The Lapidus Procedure as Salvage After Failed Surgical Treatment of Hallux Valgus A PROSPECTIVE COHORT STUDY

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1 60 COPYRIGHT 2003 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED The Lapidus Procedure as Salvage After Failed Surgical Treatment of Hallux Valgus A PROSPECTIVE COHORT STUDY BY J. CHRIS COETZEE, MD, FRCSC, SCOTT G. RESIG, MD, MICHAEL KUSKOWSKI, PHD, AND KHALED J. SALEH, MD, MSC, FRCSC Investigation performed at the Department of Orthopaedic Surgery, University of Minnesota School of Medicine, Minneapolis, Minnesota Background: Recurrent hallux valgus is a relatively common, yet challenging, condition for both the patient and the surgeon. The literature on the treatment of recurrent hallux valgus is sparse. The purpose of this study was to evaluate prospectively the functional outcome and patient satisfaction following the Lapidus procedure for the treatment of recurrent hallux valgus deformity. Methods: Twenty-four patients with a total of twenty-six symptomatic recurrences of hallux valgus after previous procedures for treatment of the deformity were included in the study. Exclusion criteria included prior fusion procedures on the foot or ankle, a previous Keller or Mayo procedure, insulin-dependent diabetes, peripheral vascular disease, or peripheral neuropathy. A visual analog pain scale and the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale were administered preoperatively, at six months postoperatively, and yearly thereafter. Weight-bearing radiographs were also made preoperatively; at six weeks, three months, six months, and one year postoperatively; and yearly thereafter. Patient satisfaction was assessed at the latest follow-up evaluation. Results: At twenty-four months, the mean score according to the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale had increased from 47.6 to 87.9 points, the mean score according to the visual analog pain scale had improved from 6.2 to 1.4, the mean hallux valgus angle had improved from 37.1 to 17.1, and the mean intermetatarsal angle had improved from 18 to 8.6. The patients were very satisfied after 77% of the twenty-six procedures, satisfied after 4%, and somewhat satisfied after 19%; no patient was dissatisfied. There were no cases of hallux varus. Complications included three nonunions, all of which occurred in smokers, and two superficial wound infections. Conclusion: In appropriately selected patients, the Lapidus procedure is a reliable and effective operation after failed surgical treatment of hallux valgus. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See p. 2 for complete description of levels of evidence. More than 150 operations for correction of hallux valgus have been described in the literature, and most have satisfactory results. Each technique is associated with certain complications, and recurrence of the deformity is among the most common 1-4. Symptomatic recurrence after a failed operation for hallux valgus can be a challenging problem, and little has been published regarding its treatment. Albrecht 5 first described arthrodesis of the first metatarsocuneiform joint for correction of hallux valgus in 1911, and Lapidus 6 popularized the technique in Lapidus thought that the deformity was most often due to an underlying metatarsus primus varus and therefore that arthrodesis at the apex of the deformity, the metatarsocuneiform joint, prevented recurrence. The procedure described by Lapidus involved shaving the cartilage from the surfaces of the first metatarsal and the first cuneiform as well as resection of the adjacent cortices of the first and second metatarsals. The site of the arthrodesis was then held with catgut suture. Since this original description, there have been many modifications of the Lapidus procedure. Some authors have suggested that the modified Lapidus procedure may be indicated for salvage after failed operative treatment of hallux valgus 1,7-9, but we are not aware of any prospective outcome studies evaluating the

