Long-term results of the Hohmann and Lapidus procedure for the correction of hallux valgus

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1 FOOT AND ANKLE Long-term results of the Hohmann and Lapidus procedure for the correction of hallux valgus F. W. M. Faber, P. M. van Kampen, M. W. Bloembergen From HAGA Hospital, Den Haag, the Netherlands A PROSPECTIVE, RANDOMISED TRIAL WITH EIGHT- TO 11-YEAR FOLLOW-UP INVOLVING 101 FEET As it remains unproven that hypermobility of the first tarsometatarsal joint (TMTJ-1) is a significant factor in hallux valgus deformity, the necessity for including arthrodesis of TMTJ- 1 as part of a surgical correction of a hallux valgus is questionable. In order to evaluate the role of this arthrodesis on the long-term outcome of hallux valgus surgery, a prospective, blinded, randomised study with long-term follow-up was performed, comparing the Lapidus procedure (which includes such an arthrodesis) with a simple Hohmann distal closing wedge metatarsal osteotomy. The study cohort comprised 101 feet in 87 patients: 50 feet were treated with a Hohmann procedure and 51 with a Lapidus procedure. Hypermobility of TMTJ-1 was assessed pre-operatively by clinical examination. After a mean of 9.25 years (7.25 to 11.42), 91 feet in 77 patients were available for follow-up. There was no difference in clinical or radiological outcome between the two procedures. Also, there was no difference in outcome between the two procedures in the subgroup clinically assessed as hypermobile. This study does not support the theory that a hallux valgus deformity in a patient with a clinically assessed hypermobile TMTJ-1 joint requires fusion of the first tarsometatarsal joint. Cite this article: Bone Joint J 2013;95-B: F. W. M. Faber, MD, PhD, Orthopaedic Surgeon P. M. van Kampen, PhD, Research Coordinator HAGA Hospital, Sportlaan 600, 2566 MJ Den Haag, the Netherlands. M. W. Bloembergen, MD, Orthopaedic Surgeon Maasstad Hospital, Maasstadweg 21, the Netherlands. Correspondence should be sent to Dr F. W. M. Faber; frankfaber@xs4all.nl 2013 The British Editorial Society of Bone & Joint Surgery doi: / x.95b $2.00 Bone Joint J 2013;95-B: Received 6 January 2013; Accepted after revision 10 May 2013 Although prospective studies on the treatment of hallux valgus have been reported, 1-4 prospective, randomised studies comparing the results of two different procedures are relatively uncommon and we have found none with a follow-up > eight years. 5 Long-term follow-up is very important as the goal of a hallux valgus operation is not only a painless, well aligned first metatarsophalangeal joint (MTPJ- 1), with normal function, but also a long-term stable correction. The role of hypermobility of the first tarsometatarsal joint (TMTJ-1) in hallux valgus is controversial. Several authors have argued that hypermobility of TMTJ-1 plays an important causative role in the occurrence and recurrence of this deformity Others consider TMTJ-1 hypermobility to be a consequence of the hallux valgus deformity 11 and do not include an arthrodesis of the TMTJ-1 in their operative procedure. 1,4 In 2004 we reported the results of a prospective, randomised trial of correction of hallux valgus deformity in 101 procedures and the role of first ray hypermobility in the deformity. 5 Two operative procedures were compared: a distal TMTJ-1 medially closing wedge osteotomy (Hohmann procedure 12 ; Fig. 1) and a TMTJ-1 arthrodesis with a distal soft-tissue procedure (Lapidus procedure 10 ; Fig. 2). We report our long-term results from this series. Theoretically a Lapidus procedure should result in a lower rate of recurrence in the long term; as the TMTJ-1 is fused, the first metatarsal is prevented from relapsing into varus, whereas with the Hohmann procedure this is not the case. The purposes of this study were: 1) to compare the long-term results of these two procedures; 2) to compare the results of this long-term follow-up with the results at two years; and 3) to investigate whether the Lapidus procedure leads to better long-term results in patients with clinically detectable hypermobility of the first ray. Patients and Methods The patients who were included in the previous study 5 were invited again to participate in this long-term follow-up study. The primary study group comprised 101 feet in 87 patients (84 of whom were women), which were operated on between October 1997 and July 2000 by a single surgeon (FWMF). Exclusion criteria were: age < 15 years or > 65 years, rheumatoid arthritis or other inflammatory diseases, or previous surgery on the affected foot. Patients 1222 THE BONE & JOINT JOURNAL

