular, vitamin D deficiency and insufficiency, was associated with nonunion after elective foot and ankle reconstruction. Patients with such abnormalities appear to have a greater risk of developing nonunion after arthrodesis procedures.
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Affiliation(s)
- Kyle R Moore
- Resident, Postgraduate Year 3, Division of Foot and Ankle Surgery, Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh, PA.
| | - Michael A Howell
- Resident, Postgraduate Year 2, Division of Foot and Ankle Surgery, Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh, PA
| | - Karl R Saltrick
- Faculty, Division of Foot and Ankle Surgery, Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh, PA
| | - Alan R Catanzariti
- Director of Residency Training, Division of Foot and Ankle Surgery, Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh, PA
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Boffeli TJ, Mahoney KJ. Intraoperative Simulated Weightbearing Lateral Foot Imaging: The Clinical Utility and Ability to Predict Sagittal Plane Position of the First Ray in Lapidus Fusion. J Foot Ankle Surg 2016; 55:1158-1163. [PMID: 27594646 DOI: 10.1053/j.jfas.2016.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Indexed: 02/03/2023]
Abstract
The sagittal plane relationship of the first to second ray is a primary determinant of proper alignment in Lapidus midfoot fusion as assessed both clinically and on postoperative weightbearing lateral radiographs. The traditional approach to intraoperative fluoroscopic imaging allows for accurate assessment of fixation placement and intermetatarsal angle correction but only a crude evaluation of final sagittal plane alignment. Surgeons have used various methods in an attempt to load the foot during lateral imaging. This had led to inconsistent results and the potential for poor outcome. Skepticism exists regarding the ability of simulated weightbearing fluoroscopy to predict the final outcome, and evidence is lacking to support this practice. A prospective investigation was performed to assess the correlation of the first to second ray sagittal plane alignment as demonstrated on intraoperative simulated weightbearing lateral foot imaging studies and the 10-week postoperative lateral weightbearing radiograph. A consistent simulated weightbearing technique was used prospectively with 50 consecutive cases of Lapidus midfoot fusion with the goal of achieving parallel sagittal plane alignment of the first and second metatarsals with no divergence. Although 47 cases had no divergence and 3 had divergence with mild first ray elevatus, all 50 cases demonstrated a direct correlation between the intraoperative simulated and postoperative full weightbearing images. In conclusion, we believe the findings from our intraoperative imaging technique are a reliable predictor of first ray sagittal plane alignment in Lapidus midfoot fusion.
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Affiliation(s)
- Troy J Boffeli
- Director, Foot and Ankle Surgical Residency Program, Regions Hospital/HealthPartners Institute for Education and Research, St. Paul, MN.
| | - Kevin J Mahoney
- Foot and Ankle Surgeon, Avera Marshall Regional Medical Center, Marshall, MN
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30
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Arcuri N, Bar-David T, Pollack S. The Mau-Reverdin Osteotomy: A Short-Term Retrospective Analysis. J Foot Ankle Surg 2016; 55:794-8. [PMID: 27086178 DOI: 10.1053/j.jfas.2016.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Indexed: 02/03/2023]
Abstract
We reviewed 33 consecutive Mau-Reverdin osteotomies in 23 patients performed for correction of hallux abducto valgus from November 2010 to May 2013. All patients were followed up and evaluated for a mean of 401 days and median of 360 days after surgery. In each foot, the preoperative first intermetatarsal angle, hallux abductus angle, and proximal articular set angle were obtained. The mean correction of these angles was as follows: intermetatarsal angle 10.5° ± 3.31°, hallux abductus angle 24.4° ± 8.8°, and proximal articular set angle 28.39° ± 11.2°. Furthermore, we evaluated for metatarsus elevates, and no statistically significant first metatarsal elevation was present in any of the 33 feet (p < .0001). Additionally, 21 of the 33 feet (63.6%) were available for first metatarsophalangeal joint American Orthopaedic Foot and Ankle Society scale score evaluation. The mean preoperative score was 25.5 ± 16.7. After correction, the mean American Orthopaedic Foot and Ankle Society scale score had increased to 95.4 ± 5.7. All these differences were statistically significant (p < .0001), and the patients had a very high level of satisfaction. In all 33 feet, no deep infection, malunion, nonunion, avascular necrosis of the first metatarsal, or hardware failure developed. One patient developed hallux varus deformity. The Mau-Reverdin osteotomy is a very effective and reproducible procedure that successfully corrects large bunion deformities and provides patients with a high level of satisfaction and a low complication rate.