2 61 results of Lapidus procedures used for revision. In a retrospective study of fifty-one failed hallux valgus procedures, Scranton and McDermott 1 recognized that hypermobility was a cause of recurrence. Six patients had had recurrence secondary to hypermobility, and all were treated successfully with the Lapidus procedure. The authors concluded that obliquity or hypermobility of the metatarsocuneiform joint is best treated with the Lapidus procedure. Sangeorzan and Hansen 8 reported that all of seven patients in whom recurrent hallux valgus had been treated with a modified Lapidus procedure had a decrease in symptoms. This led the authors to recommend the Lapidus procedure for revision of a recurrent deformity. The purpose of the present study was to evaluate prospectively the satisfaction of patients and the functional outcome of a modified Lapidus procedure performed for the treatment of recurrence following failed surgery for hallux valgus. Materials and Methods e performed a prospective observational cohort study of Wpatients who presented with a recurrent hallux valgus deformity after undergoing surgery between May 1996 and August At the time that the investigation was begun, our institution did not require Institutional Review Board approval for such studies. Twenty-four patients with a total of twenty-six symptomatic recurrences of hallux valgus met the criteria for inclusion in the study. One of the twenty-four patients was lost to follow-up after six months, but the data on that patient were included in the study. The average age was thirty-seven years (range, twenty-one to fifty-seven years), and there were fourteen women and ten men. The patients had undergone a variety of procedures to treat the hallux valgus initially; these incuded fifteen chevron procedures, four Mitchell procedures, three Scarf procedures, two proximal crescentic procedures, one Wilson procedure, and one McBride procedure. Two of the patients who underwent a chevron procedure had an Akin osteotomy of the proximal phalanx at the same time. The inclusion criteria consisted of a symptomatic recurrent hallux valgus deformity after prior surgical treatment, no prior operation (except for minor clawtoe repairs) other than an isolated hallux valgus repair, and failure of conservative measures including shoe modifications. Exclusion criteria included prior fusion procedures on the ankle or foot as these procedures can alter the biomechanics of the foot, potentially affecting the stresses across the metatarsocuneiform fusion site and affecting the weight-bearing surface of the foot. Patients with a previous Keller or Mayo procedure were also excluded to avoid confounding the problem of ray-shortening. Insulin-dependent diabetes, peripheral neuropathy, and peripheral vascular disease were also reasons for exclusion because of the increased risk for nonunion. Weight-bearing anteroposterior, lateral, and sesamoid radiographs were made preoperatively; at six weeks, three months, six months, and one year postoperatively; and yearly thereafter. The study was prospective, with baseline data collected preoperatively and outcomes recorded postoperatively at two weeks, six weeks, three months, six months, one year, and yearly thereafter. The instruments used for assessment included the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale 10, which rates pain, function, joint stability, stiffness, and alignment; a visual analog scale on which patients subjectively rated pain on a scale of 1 to 10, with 1 representing no pain and 10 representing unbearable pain; and the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Data Collection Questionnaire (version 2.0, March 1996), which assesses pain, function, shoe wear, patient expectations, and patient satisfaction. Radiographs were consistently interpreted by one rater (J.C.C.). Matched-pair t tests were used to compare patient scores at different time-points, and Spearman correlation coefficients were used to examine relationships between preoperative factors (smoking, gender, age at the operation, hallux valgus angle, and intermetatarsal angle) and the scores according to the AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale and the visual analog scale at six and twelve months postoperatively. Surgical Procedure The patient is placed supine with a tourniquet around the thigh. A 6-cm incision is made over the dorsum of the foot in line with the extensor hallucis longus tendon. The interval between the extensor hallucis longus and the extensor hallucis brevis is used to expose the first and second tarsometatarsal joints. The entire first tarsometatarsal joint is exposed. The medial aspect of the second metatarsal is exposed and is denuded of soft tissue, and the cortex is also perforated to augment the subsequent fusion. The articular cartilage is removed from the opposing surfaces of the first tarsometatarsal joint with either small osteotomes or a saw. When the first metatarsal is short as a result of the previous procedures, only the cartilage should