2 LONG-TERM RESULTS OF THE HOHMANN AND LAPIDUS PROCEDURE FOR THE CORRECTION OF HALLUX VALGUS 1223 Fig. 1 Line drawing of the Hohmann procedure. Fig. 2 Line drawing of the Lapidus procedure. were also excluded if they had osteoarthritis of TMTJ-1 and also those with moderate or severe osteoarthritis of the first MTPJ-1 (a total range of movement of < 50 and/or radiological signs of grade III or IV osteoarthritis) according to Mann et al. 13 As in 2004, we included assessment of hypermobility of the TMTJ-1, 14,15 as described by Klaue et al. 9 The hypermobility and radiological examinations were assessed by an author (FWMF). The long-term clinical follow-up examinations were performed by another observer (MWB). As before, pain was assessed using a visual analogue scale (VAS) ranging from 0 (no pain) to 10 (extreme pain). Function was assessed using the great toe metatarsophalangeal-interphalangeal scale of the American Orthopaedic Foot and Ankle Society (AOFAS). 16 Clinical measurements (assessed by an author (MWB) using a goniometer) of the hallux valgus angle and forefoot width were noted, along with deformities of the lesser toes. Patient satisfaction with the procedure was measured by asking whether the patient would choose to have the procedure again or not, or had no opinion either way. A separate question concerning the satisfaction about the position of the hallux was measured on a three-point scale: 1, fully satisfied; 2, satisfied; and 3, dissatisfied. Standardised weight-bearing dorso-plantar radiographs (tube angle 15 ) and lateral radiographs (tube distance 100 cm) were made. On the dorsoplantar radiograph, the first metatarsophalangeal and intermetatarsal angles were measured on a picture archiving and communication system (PACS). 17 Clinical recurrence was defined positive if one of the following factors was present: a satisfaction rate about the position of the toe was scored at 3 and/or AOFAS subscore for alignment was The alignment part of the AOFAS score has a maximum of 15 (good alignment) and a minimum of 0 (symptomatic malalignment). Statistical analysis. These analyses were performed using PASW Statistics v17.0 (IBM, New York, New York). We performed a two (Group: Lapidus, Hohmann) by three (period of measurement: baseline, two year follow-up, ten-year follow-up) repeated measures analysis of variance (ANOVA) in order to investigate the long-term results and the differences between the two groups. In case the sphericity assumption was violated, Greenhouse-Geisser corrections of the p-value are reported. Post-hoc comparisons were done using Bonferroni tests. In order to investigate the long-term results in patients with clinical hypermobility of the first ray, we used the same repeated measure ANOVA as above for only patients with clinical hypermobility. In addition to these tests, the change from baseline between groups was measured by an independent t-test and a Mann-Whitney U test was used for the pain score. A p-value < 0.05 was considered statistically significant. Results Between March 2008 and February 2010, 77 patients (91 feet) were available for follow-up: one patient (one foot) had died, three patients (three feet) had moved to a foreign country and six other patients (six feet) could not be traced. Of the remaining 91 feet, 45 were treated with a Hohmann procedure and 46 had a Lapidus procedure. Preoperatively, the groups were comparable with respect to age (p = 0.541), pain score (p = 0.387), AOFAS score (p = 0.500, all t-tests) and hypermobility of the TMTJ-1 measured clinically (p = 0.328, chi-squared). The mean follow-up period was 111 months (87 to 137). The mean age of the patients was 41 years (16 to 63) in the Hohmann group and 43 years (16 to 63) in the Lapidus group. The mean VAS for pain was 6 (0 to 9) and 6 (1 to 10) for the Hohmann and Lapidus groups, respectively, and the mean AOFAS score was 56.7 (29 to 85) and 58.0 (47 to 75), VOL. 95-B, No. 9, SEPTEMBER 2013

