Rate of nonunion after first metatarsal-cuneiform arthrodesis using joint curettage and two crossed compression screw fixation: a systematic review

Secondary Surgery Following Lapidus Bunionectomy

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.

The Lapidus Bunionectomy Revolution: Current Concepts and Considerations

Hallux valgus is a common foot deformity in which many surgical techniques have been introduced. Originally, Paul Lapidus detailed a midfoot arthrodesis technique to address the deformity and medial column instability that served as the foundation for the modified Lapidus bunionectomy. The appreciation of the multiplanar nature of hallux valgus deformity continues to evolve and helps to guide the investigation of the ideal surgical correction to yield more predictable results and reduced complications. Various fixation constructs have been used over the years for the Lapidus bunionectomy without a clear superior fixation technique, and literature supports early weight-bearing with each.

An Umbrella Systematic Review and Meta-Analysis of Systematic Reviews on the Topic of Foot and Ankle Arthrodesis Nonunion Rates

The purpose of this systematic review and meta-analysis was to appraise and combine the available systematic reviews reporting nonunion incidence and prevalence in foot and ankle arthrodesis procedures. The Cochrane Library and MEDLINE were searched for relevant systematic reviews from inception to January 2022. Two independent reviewers selected and reviewed eligible studies. Studies were included if they were systematic reviews or meta-analyses reporting nonunion incidence and prevalence in foot or ankle arthrodesis procedures. Fourteen systematic reviews of 8 types of joint arthrodesis procedures were included for meta-analysis. These reviews comprised 138 studies with 5793 joint arthrodesis procedures. Quality of the included reviews were assessed using the AMSTAR2 checklist. Overall and subgroup meta-analysis of prevalence were performed using random effects model. Publication bias was determined by evaluation of a DOI plot with the Luis Furuya-Kanamori index of asymmetry. The pooled prevalence for foot and ankle nonunion rate was 8.1% (95% confidence interval [CI] 6.5%-9.9%). Overall prevalence of nonunion for single joint foot and ankle joint arthrodesis was 6.1% (95% CI 4.8%-7.6%). Subgroup analysis found that the highest rate of nonunion occurred during tibiotalocalcaneal arthrodesis with 27.1% (95% CI 19.4%-35.2%). We have reported the first meta-analysis of systematic reviews on nonunion rates in foot and ankle arthrodesis procedures. The overall nonunion rate for foot and ankle arthrodesis procedures was 8.1%. For single joint fusion procedures, the nonunion prevalence was 6.1%. Our reported nonunion rates are lower than previously published numbers.

First Tarsometatarsal Joint Arthrodesis for Hallux Valgus With and Without Intermetatarsal Screw Fixation: A Comparison of Correction and Maintenance of Correction

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.

Clinical Outcomes and Rotational Correction of First Metatarso-Cuneiform Fusion With First Metatarsal to Second Cuneiform Fixation

Background:

The modified Lapidus procedure (first metatarso-cuneiform fusion) is a powerful technique for correcting triplanar deformity in hallux valgus. Although traditionally fixed with cross-screws (CS), growing awareness of intercuneiform stability and pronation deformity has led to fixation using a plate and first metatarsal–second cuneiform (1MT-2C) screw fixation (PS). We investigated Lapidus patient cohorts using CS vs PS fixation to understand patient-reported outcomes, angular and rotational correction, and complication rates.

Methods:

We retrospectively reviewed cases of modified Lapidus for hallux valgus by a single surgeon. Patients were divided into CS or PS groups according to fixation. All patients had preoperative Patient Reported Outcome Measurement Information System (PROMIS) scores and minimum 12 months of follow-up. PROMIS scores in 6 key domains were compared within and between groups. Radiographic assessment of hallux valgus angle and intermetatarsal angle were performed on pre- and postoperative XR. Pronation of the first ray was measured on pre- and postoperative weightbearing computed tomography.