be removed to limit additional shortening. When the first metatarsal is long, a small laterally based wedge is removed from the medial cuneiform to help reduce the tarsometatarsal joint. A plantar-based wedge is also removed from the tarsometatarsal joint to ensure slight plantar flexion of the metatarsal. Next the adductor hallucis tendon is released through a 2-cm incision in the first web space. The lateral aspect of the first metatarsophalangeal joint capsule is incised longitudinally to allow the sesamoids to reduce. A medial incision is then made over the first metatarsophalangeal joint, the capsule is incised longitudinally, and any residual bunion prominence is removed. The first metatarsal is then reduced parallel to the second, closing the intermetatarsal gap. It is very important at this time to confirm that the first metatarsal is slightly plantar flexed and is rotated correctly. One 3.5-mm cortical screw is then inserted from the cuneiform into the first metatarsal under compression. A second screw is inserted from the medial aspect of the first metatarsal into the base of the second meta-

3 62 TABLE I Measurements of Angles and Range of Motion* Baseline At 6 Mo At 12 Mo (N = 25) At 24 Mo (N = 18) Intermetatarsal angle (deg) 18.0 ± ± ± ± 1.8 Hallux valgus angle (deg) 37.1 ± ± ± ± 3.1 Metatarsal length (mm) 0.54 ± ± ± ± 1.3 Metatarsophalangeal joint dorsiflexion (deg) 50.9 ± ± ± ± 12.0 Metatarsophalangeal joint plantar flexion (deg) 29.6 ± ± ± ± 10.6 *The values are given as the mean and standard deviation. tarsal to close the intermetatarsal gap securely. With the intermetatarsal gap reduced, the medial aspect of the capsule is plicated at the first metatarsophalangeal joint. It should not be necessary to overtighten the capsule in order to maintain the alignment of the hallux. Local bone graft is packed into any osseous defects at the bases of the metatarsals. The tourniquet is deflated, and the wounds are closed in layers. Postoperatively, the foot is immobilized in a slipper cast (fiberglass great-toe spica) for two weeks. At two weeks, the sutures are removed and a second slipper cast is applied; this cast is worn for an additional four to six weeks. The patient should remain non-weight-bearing for six weeks. If the six-week ra- Fig. 1-A Fig. 1-B Fig. 1-A: Anteroposterior radiograph made before the original procedure for the hallux valgus. Fig. 1-B: Radiograph, made eighteen months after the initial procedure for the hallux valgus, showing recurrence of the hallux valgus and excessive shortening of the first metatarsal.

4 63 TABLE II Outcome Data* Baseline At 6 Mo At 12 Mo (N = 25) At 24 Mo (N = 18) Visual analog scale 6.2 ± ± ± ± 1.3 AOFAS Hallux Metatarsophalangeal-Interphalangeal 47.6 ± ± ± ± 11.7 Scale (points) *The values are given as the mean and standard deviation. diographs demonstrate satisfactory progression of the fusion, the cast is removed and physical therapy is started. Patients are advised not to return to any vigorous physical activity for at least three months, although they may begin swimming and bicycling at eight weeks (Figs. 1-A through 1-D). Results wenty-six feet in twenty-four patients were followed pro- for an average of 1.8 years (range, six months Tspectively to three years). On preoperative examination, nine feet were found to have severe hypermobility of the first metatarsal, twelve had mild-to-moderate hypermobility, and five had a stable first metatarsal. The means and standard deviations for the outcome variables are displayed in Tables I and II, and data on each patient are shown in the Appendix. All scores and measurements at all of the postoperative time-points were significantly different from the baseline scores and measurements (matchedpair t tests, all p < 0.001). According to the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Data Questionnaire, the patients were very satisfied after twenty (77%) of the twentysix procedures, the patient was satisfied after one procedure (4%), the patients were somewhat satisfied after five procedures (19%), and no patient was dissatisfied. The patients returned to work in a mean of thirty-six days (median, fourteen Fig. 1-D Weight-bearing anteroposterior (Fig. 1-C) and lateral (Fig. 1-D) radiographs made thirty-six months after the Lapidus procedure and a Weil shortening osteotomy of the second metatarsal. Fig. 1-C