3 1224 F. W. M. FABER, P. M. VAN KAMPEN, M. W. BLOEMBERGEN Table I. Clinical and radiological results for the two procedures Procedure Mean variable (range) * Hohmann (n = 45) Lapidus (n = 46) p-value AOFAS score Pre-operative 56.7 (29 to 85) 58.0 (47 to 75) 2 years 88.0 (55 to 100) 87.8 (62 to 100) Difference vs baseline 31.3 (-5 to 51) 29.8 (3 to 48) years 82.0 (34 to 100) 79.4 (44 to 95) Difference vs baseline 25.3 (-23 to 48) 21.4 (-4 to 48) 0.19 VAS for pain Pre-operative 6 (0 to 9) 6 (1 to 10) 2 years 2 (0 to 8) 2 (0 to 8) Difference vs baseline -4 (-9 to 2) -4 (-10 to 3) years 2 (0 to 9) 1 (0 to 7) Difference vs baseline -4 (-9 to 4) -5 (-10 to 1) 0.77 First metatarsophalangeal angle ( ) Pre-operative 31.2 (14 to 52) 33.8 (18 to 50) 2 years 11.3 (-10 to 29) 13.9 (-11 to 34) Difference vs baseline (-42 to 2) (-42 to 4) years 10.8 (-10 to 29) 15.0 (-18 to 40) Difference vs baseline (-42 to 6) (-47 to 5) 0.46 Intermetatarsal angle ( ) Pre-operative 13.1 (9 to 22) 13.5 (7 to 18) 2 years 6.3 (2 to 16) 5.7 (3 to 12) Difference vs baseline -6.8 (-15 to 2) -7.8 (-17 to 2) years 6.9 (0 to 13) 6.9 (0 to 17) Difference vs baseline -6.2 (-13 to -1) -6.6 (-15 to 3) 0.60 * AOFAS, American Orthopaedic Foot and Ankle Society great toe metatarsophalangeal-interphalangeal scale; VAS, visual analogue scale independent t-test respectively. Pre-operative clinical hypermobility of the TMTJ-1 was found in 29 feet (64%) in the Hohmann group and 34 (76%) in the Lapidus group. The pre-operative measurements of the MTPJ-1 angles and intermetatarsal angles were also comparable (Table I). Additional procedures in the follow-up period between two and ten years consisted of further correction of hammer-toe deformities in two feet (both in the Hohmann group). No re-operations on the hallux were performed. Clinical outcomes. The mean AOFAS scores for the two groups at baseline, two years and eight-to-ten years are given in Table I. A repeated measures ANOVA showed that there were significant differences between the pre-operative score and the two follow-up measurements (p < 0.001). Post-hoc tests revealed that there was a significant increase between the pre- operative score and two years post-operatively (p < 0.001). There was also a significant decrease from the two- to ten-year follow-up scores (p < 0.001), although the ten-year scores were still significantly improved compared with baseline values (p < 0.001). No significant interaction effects (p = 0.38) or group effects were found (p = 0.75). The mean pain score on the VAS improved to 4 (9 to 4) in the Hohmann group and 5 (10 to 1) in the Lapidus group. No significant difference in pain reduction was found when comparing the two procedures (Mann Whitney U test, p = 0.77) or between the hypermobile and the non-hypermobile subgroups (Mann Whitney U test, p = 0.18). There was no statistically significant improvement in the pain score between the two- and ten-year follow-up in either group (Hohmann, p = 0.77; Lapidus, p = 0.75; Wilcoxon signed-ranks test). In the Hohmann group, 35 procedures (78%) were considered satisfactory, one patient (2%) was undecided and nine procedures (20%) were considered unsatisfactory. Dissatisfaction was attributed to re-operation for nonunion (n = 1), dissatisfaction with the appearance of the hallux (n = 1), pain and stiffness of the MTPJ-1 (n = 1), secondary overriding of the second toe (n = 1), severe immediate postoperative pain despite a good end result (n = 2) and no expressed reason (n = 3). In the Lapidus group 38 procedures (83%) were considered satisfactory by the patients and in two (4%) the patients were uncertain; and six (13%) were considered to be unsatisfactory. Dissatisfaction was attributed to restricted mobility after developing chronic regional pain syndrome (n = 1), re-operation for under correction (n = 1), transfer metatarsalgia (n = 2), dissatisfied with the (painless) scar (n = 1) and one patient gave no THE BONE & JOINT JOURNAL

4 LONG-TERM RESULTS OF THE HOHMANN AND LAPIDUS PROCEDURE FOR THE CORRECTION OF HALLUX VALGUS 1225 Table II. Results of the hypermobile subgroup Procedure Mean variable (range) Hohmann (n = 29) Lapidus (n = 34) AOFAS score * Baseline 57.3 (44 to 75) 57.1 (47 to 70) 2 years 90.8 (72 to 100) 88.2 (62 to 100) 10 years 85.2 (44 to 100) 78.0 (44 to 95) First metatarsophalangeal angle ( ) Baseline 32.2 (14 to 52) 34.8 (18 to 50) 2 years 10.7 (0 to 29) 13.3 (-11 to 34) 10 years 11.0 (-3 to 29) 14.4 (-18 to 40) Intermetatarsal angle ( ) Baseline 13.6 (10 to 22) 13.9 (8 to 18) 2 years 6.1 (2 to 10) 5.5 (-3 to 12) 10 years 7.2 (2 to 13) 6.9 (0 to 17) * AOFAS, American Orthopaedic Foot and Ankle Society great toe metatarsophalangeal-interphalangeal scale reason, yet had an AOFAS score of 95 points. There were