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Affiliation(s)
- Nicolas Arcuri
- Podiatrist, Department of Surgery, Jackson Madison County General Hospital, Jackson, TN.
| | - Tzvi Bar-David
- Director of Podiatric Surgery, Department of Orthopedics, New York Presbyterian Hospital-Columbia University Campus, New York, NY
| | - Simcha Pollack
- Professor, Computer Information Systems and Decision Sciences, St. John's University, Queens, NY
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MacMahon A, Karbassi J, Burket JC, Elliott AJ, Levine DS, Roberts MM, Deland JT, O'Malley MJ, Yu J, Mancuso CA, Ellis SJ. Return to Sports and Physical Activities After the Modified Lapidus Procedure for Hallux Valgus in Young Patients. Foot Ankle Int 2016; 37:378-85. [PMID: 26578481 DOI: 10.1177/1071100715617750] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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). CONCLUSION 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 OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Aoife MacMahon
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, NY, USA
| | - John Karbassi
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, NY, USA
| | - Jayme C Burket
- Department of Epidemiology and Biostatistics, Hospital for Special Surgery, NY, USA
| | - Andrew J Elliott
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, NY, USA
| | - David S Levine
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, NY, USA
| | - Matthew M Roberts
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, NY, USA
| | - Jonathan T Deland
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, NY, USA
| | - Martin J O'Malley
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, NY, USA
| | - Jeanne Yu
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, NY, USA
| | - Carol A Mancuso
- Department of Medicine, Hospital for Special Surgery, NY, USA
| | - Scott J Ellis
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, NY, USA
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Prissel MA, Hyer CF, Grambart ST, Bussewitz BW, Brigido SA, DiDomenico LA, Lee MS, Reeves CL, Shane AM, Tucker DJ, Weinraub GM. A Multicenter, Retrospective Study of Early Weightbearing for Modified Lapidus Arthrodesis. J Foot Ankle Surg 2016; 55:226-9. [PMID: 26763868 DOI: 10.1053/j.jfas.2015.09.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Indexed: 02/03/2023]
Abstract
The modified Lapidus arthrodesis is a long-established surgical technique for management of hallux valgus that provides reproducible results and quality patient outcomes. The data from 367 consecutive patients undergoing unilateral modified Lapidus arthrodesis from January 1, 2007 to December 31, 2008 at participating centers were retrospectively evaluated. The included patients were categorized into early weightbearing (≤ 21 days) and delayed weightbearing (> 21 days) groups. A total of 24 nonunions (6.5%) were identified, with 13 (7.1%) in the early weightbearing group and 11 (6.0%) in the delayed weightbearing group. To date, the present study is the largest multicenter investigation to evaluate early weightbearing after modified Lapidus arthrodesis and the only large study to directly compare early and delayed weightbearing. The findings of the present study have shown that early weightbearing for modified Lapidus arthrodesis does not increase the risk of nonunion when evaluating various fixation constructs.
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Affiliation(s)
- Mark A Prissel
- Fellow, Orthopedic Foot and Ankle Center, Westerville, OH
| | | | | | | | - Stephen A Brigido
- Fellowship Director, Foot and Ankle Center at Coordinated Health, Bethlehem, PA
| | | | - Michael S Lee
- Attending Physician, Capital Orthopedics and Sports Medicine, Clive, IA
| | | | - Amber M Shane
- Attending Physician, Orlando Foot and Ankle Clinic, Orlando, FL
| | - Daniel J Tucker
- Fellowship Director, The Southeast Permanente Medical Group, Atlanta, GA
| | - Glenn M Weinraub
- Attending Physician, Department of Orthopaedic Surgery, The Permanente Medical Group, San Leandro, CA
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McAlister JE, Peterson KS, Hyer CF. Corrective Realignment Arthrodesis of the First Tarsometatarsal Joint Without Wedge Resection. Foot Ankle Spec 2015; 8:284-8. [PMID: 25472700 DOI: 10.1177/1938640014560167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
UNLABELLED Moderate to severe hallux valgus (HV) has traditionally been treated with a corrective osteotomy or a tarsometatarsal arthrodesis. Tarsometatarsal arthrodesis can be performed as a planar wedge resection or using a joint curettage technique. Little is known about whether adequate correction can be obtained with purely a joint curettage technique. The purpose of this study is to evaluate the corrective power of a first tarsometatarsal joint (TMTJ) arthrodesis using a nonplanar wedge curettage technique. A retrospective radiograph and chart review was performed on 99 consecutive patients (110 feet) who underwent a first TMTJ arthrodesis for primary HV correction utilizing a curettage technique. The radiographic measurements collected were the first intermetatarsal angle, HV angle, and tibial sesamoid position and were obtained at the following intervals: preoperative, immediate postoperative, and 6 months postoperative. In all, 91 patients (100 feet) qualified for statistical analysis. There was a significant decrease in all 3 measurements from the preoperative throughout the entire postoperative time period (P < .001). The authors demonstrate the ability to achieve significant angular correction with a joint curettage method for a tarsometatarsal arthrodesis. LEVELS OF EVIDENCE Therapeutic, Level IV: Case series.