Results:

We compared 42 patients with PS fixation to 43 with CS fixation. Both groups had significant improvement in hallux valgus angle and intermetatarsal angle (P < .001), with no difference between groups. PS patients experienced a greater correction of first metatarsal pronation, an average reduction of 11 degrees, compared to 8 degrees in the CS group (P < .039). Both cohorts experienced improvement in PROMIS physical function, pain interference, pain intensity, and global physical function. There were no differences in PROMIS score improvements between the cohorts. The CS group started weightbearing at 6 weeks vs 3.6 weeks for the PS group. Complication and revision rates were similar.

Conclusion:

A plate and 1MT-2C screw fixation provides safe, robust fixation of Lapidus procedure and prevents instability through the intercuneiform joint. We observed similar improvement in PROMIS compared with patients treated with cross-screws. Complications did not increase despite the PS group weightbearing much earlier. PS patients achieved greater first ray rotational correction.

Level of Evidence:

Level III, retrospective cohort study.

Early Radiographic Outcomes of Minimally Invasive Chevron Bunionectomy Compared to the Modified Lapidus Procedure

Background

Minimally invasive (MIS) bunion surgery has become increasingly popular. Although early reports on outcomes have been encouraging, no study to date has compared outcomes from the MIS chevron and Akin procedures to the modified Lapidus procedure. Our primary aim was to compare early radiographic outcomes of the MIS chevron and Akin osteotomies to those of the modified Lapidus procedure in patients with comparable deformities, and secondarily to compare clinical outcomes.

Methods

Patients were retrospectively reviewed for inclusion from a prospectively collected foot and ankle registry. Patients were eligible if they underwent either the MIS bunionectomy or modified Lapidus procedure and had preoperative and minimum 5-month postoperative weightbearing radiographs. Forty-one patients who underwent MIS bunionectomy were matched to 41 patients who underwent Lapidus bunionectomy based on radiographic parameters. Demographics, radiographic parameters, complications, reoperations, and PROMIS scores were compared between groups.

Results

Both groups achieved similar radiographic correction. There was no significant difference in pre- or postoperative PROMIS scores between groups. Procedure duration was significantly faster in the MIS group (P < .001). Bunion recurrence (hallux valgus angle ≥20 degrees) occurred in 1 MIS patient and 2 Lapidus patients, with all patients asymptomatic. The most common reason for reoperation was removal of hardware (4 patients in the MIS group, 2 patients in the Lapidus group).

Conclusion

This is the first study to our knowledge to compare early radiographic outcomes between MIS bunionectomy and the modified Lapidus procedure in patients matched for bunion severity. We found that patients with similar preoperative deformities experience similar radiographic correction following MIS chevron and Akin osteotomies vs modified Lapidus bunionectomy. Further research is needed to investigate satisfaction differences between the procedures, longer-term outcomes, and which deformities are best suited to each procedure.

Level of Evidence

Level III, Retrospective case control study.

Vascular anatomy of the first metatarsal bone and surgical implications according to the severity of hallux valgus deformity: A cadaveric study

BACKGROUND

Vascular injury after hallux valgus surgery is a rare condition but serious complications can ensue.

METHODS

We performed an anatomical study using 26 cadaveric lower extremities. We enhanced first metatarsal bone's (FMB) vascularization by injecting latex. Each specimen was classified according to the severity of hallux valgus deformity (HVD). Then we measured two distances: one between the first tarsometatarsal joint (FTMJ) to the first dorsal branch's origin, the other between the first metatarsophalangeal joint (MTP) to the dorsal plexus's origin.

RESULTS

The distance between the FTMJ and the first dorsal branch to the FMB ranges from 10 mm in normal feet to 15 mm in severe deformed feet. The distance between the MTP and the dorsal plexus' origin ranges from 20 mm in normal feet to 25 mm in severe deformed feet.

CONCLUSIONS

Understanding the foot's vascular anatomy has allowed us to adapt surgical landmarks to the severity of the HVD and to avoid post-operative complications.

Revision of Malaligned Lapidus and Nonunited Lapidus

"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.