no significant differences between the groups regarding satisfaction (p = 0.55, Pearson chi-squared test). The radiological results are provided in Table I. The first metatarsophalangeal angle showed a main effect on period of measurement (p < 0.001). Post-hoc tests revealed a significant effect between baseline and the two follow-up periods (p < 0.001) but not between the two- and ten-year follow-up. The intermetatarsal angle showed a main effect on period of measurement (p < 0.001). Post-hoc tests revealed a significant difference between baseline and the two follow-up periods (p < 0.001) and between the two and ten-year follow-up (p = 0.005) No significant group effect was found between the Hohmann and the Lapidus procedure regarding the intermetatarsal angle (p = 0.85). Hypermobility of the TMTJ-1. Results of the subgroup with hypermobility are shown in Table II. Pre-operatively a total of 63 feet were categorised as having hypermobility of the TMTJ-1, 29 of whom underwent the Hohmann procedure and 34 the Lapidus procedure. Repeated-measures ANOVA showed a significant main effect of period of measurement (p < 0.001). Post-hoc tests revealed that the overall mean pre-operative AOFAS score (57.2 (44 to 75)) was significantly lower than at the two-year follow-up (89.4 (62 to 100); p < 0.001) and the ten years follow-up (81.4 (44 to 100); p < 0.001). There was a significant decrease in AOFAS score between the two- and ten-year follow-up (p < 0.001). No main effect of group was found (p = 0.06). A repeated measures ANOVA on the first metatarsophalangeal angle revealed a significant main effect of period of measurement (p < 0.001). Post-hoc tests revealed that the first metatarsophalangeal angle was significantly larger before surgery compared with the two- and ten-year follow-up (p < 0.001). The angle did not change in either group between the two- and ten-year follow-up (p = 0.828). No main effect of group (p = 0.20) nor interaction was found (p = 0.92). The intermetatarsal angle revealed a main effect of period of measurement (p < 0.001). Post-hoc tests indicated that the angle was significantly smaller at two- (p < 0.001) and ten-year follow-up (p < 0.001) compared with the baseline. Nevertheless, there was a small decline between the two- and ten-year follow-up (p < 0.001). Complications and recurrence. As short term complications were described in our former publication, 5 we paid particular attention to the long-term complications of recurrence, transfer metatarsalgia and arthritis of the MTPJ-1. The rate of clinical recurrence at the ten years follow-up was 8.8% (four in the Hohmann group (8.9%) and four in the Lapidus group (8.7%)). No operations were performed for a clinical recurrence of the hallux valgus. Of the eight patients with recurrence, four were still sufficiently satisfied that they would choose the procedure again in the same circumstances. Transfer metatarsalgia occurred in eight patients (three Hohmann, five Lapidus) and this was treated with an insole in all cases. Discussion In our patient group the results after a ten-year follow-up showed a significant improvement in the AOFAS and pain scores and radiological parameters with the pre-operative score. These results are comparable to other long-term studies. 2,14,18,19 In the present study, the long-term overall rate of satisfaction for the Hohmann procedure was 78% and that for the Lapidus procedure was 83%; these results are similar to the previously reported two year results (76% and 84%, respectively). 5 A comparison between the tenand two-year follow-up shows a slight decrease in the clinical scores. This is in contrast to two other studies. Schneider et al 2 reported a stable clinical and radiological result between a 5.6-year and 12.7-year follow-up of a distal chevron osteotomy, and Veri et al 18 found a stable clinical and radiological result between the one- and 12.2-year follow-up with a crescenteric proximal metatarsal osteotomy. We also found stable correction of the hallux valgus angle but slight decrease in intermetatarsal angle and AOFAS score. We have no explanation for this difference, although the pre-operative score in the study by Schneider et al 2 was only retrospectively converted to an AOFAS score, which might explain some of the differences. Reports with only a short-term follow-up should be read with some caution, as we have shown here that the rate of success slightly deteriorates over time. However, the difference between the pre-operative clinical and radiological scores and the ten-year post-operative scores remain significantly improved for all parameters in both procedures. There are varying opinions regarding the relationship between TMTJ-1 hypermobility and a hallux valgus deformity. Morton, 6 Lapidus 7 and Hansen 8 considered hypermobility to be the cause, while others proposed that it is an effect of the hallux valgus deformity, which can be VOL. 95-B, No. 9, SEPTEMBER 2013