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Affiliation(s)
- Jeffrey E McAlister
- CORE Institute, Phoenix, Arizona (JEM), Suburban Orthopadeics, Bartlett, IL (KSP) and Orthopedic Foot and Ankle Center, Westerville, Ohio (CFH)
| | - Kyle S Peterson
- CORE Institute, Phoenix, Arizona (JEM), Suburban Orthopadeics, Bartlett, IL (KSP) and Orthopedic Foot and Ankle Center, Westerville, Ohio (CFH)
| | - Christopher F Hyer
- CORE Institute, Phoenix, Arizona (JEM), Suburban Orthopadeics, Bartlett, IL (KSP) and Orthopedic Foot and Ankle Center, Westerville, Ohio (CFH)
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34
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Correction power and complications of first tarsometatarsal joint arthrodesis for hallux valgus deformity. INTERNATIONAL ORTHOPAEDICS 2014; 39:467-76. [DOI: 10.1007/s00264-014-2601-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 11/06/2014] [Indexed: 11/25/2022]
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Roth KE, Peters J, Schmidtmann I, Maus U, Stephan D, Augat P. Intraosseous fixation compared to plantar plate fixation for first metatarsocuneiform arthrodesis: a cadaveric biomechanical analysis. Foot Ankle Int 2014; 35:1209-16. [PMID: 25121509 DOI: 10.1177/1071100714547082] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Metatarsocuneiform (MTC) fusion is a treatment option for management of hallux valgus. We compared the biomechanical characteristics of an internal fixation device with plantar plate fixation. METHODS Seven matched pairs of feet from human cadavers were used to compare the intramedullary (IM) device plus compression screw to plantar plate combined with a compression screw. Specimen constructs were loaded in a cyclic 4-point bending test. We obtained initial/final stiffness, maximum load, and number of cycles to failure. Bone mineral density was measured with peripheral quantitative computed tomography. Performance was compared using time to event analysis with number of cycles as time variable, and a proportional hazard model including shared frailty model fitted with treatment and bone mineral density as covariates. RESULTS On average the plates failed after 7517 cycles and a maximum load of 167 N, while the IM-implants failed on average after 2946 cycles and a maximum load of 69 N. In all pairs the 1 treated with IM-implant failed earlier than the 1 treated with a plate (hazard ratio for IM-implant versus plate was 79.9 (95% confidence interval [6.1, 1052.2], P = .0009). The initial stiffness was 131 N/mm for the plantar plate and 43.3 N/mm for the IM implant. Initial stiffness (r = .955) and final stiffness (r = .952) were strongly related to the number of cycles to failure. Bone mineral density had no effect on the number of cycles to failure. CONCLUSION Plantar plate fixation created a stronger and stiffer construct than IM fixation. CLINICAL RELEVANCE A stiffer construct can reduce the risk of nonunion and shorten the period of non-weight-bearing.
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Affiliation(s)
- Klaus Edgar Roth
- Center of Orthopedic and Trauma Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Jennifer Peters
- Center of Orthopedic and Trauma Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Irene Schmidtmann
- Institute for Medical Biometry, Epidemiology and Computer Science, Johannes Gutenberg University, Mainz, Germany
| | - Uwe Maus
- Center of Orthopedic and Trauma Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Daniel Stephan
- Institute for Biomechanics, Traumacenter, Murnau, Germany Paracelsus Medical University, Salzburg, Austria
| | - Peter Augat
- Institute for Biomechanics, Traumacenter, Murnau, Germany Paracelsus Medical University, Salzburg, Austria
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King CM, Richey J, Patel S, Collman DR. Modified lapidus arthrodesis with crossed screw fixation: early weightbearing in 136 patients. J Foot Ankle Surg 2014; 54:69-75. [PMID: 25451208 DOI: 10.1053/j.jfas.2014.09.034] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Indexed: 02/03/2023]
Abstract
Modified Lapidus arthrodesis is a versatile and powerful procedure for correcting the hallux valgus deformity typically associated with significant metatarsus primus varus or increased first ray mobility. Traditionally, patients have remained non-weightbearing until the arthrodesis has consolidated. More recently, numerous studies have evaluated the outcomes of early postoperative weightbearing using a variety of fixation constructs. The present retrospective cohort study evaluated 136 consecutive patients who had undergone modified Lapidus arthrodesis for hallux valgus deformity with conventional, crossed, solid core, screw fixation, were enrolled in an early weightbearing protocol, and were followed for 12 months. All the patients were partial weightbearing in a protective boot a mean of 12.2 (SD ± 4.36) days after surgery, with full weightbearing at 34.4 (SD ± 11.89) days. Union was achieved in 133 patients (97.8%). Of the 3 (2.2%) patients with nonunion, 2 (1.5%) remained asymptomatic. The mean time to radiographic union was 65 (SD ± 37.24) days. Significant improvement was seen in the first intermetatarsal angle and hallux abductus angle after surgery (p < .0001). Deformity correction was not compromised by early weightbearing and was well maintained over time. These results support early weightbearing with traditional crossed screw fixation for modified Lapidus arthrodesis with outcomes and complication rates comparable to those previously published.