Maintenance of Correction of the Modified Lapidus Procedure With a First Metatarsal to Intermediate Cuneiform Cross-Screw Technique

BACKGROUND

Recurrence of deformity remains a concern when fusing the first tarsometatarsal joint for correction of hallux valgus (HV). A recently described construct adds an additional point of fixation from the plantar medial first metatarsal to the intermediate cuneiform. The purpose of this study was to determine the maintenance of correction of the first and second intermetatarsal angle, hallux valgus angle, and tibial sesamoid position after undergoing a first tarsometatarsal joint arthrodesis using the proposed construct.

METHODS

A radiographic review was performed of patients with HV treated with a first tarsometatarsal joint arthrodesis with the addition of a cross-screw intermediate cuneiform construct. Three observers reviewed radiographic data, including preoperative weightbearing, first weightbearing, and final weightbearing plain-film radiographs. Initial improvement and maintenance of intermetatarsal angle, hallux valgus angle (HVA), and tibial sesamoid position were evaluated radiographically. A total of 62 patients met inclusion criteria and were included in the study. Mean follow-up time was 9.3 months (SD 6.7).

RESULTS

Bony union was achieved in 60 of 62 patients (96.7%). Two of 62 patients required revision surgery as a result of recurrence (3.3%). Final mean improvement of the intermetatarsal angle (IMA) was 6.8 degrees (±2.9 degrees), HVA was 14.8 degrees (±7.5 degrees), and tibial sesamoid position was 2.4 (±1.4) positions. Mean loss of IMA correction was 1.5 degrees (±1.6), HVA was 2.9 degrees (±4.8 degrees), and tibial sesamoid position was 0.8 (±0.8).

CONCLUSION

This study showed that the cross-screw intermediate cuneiform construct for first tarsometatarsal joint arthrodesis had a good union rate, a low complication rate, and maintained radiographic correction.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Bioabsorbable vs. titanium screws for first tarsometatarsal joint arthrodesis: An in-vitro study

BACKGROUND

The TMT-1 joint arthrodesis is a common repair for severe hallux valgus. Two crossing interfragmental screws, usually titanium or steel, and a locking plate or a plate with a compression screw are the most common fixation methods for first TMT joint arthrodesis. The qualities of an ideal fixation material include adequate strength and rigidity, biocompatibility, lack of interference with bone healing, lack of visibility and palpability, and a low risk of surgical removal. We sought to determine whether bioabsorbable cannulated screws would perform as well as titanium screws in anatomical models.

METHODS

Identical anatomical TMT-1 arthrodesis was created with a saw by making a straight cut in 30 anatomical models (Sawbone®). The bioabsorbable and titanium screws were placed one at a time in exactly the same location in each model according to careful measurements. All 30 models were analyzed with a material testing machine (MTS Insight 30, Eden Prairie, USA). Each model was oriented 15° to the platform to simulate its position to the ground during mid-stance.

RESULTS

In the single-cycle load-to-failure test, the mean yield load was 61.4 N ± 5.7 N (range, 50.1 N-70.3 N) in the bioabsorbable screw group and 81.2 N ± 12 N (range, 61.7 N-113.4 N) in the titanium screw group (P < .001). The respective values for the stiffness of the fixation were 8.1 N/mm ± 0.8 N/mm (range, 6.7 N/mm to 9.1 N/mm) and 9.7 N/mm ± 1.8 N/mm (range, 6.9 N/mm to 12.6 N/mm) for the bioabsorbable and titanium groups (P = .004). The mean maximum failure loads in the bioabsorbable group were 85.1 N ± 8.5 N (range, 67.1 N-97.2 N) and in the titanium group 120.6 N ± 13.2 N (range, 96.7 N-136.7 N), respectively (P < .001). Analysis of the failure models shows bioabsorbable fixation failures caused by bending occur more often than in the titanium group.

CONCLUSION

In biomechanical testing, titanium screws were stronger than bioabsorbable screws in the TMT-1 arthrodesis model tested, although bioabsorbable cannulated screws may be an alternative to titanium screws in the fixation Lapidus procedure.

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

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.