5 64 days; range, two to 224 days) after the surgery, and no patient had to change occupations. The patients were able to return to their previous level of activity at a mean of 14.1 weeks (range, nine to thirty-two weeks). The mean amount of metatarsal shortening (and standard deviation) was 2.7 ± 0.7 mm at six months postoperatively. The preoperative scores on the AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale and the visual analog pain scale were strongly correlated (as measured with Spearman correlation coefficients), across subjects, with the scores at six and twelve months (all p < 0.01). Gender, hallux valgus angle, intermetatarsal angle, and age at the operation were not significantly correlated with the score on the Hallux Metatarsophalangeal-Interphalangeal Scale or the visual analog pain scale at six or twelve months. It is important to note that the preoperative angles did not correlate with the outcome scores. As expected, poorer preoperative functional scores correlated with poorer final results. Five of the twentyfour patients were smokers, and smoking status was significantly correlated with poorer outcomes according to the Hallux Metatarsophalangeal-Interphalangeal Scale and the visual analog scale at six months (both p < 0.05) and with a poorer AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale score at twelve months (p < 0.05). Complications included three nonunions, all of which occurred in smokers and all of which required revision with bone-grafting. There were two superficial wound infections, which were treated successfully with oral antibiotics. No patient had transfer metatarsalgia, recurrent hallux valgus, or hallux varus at the time of this short to intermediate-term follow-up (mean, 1.8 years). It is always difficult and somewhat subjective to judge the time to fusion. Radiographs were made at six and twelve weeks. Usually, by twelve weeks, it is obvious whether there is a solid fusion or a delayed union or nonunion. Our subjective impression was that the average time to fusion was between eight and ten weeks. Discussion alvage after a failed hallux valgus procedure is a challeng- problem, and there have been few reports regarding Sing proper treatment after such failures 2,3, To our knowledge, no one has analyzed the outcomes of Lapidus procedures performed for salvage after failed hallux valgus surgery. Our short to intermediate-term study of twenty-six feet showed a significant improvement in pain scores and other outcome measures, and the patients reported satisfaction after 81% of the procedures. One should be aware of the downsides and complications of fusion of the first tarsometatarsal joint for treatment of hallux valgus. As with any procedure, there is a learning curve. The surgeon has to take care not to fix the first ray in a dorsiflexed position. He or she must make sure to remove the cartilage from the plantar aspect of the joint to avoid this problem. The time to healing after this fusion is longer than that after most other bunion procedures. It is therefore necessary for the patient to bear no or minimal weight on the treated foot for at least six weeks. Smoking seems to delay healing of the fusion site and should be considered a relative contraindication to the procedure. Perhaps the surgeon should consider the use of autogenous bone graft to supplement the fusion in patients who smoke. Patients who present for revision surgery for recurrent hallux valgus are searching for the final answer to relieve symptoms and prevent another recurrence. They are less concerned with the duration for which they must remain nonweight-bearing after the operation or with the time to recovery as long as the results are predictable. The Lapidus procedure could be the answer for such patients. The tarsometatarsal and first and second metatarsal fusions eliminate any rotation or translation of the first ray. When the space between the first and second intermetatarsals is reduced adequately, it is almost impossible for the hallux valgus or metatarsus primus varus deformity to recur. One of the potential downsides of using the Lapidus procedure as a revision is additional shortening of the metatarsal and transfer overload of the lesser metatarsals. Although transfer metatarsalgia has been previously reported in association with the Lapidus procedure 7,14,15, it was avoided in this series. The methods that we used to avoid this problem depended on the relative shortening of the first metatarsal compared with the second and third metatarsals. We do not think that <0.5 cm of shortening of the first ray is important. As a rule, when the first metatarsal was this short, only the articular cartilage was removed. If the