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Affiliation(s)
- Christy M King
- Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Foundation Hospital, Oakland, CA
| | - Johanna Richey
- Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Foundation Hospital, Walnut Creek, CA
| | - Sandeep Patel
- Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Foundation Hospital, Antioch, CA
| | - David R Collman
- Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics, Kaiser Foundation Hospital, San Francisco, CA.
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Paulick TA, Conley BJ, Brarens RM, Ash RL. A retrospective study of two Lapidus groups, each with a different method of rail application. J Foot Ankle Surg 2014; 54:323-5. [PMID: 25128308 DOI: 10.1053/j.jfas.2014.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Indexed: 02/03/2023]
Abstract
To date, few studies discussing the use of rail external fixation for the Lapidus procedure have presented acceptable complication rates. At least 1 study has suggested the technique is not recommended for routine use with this procedure. We present 2 methods of external fixation application and 2 protocols of early postoperative weightbearing in 25 patients, with a marked decrease in complication rates from previously published studies. A retrospective study of 25 patients (within 2 patient groups) was performed, with a mean follow-up of 20 (range 12 to 38) months. Age, sex, incidence of fusion, interval to fusion, weightbearing status, and complication rates were evaluated. All subjects underwent Lapidus bunionectomy with joint preparation using sagittal planning. The fusion sites for group A fixation included a medially placed external fixation rail. Group B fixation included an interfragmentary screw and dorsal rail placement. Weightbearing was allowed in group A on day 1 and in group B on day 14. Our patient population consisted of 19 females (76%) and 6 males (24%). The mean patient age was 45.6 (range 28 to 63) years. The overall incidence of fusion was 96% (24 of 25), with complete union, although 1 patient's union was delayed. The mean interval to union for group A was 7.6 (range 6 to 8) weeks and for group B, was 9 (range 8 to 13) weeks. The primary complication encountered was pin tract infection in 11 patients (44%). The use of rail external fixation for Lapidus bunionectomy using either of the outlined techniques resulted in significant reduction of previously reported complication rates and allowed for early weightbearing.
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Affiliation(s)
- Thomas A Paulick
- Resident, Department of Podiatric Surgery, The Jewish Hospital, Cincinnati, OH.
| | - Brian J Conley
- Resident, Department of Podiatric Surgery, The Jewish Hospital, Cincinnati, OH
| | - Robert M Brarens
- Attending Surgeon, SureStep Foot & Ankle Medical Center, Cincinnati, OH
| | - Renee L Ash
- Attending Surgeon, Foot & Ankle Specialists, Cincinnati, OH
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Abstract
Due to its proximal correction site and long lever arm, the Lapidus fusion, modified or not, is a powerful technique to correct hallux valgus deformities. The disadvantages are a high complication rate and a long postoperative rehabilitation period. It is only performed in 5% to 10% of all hallux valgus deformity corrections but remains, however, an important procedure, especially in moderate to severe deformities with intermetatarsal angles more than 14°, hypermobility of the first ray, arthritis of the first tarsometatarsal joint, and recurrent deformities. This article provides an overview of the procedure with special focus on the surgical technique.
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Affiliation(s)
- Timo Schmid
- Department of Orthopaedic Surgery, Inselspital, University of Berne, Freiburgstrasse, Bern 3010, Switzerland
| | - Fabian Krause
- Department of Orthopaedic Surgery, Inselspital, University of Berne, Freiburgstrasse, Bern 3010, Switzerland.