Progression of Healing on Serial Radiographs Following First Ray Arthrodesis in the Foot Using a Biplanar Plating Technique Without Compression

A review of 195 first ray arthrodeses fixated with a twin-plate biplanar construct, without interfragmentary compression, is presented. This fixation construct was evaluated in a consecutive cohort of patients undergoing first metatarsophalangeal joint (MTP) arthrodesis or the first tarsometatarsal joint (TMT) arthrodesis. Multiple radiographs were used to assess the progression of healing at the following postoperative time frames: 4 to 9 weeks, 10 to 12 weeks, >12 weeks, and the final follow-up. In total, 85 feet underwent first MTP arthrodesis, and 110 feet underwent first TMT arthrodesis. At the final radiographic follow-up, 97.44% of all cases had shown progressive osseous gap filling at the arthrodesis site, stable position of the bone segments, and intact hardware without loosening, 98.24% of the first MTP arthrodesis group and 96.82% of the first TMT arthrodesis group. Five (5.43%) feet had the presence of lucency at the fusion interface at the final follow-up, without positional change or hardware failure. Four (1.8%) feet had a failure of the hardware, loss of position, or frank gapping at the fusion site. Lucency decreased consistently over time in this series of patients (p < .00001). Progressive increase in callus density at the fusion site on serial radiographs was noted to be a consistent finding for both procedures and was the primary indicator of secondary bone healing at the noncompressed, relatively stable arthrodesis site. Our results confirm that biplanar plating construct without interfragmentary compression produces high fusion rates following the first MTP or TMT arthrodesis, with early weightbearing.

Hallux Valgus/Medial Column Instability and Their Relationship with Posterior Tibial Tendon Dysfunction

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.

Comparison of Locking Plate with Interfragmentary Screw Versus Plantarly Applied Anatomic Locking Plate for Lapidus Arthrodesis: A Biomechanical Cadaveric Study

Arthrodesis of the first metatarsal cuneiform joint, or Lapidus procedure, is a widely accepted treatment for hallux valgus. Recent studies have focused on comparing various constructs for this procedure both in the laboratory and clinical settings. The current study compared in a cadaveric model the strength of 2 constructs. The first construct utilized a medially applied low-profile locking plate and an interfragmentary screw directed from plantar-distal to dorsal-proximal. The second construct consisted of a plantarly applied plate with a compression screw placed through the plate from plantar-distal to dorsal-proximal. The ultimate load to failure for the 2 groups tested was 255.38 ± 155.38 N and 197.48 ± 108.61 N, respectively (P = .402). There was no significant difference found between the 2 groups with respect to ultimate load to failure, stiffness of the construct, or moment at time of failure. In conclusion, the medially applied plate with plantar interfragmentary screw appears to be stronger than the plantar Lapidus plate tested for first metatarsal cuneiform arthrodesis, though this difference did not reach statistical significance.

LEVELS OF EVIDENCE

Level V: Biomechanical Study.

Evaluation of Fixation Techniques for Metatarsocuneiform Arthrodesis

First metatarsocuneiform joint arthrodesis has been used in foot and ankle surgery for the treatment of hallux abductovalgus deformity, among other pedal pathologic entities. The goal of the present retrospective study was to compare the fusion rates and complications of an intraplate compression screw fixation, crossing solid core screw fixation, and a single interfragmentary screw with a simple locking plate. All procedures were performed by a single surgeon, and all patients received an identical postoperative protocol. A medical record review was performed of 147 evenly distributed surgical methods. All patients were non-weightbearing by protocol for 4 weeks. The patient covariates included sex, age, nicotine status, osteoporosis, and diabetes. These variables were balanced among the treatment groups and were noncontributory, with the exception of sex. Male patients had a 6 times greater odds of experiencing nonunion. The overall nonunion rate was 6.7%, with 4% symptomatic and requiring revision. The individual nonunion rates for each method were 2% for intraplate compression screw fixation, 5% for single interfragmentary screw with locking plate fixation, and 9% for crossing solid core screw fixation. None of the differences reached statistical significance. The corresponding hardware removal rates were 12%, 11%, and 0%.