5 1226 F. W. M. FABER, P. M. VAN KAMPEN, M. W. BLOEMBERGEN corrected by treating the hallux valgus operatively without fusing the TMTJ-1. 1,4 Easley and Trnka 20 stated insufficient evidence (Level III to V) exists to support or disprove the contribution of first TMTJ hypermobility to the development of hallux valgus. If hypermobility of TMTJ-1 is the cause of the hallux valgus, one should expect better longterm results in the subgroup of patients with clinically hypermobile TMTJ-1 in the Lapidus group than in the Hohmann group. Table II shows that this not the case either radiologically or clinically. This tends to support the theory that hypermobility of the TMTJ-1 is secondary to the hallux valgus deformity. 1 However one should be cautious in this interpretation given that the clinical test of hypermobility 9,14,21 and its accuracy and reproducibility is open to conjecture. Several methodologies have been developed to quantify this hypermobility. 9,22,23 Most studies on operative procedures for valgus operations focus on the rate of success and satisfaction of the patients. Another important outcome is the rate of recurrence, which is not always reported in hallux valgus studies, 19,24,25 or the rate of recurrence is given in the absence of an exact definition. 12,13,26-29 We defined a recurrence when the patient was dissatisfied with the position of the hallux and/or the AOFAS alignment score was 0. This definition is more satisfactory than the rate of re-operation because it represents the opinion of the patient, as not every clinical recurrence leads to a re-operation. In our early study the rate of recurrence was 8.8% (four patients in each group), leading to a re-operation in one patient in the Lapidus group and two in the Hohmann group: there have been no subsequent operations at this longer term follow-up. Therefore the long-term results of the Hohmann and the Lapidus procedure are comparable with other operative procedures as far as the rate of recurrence is concerned. Reported rates of recurrence of the Lapidus procedure vary between 2.5% and 16.1% 14,26-28,30 whereas in the Hohmann procedure recurrence is reported to be 9.7% 12 and 16% 31 in two series. The strength of our study is its prospective, randomised design in a large group of patients with a long follow-up period of ten years with a low drop-out rate of 10%. The operations and after care were performed by a single surgeon. All patients were examined by an independent investigator (MWB). The possible weakness of the study is the fact that the degree of TMTJ-1 hypermobility was determined only by clinical assessment, although this is common practice. In conclusion the Hohmann and Lapidus operations are good options for correction of a hallux valgus deformity, with similar reliable long-term results and comparable with other types of surgery for the same condition. The presence or absence of a hypermobile TMTJ-1 makes no difference to the outcomes. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This article was primary edited by D. Rowley and first-proof edited by G. Scott. References 1. Coughlin MJ, Jones CP. Hallux valgus and first ray mobility: a prospective study. J Bone Joint Surg [Am] 2007;89-A: Schneider W, Aigner N, Pinggera O, Knahr K. Chevron osteotomy in hallux valgus: ten-year results of 112 cases. J Bone Joint Surg [Br] 2004;86-B: Coetzee JC, Resig SG, Kuskowski M, Saleh KJ. The Lapidus procedure as salvage after failed surgical treatment of hallux valgus: a prospective cohort study. 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J Bone Joint Surg [Am] 2003;85-A: Popelka S, Vavrík P, Hromádka R, Sosna A. Our results of the Lapidus procedure in patients with hallux valgus deformity. Acta Chir Orthop Traumatol Cech 2008;75: (in Czech). 31. Copin G. Lóperation de Hohmann: ostéotomie sous capitale du 1er métatarsien: analyse d une série homogène. Orthop Traumatol 1991;1:40 46 (in French). THE BONE & JOINT JOURNAL