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Lamm BM, Wynes J. Immediate weightbearing after Lapidus arthrodesis with external fixation. J Foot Ankle Surg 2014; 53:577-83. [PMID: 24880862 DOI: 10.1053/j.jfas.2014.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Indexed: 02/03/2023]
Abstract
A common surgical treatment of severe hallux abductovalgus deformity with coincident first ray hypermobility is metatarsal-cuneiform fusion or Lapidus procedure. The aim of the present study was to illustrate a reliable and novel method of fixation for Lapidus fusion using an external fixation device through a retrospective cohort investigation of consecutive patients. Twenty Lapidus fusions were performed in 19 patients, including 17 females (89.47%) and 2 males (10.53%). The mean age at surgery was 41 (range 20 to 64) years. The patients were evaluated clinically and radiographically pre- and postoperatively. The mean duration in the fixator was 12 (range 3 to 34) weeks. The mean interval to radiographic union was 9.2 (range 4.7 to 30.7) weeks in 18 of 20 feet (90%) and 2 (10%) were designated as nonunion. The mean follow-up period was 37 (range 5.6 to 211.1) weeks. The most common complication was pin tract infection in 5 patients (6 feet) and was treated with oral antibiotics; only 1 foot required early hardware removal. According to the visual analog scale, the mean patient pain score decreased significantly from 8.2 ± 2.7 to 0.83 ± 0.98 postoperatively (p < .001). Our results highlight that immediate weightbearing after Lapidus fusion with external fixation is a viable treatment option for the correction of severe hallux abductovalgus with associated hypermobility.
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Affiliation(s)
- Bradley M Lamm
- Head, Foot and Ankle Surgery, and Director, Foot and Ankle Deformity Correction Fellowship, Rubin Institute of Advanced Orthopedics, International Center for Limb Lengthening, Sinai Hospital of Baltimore, Baltimore, MD
| | - Jacob Wynes
- Clinical Fellow, Foot and Ankle Deformity Fellowship, Rubin Institute of Advanced Orthopedics, International Center for Limb Lengthening, Sinai Hospital of Baltimore, Baltimore, MD.
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40
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Baravarian B, Ben-Ad R. Contemporary approaches and advancements to the Lapidus procedure. Clin Podiatr Med Surg 2014; 31:299-308. [PMID: 24685195 DOI: 10.1016/j.cpm.2014.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The Lapidus procedure as evolved over the last 50 years. What originally was a difficult procedure with poor outcomes has changed to a procedure that allows for ideal realignment of the deformity at its source, improved foot alignment, and minimal to no need for further surgery. The authors now use a weight bearing plate which has improved overall patient care, with a minimized risk of nonunions, and more rapid return to early weight bearing and range of motion. This method has opened up the procedure to more patients, decreased the recovery time, and allowed for early physical therapy, resulting in outstanding patient outcomes.
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Affiliation(s)
- Bob Baravarian
- Podiatric Foot and Ankle Surgery, Santa Monica UCLA Medical Center and Orthopedic Hospital, UCLA School of Medicine, Los Angeles, CA, USA; University Foot and Ankle Institute, Los Angeles, CA, USA.
| | - Rotem Ben-Ad
- University Foot and Ankle Institute, Los Angeles, CA, USA
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41
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Abstract
The Lapidus procedure should no longer be considered a strict nonweightbearing bunionectomy. In the past few years, several studies have emerged demonstrating that early weightbearing after a Lapidus fusion is indeed possible with satisfactory fusion rates. This is mainly because of improved fixation techniques available today, which have allowed for better stabilization of the fusion site. Surgeons should still properly indicate patients for early weightbearing protocols.
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Affiliation(s)
- Neal M Blitz
- Department of Orthopaedic Surgery, Bronx-Lebanon Hospital Center, Albert Einstein College of Medicine, 1650 Grand Concourse, 7th Floor, Bronx, NY 10457, USA.