Clinical and Operative Factors Related to Successful Revision Arthrodesis in the Foot and Ankle

BACKGROUND

Arthrodesis is a common operative procedure used to manage arthritis and deformity in the foot and ankle. Nonunion is a possible and undesirable outcome in any arthrodesis surgery. Rates of nonunion in the foot and ankle literature range from 0% to 47% depending on the patient population and joint involved. Multiple factors can contribute to developing a nonunion including location, fixation method, tobacco use, diabetes, infection, and others.

METHODS

The case logs of 3 foot and ankle surgeons were reviewed from January 2007 to September 2014 to identify nonunion arthrodesis revision cases. The patient factors reviewed included diabetes, inflammatory arthropathy, tobacco use, history of infection, nonunion elsewhere, neuropathy, Charcot arthropathy, posttraumatic arthritis, and prior attempt at revision arthrodesis at the same site. Operative records were reviewed to identify location of the nonunion, instrumention, use of allograft or autograft bone, use of iliac crest bone marrow aspirate (ICBMA) and use of orthobiologics such as bone morphogenetic protein (BMP) during the revision arthrodesis. Successful revision was defined as radiographic union on the final radiograph during follow-up. Eighty-two cases of revision arthrodesis were identified with an average follow-up of 16 months.

RESULTS

The overall nonunion rate was 23%. Neuropathy and prior attempts at revision were identified as significant risks (P <.05) for persistent nonunion. Odds ratio calculated based on previous attempts at revision arthrodesis found a 2.8-fold increase in the risk of failure for each attempt at revision.

CONCLUSION

Revision arthrodesis for nonunion in the foot and ankle was successful (77%) under a variety of patient and operative conditions. Neuropathy was a significant patient risk factor for persistent nonunions, and we believe it is important to identify even in the nondiabetic patient. As the number of attempts at revisions increases, there is a subsequent 3-fold increase in the risk of persistent nonunion.

LEVEL OF EVIDENCE

Level IV, case series.

A Multicenter, Retrospective Study of Early Weightbearing for Modified Lapidus Arthrodesis

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.

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

BACKGROUND

The modified Lapidus procedure is widely used to correct hallux valgus but has been reported with high nonunion rates. In this study, we retrospectively reviewed the nonunion rate of the modified Lapidus procedure performed with rigid cross screw fixation, meticulous joint preparation, and shear-strain-relieved calcaneal bone graft.

QUESTIONS/PURPOSES

Does the performance of the Lapidus procedure with rigid cross screw fixation, complete joint preparation, and shear-strain-relieved calcaneal bone graft achieve higher union rates than currently reported? If nonunion does occur, what is the clinical course?

METHODS

We reviewed both radiographic and clinical results of the modified Lapidus procedure with the above technique in 171 patients (182 feet). Evaluation included age, gender, tobacco use, diabetic status, and radiographic analysis at least 3 months postoperatively.

RESULTS

The modified Lapidus procedure described above resulted in a union rate of 97.3% (177 of 182 feet). Three of the five feet with radiographic nonunions were clinically symptomatic.

CONCLUSIONS

The union rate of the modified Lapidus procedure is higher than previously reported when performed with rigid cross screw fixation, meticulous joint preparation, and shear-strain-relieved bone graft. Nonunion of the first tarsometatarsal joint should be considered an infrequent occurrence.

Endosseous Fixation Device for Lapidus Arthrodesis: Technique, Early Experience, and Comparison With Crossed Screw Fixation