shortening is between 0.5 and 1 cm, the surgeon must be sure that the first metatarsal is fixed in a slightly plantar flexed position. For shortening of >1 cm, we recommend adding Weil shortening osteotomies of the second and third metatarsals 16. If the first ray is >2 cm short, the preferred procedure is lengthening of the first ray with an interpositional bone block fusion. There were no cases of hallux varus. This is one of the advantages of the Lapidus procedure. The correction is done at the tarsometatarsal joint and does not rely on the distal bone and soft-tissue procedures that could lead to overcorrection. Without a clear method of measurement, it is virtually impossible to determine the prevalence of hypermobility of the first tarsometatarsal joint in the general population. In our study, there was a seemingly disproportionately high number of patients with such hypermobility. It is likely that patients with a hypermobile first ray are more likely to have a recurrence of a hallux valgus deformity unless the hypermobility of the metatarsocuneiform joint is addressed at the initial procedure. Unfortunately, we were unable to examine these patients prior to the initial procedure and therefore we cannot rule out the possibility of an aquired hypermobility of the metatarsocuneiform joint following the primary procedure. This study had shortcomings. We presumed that we were able to reduce the sesamoids with the Lapidus procedure, but we did not collect data regarding the position of the sesamoids preoperatively or postoperatively. In addition, although

6 65 we did not observe any recurrences after the fusions became solid, the study included only a small number of patients and the follow-up was relatively short. It would be ideal to perform a multicenter study with a longer follow-up to see if these results are reproducible. In summary, we believe that the Lapidus procedure is a reliable option for revision after failure of surgical treatment of hallux valgus. Appendix A table showing data for all twenty-six feet is available with the electronic versions of this article, on our web site at (go to the article citation and click on Supplementary Material ) and on our quarterly CD-ROM (call our subscription department, at , to order the CD-ROM). J. Chris Coetzee, MD, FRCSC Scott G. Resig, MD Khaled J. Saleh, MD, MSc, FRCSC Department of Orthopaedic Surgery, University of Minnesota School of Medicine, 420 Delaware Street S.E., Box 492, Minneapolis, MN E- mail address for J.C. Coetzee: coetz001@tc.umn.edu Michael Kuskowski, PhD Minneapolis Veterans Affairs Medical Center, 1 Veterans Drive, Minneapolis, MN The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated. References 1. Scranton PE Jr, McDermott JE. Prognostic factors in bunion surgery. Foot Ankle Int. 1995;16: Kitaoka HB, Patzer GL. Salvage treatment of failed hallux valgus operations with proximal first metatarsal osteotomy and distal soft-tissue reconstruction. Foot Ankle Int. 1998;19: Kitaoka HB, Patzer GL. Arthrodesis versus resection arthroplasty for failed hallux valgus operations. Clin Orthop. 1998;347: Grace D, Delmonte R, Catanzariti AR, Hofbauer M. Modified lapidus arthrodesis for adolescent hallux abducto valgus. J Foot Ankle Surg. 1999;38: Albrecht GH. The pathology and treatment of hallux valgus. Russk Vrach. 1911;10: Lapidus PW. Operative correction of the metatarsus varus primus in hallux valgus. Surg Gynecol Obstet. 1934;58: Catanzariti AR, Mendicino RW, Lee MS, Gallina MR. The modified Lapidus arthrodesis: a retrospective analysis. J Foot Ankle Surg. 1999;38: Sangeorzan BJ, Hansen ST Jr. Modified Lapidus procedure for hallux valgus. Foot Ankle. 1989;9: Myerson M. Metatarsocuneiform arthrodesis for treatment of hallux valgus and metatarsus primus varus. Orthopedics. 1990;13: Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994;15: Thompson FM. Complications of hallux valgus surgery and salvage. Orthopedics. 1990;13: Wu KK. First metatarsophalangeal fusion in the salvage of failed hallux abducto valgus operations. J Foot Ankle Surg. 1994;33: Coughlin MJ, Mann RA. Arthrodesis of the first metatarsophalangeal joint as salvage for the failed Keller procedure. J Bone Joint Surg Am. 1987; 69: Bednarz PA, Manoli A 2nd. Modified lapidus procedure for the treatment of hypermobile hallux valgus. Foot Ankle Int. 2000;21: Butson AR. A modification of the Lapidus operation for hallux valgus. J Bone Joint Surg Br. 1980;62: Barouk LS. [Weil s metatarsal osteotomy in the treatment of metatarsalgia]. Orthopade. 1996;25: German.