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Donnenwerth MP, Borkosky SL, Abicht BP, Plovanich EJ, Roukis TS. Rate of nonunion after first metatarsal-cuneiform arthrodesis using joint curettage and two crossed compression screw fixation: a systematic review. J Foot Ankle Surg 2011; 50:707-9. [PMID: 21908206 DOI: 10.1053/j.jfas.2011.08.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Indexed: 02/03/2023]
Abstract
First metatarsal-cuneiform joint arthrodesis is a commonly performed procedure to correct first ray pathology. The most widely accepted approach is curettage and 2 crossed compression screw fixation followed by a period of non-weight-bearing. Despite adequate joint preparation and stable internal fixation, nonunion has been cited as a known complication. This can lead to the need for revision surgery, which is undesirable and drives healthcare costs. To further investigate this topic, we conducted a systematic review to determine the rate of nonunion after the first metatarsal-cuneiform joint arthrodesis using curettage and 2 crossed compression screw fixation. Studies were eligible for inclusion only if they involved the following: arthrodesis of the first metatarsal-cuneiform joint with curettage and 2 crossed compression screw fixation, a minimum of 25 feet, with a mean follow-up of at least 6 months, and a period of postoperative non-weight-bearing. After considering all the potentially eligible references, 1 (1.8%) evidence-based medicine level I and 4 (7.3%) evidence-based medicine level IV studies met our inclusion criteria. A total of 537 patients (599 feet), 54 (10%) males and 483 (90%) females, with a weighted mean age of 49.4 years, were included. For those studies that specified the exact follow-up, the weighted mean was 30.9 months. A total of 30 nonunions (5%) were reported, with 17 (56.7%) symptomatic. The results of our systematic review revealed a relatively high rate of nonunion for first metatarsal-cuneiform joint arthrodesis with curettage and 2 crossed compression screw fixation, even when performed by experienced surgeons. Therefore, given the available data, additional prospective investigations are warranted, especially in the evaluation and comparison of fixation constructs and postoperative management.
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Affiliation(s)
- Michael P Donnenwerth
- Podiatric Medicine and Surgery Resident (PGY-II), Gundersen Lutheran Medical Foundation, La Crosse, WI 54601, USA
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Ellington JK, Myerson MS, Coetzee JC, Stone RM. The use of the Lapidus procedure for recurrent hallux valgus. Foot Ankle Int 2011; 32:674-80. [PMID: 21972761 DOI: 10.3113/fai.2011.0674] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The objective of this study was to evaluate the Lapidus procedure or it's modifications for treatment of recurrent hallux valgus (HV). Our hypothesis was that the Lapidus procedure would achieve good correction of recurrent HV and patients would be satisfied. MATERIALS AND METHODS A retrospective review of 32 feet (30 patients) treated with the Lapidus procedure for recurrent HV with at least 1-year followup was performed. Evaluation included radiographs, examination, and chart review. Outcomes were assessed with a pain visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, SF-12, Revised Foot Function Index (RFFI), and a survey. Twenty-three of 30 patients (25 feet) met the criteria for inclusion in the study and were available for followup evaluation. The average followup was 31.6 months. RESULTS Arthrodesis was present in 24 out of 25 feet (96%). The time from initial HV correction to revision surgery was 91 months. The initial surgery performed was a distal osteotomy (15), proximal osteotomy (five), exostectomy (two), diaphyseal osteotomy (two), and proximal/distal osteotomy (one). Preoperative evaluation revealed 96% of patients had clinical hypermobility of the first TMT joint and 52% had radiographic findings of instability. The average postoperative AOFAS hallux score was 82.8, SF-12 score was 94.5, and RFFI was 101. The average preoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) were 36.2, 13.6, 18.6 degrees, respectively, which corrected to an average of 15.2, 7.5, 11.7 degrees postoperatively (p < 0.001). The average shortening of the first ray was 2.9 mm. Average pain VAS was 2.4. Eighty-seven percent reported good to excellent results. Using a multivariable linear regression analysis, postoperative HVA along with change in length of the first ray were significant predictors of quality of life based on SF-12 (p < 0.05). CONCLUSION The Lapidus procedure corrected recurrent HV with a low nonunion rate and excellent radiographic correction and patients were satisfied with their outcome. LEVEL OF EVIDENCE IV, Retrospective Case Series
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Affiliation(s)
- J Kent Ellington
- Institute for Foot and Ankle Reconstruction, Mercy Medical Center, Baltimore, MD, USA.
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Menke CRD, McGlamry MC, Camasta CA. Lapidus arthrodesis with a single lag screw and a locking H-plate. J Foot Ankle Surg 2011; 50:377-82. [PMID: 21596589 DOI: 10.1053/j.jfas.2011.03.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Indexed: 02/03/2023]
Abstract
The aim of this pilot study was to assess if using an interfragmental lag screw and a Darco(®) locking H-plate for the modified Lapidus arthrodesis in the treatment of hallux abducto valgus deformity (1) would allow for earlier weight bearing than previously described and (2) would indicate whether any changes would occur radiographically with the earlier weight bearing. Twenty-one metatarsocuneiform arthrodeses, in 18 patients, were retrospectively evaluated through chart review and postoperative radiographs. Original diagnoses included painful hallux abducto valgus and osteoarthritis of the first metatarsocuneiform joint. The mean age of the patients was 48 (range, 16 to 70) years. The mean follow-up duration was 38.5 (range, 29 to 60) months. The overall radiographic osseous union rate was 90.5% (19/21 feet), although there were 2 asymptomatic nonunions. There were no cases of fixation failure, and the surgical correction was preserved on follow-up radiographs. Overall, the mean time to full weight bearing was 4.7 (range, 3 to 7.5) weeks, and it was a mean of 8 (range, 7 to 10) weeks before the patient was back to wearing comfortable shoes. The authors concluded that metatarsocuneiform arthrodesis fixated with 1 interfragmentary lag screw and a Darco(®) locking H-plate provides sufficient stability to allow earlier weight bearing than has been previously described with other internal fixation constructs.