First metatarsal cuneiform joint arthrodesis has been commonly used since the early 1900s for definitive treatment of a variety of conditions involving the medial column of the foot. Early applications of this procedure resulted in a relatively high rate of complications, including malunion and nonunion. We retrospectively examined a novel method of fixation involving an endosseous implant with a nonporous, rough exterior surface and compared it with the traditional crossed screw fixation, considered the standard of care for the procedure. Twenty-one feet in 19 patients served as the control group with crossed screws, and 18 feet in 17 patients served as the trial group using the study device. Null hypothesis testing was used to compare the outcomes parameters between the comparative groups. Postoperatively, the patients were allowed to walk in a prefabricated, removable, below-the-knee cast boot at a mean of 48.3 ± 8.2 days in the control group and 24.4 ± 9.7 days in the trial group. These differences were highly significant (p < .0001). Postoperatively, the patients were allowed to walk in a stiff-soled shoe at a mean of 65.2 ± 8.4 days in the control group and 49.7 ± 19.2 days in the trial group. These differences were also statistically significant (p = .0020). The patients in the control group required revision surgery in 7 of 21 procedures (33%), with 2 patients developing nonunion (9.5%). Only 1 patient in the trial group required revision surgery (5.8%), and no patient developed nonunion. From these results, we believe that the endosseous trial implant is a reliable option for fixation of the first metatarsal cuneiform arthrodesis procedure and might allow for earlier weightbearing with fewer postoperative complications.

Metatarsus Primus Varus Correction

We present a discussion on the use of proximal first-ray osteotomies in the surgical treatment for hallux valgus as a valid option compared with first-tarsometatarsal arthrodesis. Recent and historical literature tells us that stability of the first ray is a function of the alignment and reestablishment of retrograde stabilizing forces at the first tarsometatarsal joint. This realignment and stabilization may be accomplished with the use of distal soft tissue and proximal osteotomy procedures.

Enhanced Lapidus arthrodesis: crossed screw technique with middle cuneiform fixation further reduces sagittal mobility

Persistent medial column sagittal mobility can be encountered despite successful first tarsometatarsal stabilization if fixation has been limited to the first tarsometatarsal joint. The purpose of the present cadaveric research was to quantify the effect of a third point of fixation from the base of the first metatarsal to the middle cuneiform compared with the traditional isolated first tarsometatarsal fixation. Ten matched pairs of below-the-knee specimens, with a known cause of death, sex, ethnicity, and age, height, weight, and body mass index at death, were used for our examination. Portable fluoroscopy aided with the accurate placement of all points of fixation. Measurements of movement were obtained using the validated Klaue device. The 20 matched below-the-knee specimens were from 10 cadavers (2 female and 8 male donors, aged 72.8 ± 9.3 years, body mass index 21.1 ± 4.2 kg/m(2)). The sagittal plane motion of the first ray was 7.45 ± 1.82 mm before fixation. With isolated first tarsometatarsal fixation, the sagittal motion decreased to 4.41 ± 1.51 mm and decreased further to 3.12 ± 1.06 mm, with the addition of middle cuneiform fixation. Statistically significant enhancement of the stability of sagittal first ray motion was noted with the addition of the first metatarsal to middle cuneiform pin, even after simulated Lapidus fixation. Our findings suggest that first metatarsal to middle cuneiform fixation can be beneficial if excessive sagittal motion is present after standard 2-point fixation and can play a role in the prevention of recurrence and complications.

Modified lapidus arthrodesis with crossed screw fixation: early weightbearing in 136 patients

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.

A retrospective study of two Lapidus groups, each with a different method of rail application

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.

New techniques and alternative fixation for the lapidus arthrodesis

Arthrodesis of the first metatarsocuneiform joint is a powerful and durable procedure to help correct moderate to severe hallux valgus and/or first ray hypermobility. However, painful nonunion remains a notoriously high potential outcome. Research regarding locking plates seems promising, and data show lower rates of nonunion. Innovative fixation techniques are new and should be considered in the future as further literature is available on their long-term use. Regardless of the fixation, proper joint preparation and good compression is fundamentally the most important. A case of Lapidus fusion with locking plates after a failed arthrodesis with screws alone is presented.

Fixation of the Lapidus arthrodesis with a plantar interfragmentary screw and medial low profile locking plate

The Lapidus arthrodesis can be used to correct pathology within the forefoot or midfoot, and severe hallux valgus deformities as well as hypermobility of the medial column may be amenable to correction with this procedure. Many different skeletal fixation methods have been described for this procedure, and one form that appears to provide enough construct stability to allow patients to bear weight early in the postoperative period is described herein. This construct consists of an interfragmental compression screw oriented from the plantar aspect of the first metatarsal to the superior aspect of the medial cuneiform, with medial locking plate augmentation.