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Fleming L, Savage TJ, Paden MH, Stone PA. Results of modified lapidus arthrodesis procedure using medial eminence as an interpositional autograft. J Foot Ankle Surg 2011; 50:272-5. [PMID: 21513868 DOI: 10.1053/j.jfas.2011.02.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Lee Fleming
- Presbyterian/St Luke's Medical Center, Denver, CO 80111, USA
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Jordan TH, Rush SM, Hamilton GA, Ford LA. Radiographic outcomes of adult acquired flatfoot corrected by medial column arthrodesis with or without a medializing calcaneal osteotomy. J Foot Ankle Surg 2011; 50:176-81. [PMID: 21354002 DOI: 10.1053/j.jfas.2010.12.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Indexed: 02/03/2023]
Abstract
Medial column arthrodesis and calcaneal osteotomies are commonly used for adult acquired flatfoot surgical reconstruction. In this retrospective study, 41 patients (47 feet) with a mean age of 55 ± 13.5 years underwent a medial column arthrodesis, with or without calcaneal osteotomy, between 1999 and 2007. The indication for surgery was a painful flatfoot deformity with peritalar subluxation, and a fault in the naviculocuneiform joint. At a mean of 9.6 (range 3-43) months postoperatively, in patients who underwent a medial column arthrodesis, radiographs showed a mean decrease in the talonavicular coverage angle of 10.2° ± 8.7° (P < .001), and mean increases in the lateral talometatarsal and calcaneal inclination angle of 10.7° ± 5.1° (P < .001) and of 3.2° ± 2.7° (P < .001), respectively. In patients who underwent a combined medial column arthrodesis and a medializing calcaneal osteotomy, the talonavicular coverage angle decreased by a mean of 12.1° ± 6.1° (P < .001), while the lateral talometatarsal angle and calcaneal inclination angle increased by a mean of 12.3° ± 6.1° (P < .001) and 3.1° ± 2.7° (P < .001), respectively, from preoperative values. Four nonunions (4 of 47, 8.51%) occurred at the naviculocuneiform joint and 1 nonunion (1 of 32, 3.13%) occurred at the tarsometatarsal joint. These findings demonstrate marked improvement of radiographic flatfoot parameters following a medial column arthrodesis with or without a medializing calcaneal osteotomy.
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Affiliation(s)
- Thomas H Jordan
- Kaiser Permanente San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Permanente Medical Center, Oakland, CA 94611, USA
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The arthroscopic Lapidus procedure. Foot Ankle Surg 2011; 17:25-8. [PMID: 21276561 DOI: 10.1016/j.fas.2009.12.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Revised: 11/20/2009] [Accepted: 12/09/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hypermobility of the first metatarsocuneiform (MC) joint is one of the causes believed to contribute to symptomatic hallux valgus. An arthrodesis of the first MC joint offers definitive correction of the intermetatarsal angle. This procedure can be associated with pseudoarthrosis and shortening of the first ray. This study presents our experience and results with an arthroscopic technique for performing this arthrodesis. MATERIALS AND METHODS Five patients with severe hallux valgus associated with hypermobility of the first MC joint were treated with this operation. RESULTS The functional assessment scales revealed very good results. Radiographic evaluation confirmed fusion in all the patients. The hallux valgus angle improved by 25.6°, the intermetatarsal angle improved by 10.6°. The shortening of the first ray was limited to 2.7 mm. CONCLUSION This new technique is a valid option for performing an arthrodesis of the MC joint.
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Espinosa N, Wirth SH. Tarsometatarsal arthrodesis for management of unstable first ray and failed bunion surgery. Foot Ankle Clin 2011; 16:21-34. [PMID: 21338927 DOI: 10.1016/j.fcl.2010.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This article focuses on arthrodesis of the first tarsometatarsal joint as the primary intervention to treat hypermobility of the first ray or as a salvage procedure to treat prior failed bunion surgery and provides a concise review including historical perspective, definitions, pathomechanics, and treatment of specific forefoot disorders (ie, hypermobility of the first ray and failed bunion surgery).
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Affiliation(s)
- Norman Espinosa
- Department of Orthopaedics, University of Zurich, Balgrist, Forchstrasse 340, 8008 Zurich, Switzerland.
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DeVries JG, Granata JD, Hyer CF. Fixation of first tarsometatarsal arthrodesis: a retrospective comparative cohort of two techniques. Foot Ankle Int 2011; 32:158-62. [PMID: 21288415 DOI: 10.3113/fai.2011.0158] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Presently, indications for the Lapidus procedure include patients with many pathologies of the first metatarsocuneiform joint. Currently the standard in many areas is that of two or three crossed screws through the first tarsometatarsal region. This type of fixation requires an extended period of nonweightbearing and may be difficult for patient compliance. MATERIALS AND METHODS The present study is a retrospective comparison of crossed screw fixation to locking plate fixation without a lag screw on union rates, time to weightbearing, and complications. RESULTS One hundred forty-three first TMT fusions met the inclusion criteria. There were 96 fused by crossed screw construct (CS) and 47 by the locked plate with or without compression screw (LP). There was a significant difference in time to full weightbearing and union rate. Time to full weightbearing was 8.8 (range, 3 to 16) weeks and 7.8 (range, 1.5 to 34) weeks in the CS and LP groups, respectively (p < 0.001). Union rate was 89.4% (88 of 96 joints) and 98.5% (46 of 47 joints) in the CS and LP groups, respectively (p < 0.001). CONCLUSIONS We found that when using a dorsal-medial locked plate with or without lag screw lead to a superior rate of union compared to standard crossed screw constructs even while allowing earlier return to full weightbearing.
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Affiliation(s)
- J George DeVries
- Orthopedic Foot & Ankle Center, 300 Polaris Parkway, Suite 2000, Westerville, OH 43082, USA.
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Bock P, Lanz U, Kröner A, Grabmeier G, Engel A. The Scarf osteotomy: a salvage procedure for recurrent hallux valgus in selected cases. Clin Orthop Relat Res 2010; 468:2177-87. [PMID: 20496024 PMCID: PMC2895827 DOI: 10.1007/s11999-010-1363-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2009] [Accepted: 04/12/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Scarf osteotomy was described as a technique to correct a metatarsus primus varus in primary hallux valgus surgery, but it is unclear whether the technique could correct recurrent hallux valgus when an initial procedure failed to provide any or an adequate lateral displacement of the metatarsal head. QUESTIONS/PURPOSES We asked whether the Scarf osteotomy could reduce pain, improve the AOFAS score, reduce the deformity, and prevent further recurrence when used as a revision procedure. PATIENTS AND METHODS Of 41 patients (45 feet) we treated for failed initial operations, we retrospectively reviewed 35 (39 feet) who underwent a Scarf osteotomy. We administered a VAS for pain and the AOFAS score preoperatively and postoperatively. Preoperative and postoperative radiographs were taken to assess the hallux valgus angle [HVA] and intermetatarsal angle [IMA]. The minimum followup was 24 months (mean, 42 months; range, 24-89 months). RESULTS The mean VAS for pain improved from 5.9 to 0.4 points. The mean AOFAS score improved from 56 to 90 points. The radiographic evaluation showed improvement of the mean HVA from 30 degrees to 8 degrees and improvement of the IMA from 13 degrees to 4 degrees. Complications included one asymptomatic recurrence with a 20 degrees -HVA, one overcorrection with a 3 degrees-varus deformity, and pain attributable to irritation caused by screws in five patients. CONCLUSIONS As a revision procedure the Scarf osteotomy clinically and radiographically corrected recurrent hallux valgus recurrence in most patients. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Peter Bock
- Department of Orthopedic Surgery, Danube Hospital, Vienna, Langobardenstrasse 122, 1220 Vienna, Austria
| | - Ulrich Lanz
- Department of Orthopedic Surgery, Danube Hospital, Vienna, Langobardenstrasse 122, 1220 Vienna, Austria
| | - Andreas Kröner
- Department of Orthopedic Surgery, Danube Hospital, Vienna, Langobardenstrasse 122, 1220 Vienna, Austria
| | - Georg Grabmeier
- Department of Orthopedic Surgery, Danube Hospital, Vienna, Langobardenstrasse 122, 1220 Vienna, Austria
| | - Alfred Engel
- Department of Orthopedic Surgery, Danube Hospital, Vienna, Langobardenstrasse 122, 1220 Vienna, Austria
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