Surgical Techniques to Correct Hallux Valgus

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Hallux valgus surgery remains a challenging surgical issue, not only from a surgical technique perspective but also from a preoperative decision-making standpoint. The biomechanics of the foot are complex and selecting the right surgical intervention to achieve our surgical goals remains a challenge. The ideal procedure should alleviate the patients’ symptoms and reliably correct the first ray alignment while avoiding the pitfalls of transfer metatarsalgia and forefoot imbalance, deformity recurrence, non-union and persistent postoperative pain.

In this Viewpoints article, Dr. Rupke examines the principles behind the Lapidus procedure, which consists of correcting a moderate to severe hallux valgus deformity through a fusion of the 1st tarsometatarsal joint and a distal soft tissue procedure. As a counterpoint to this approach, Dr. Di Silvestro describes correcting similar deformities with an opening wedge proximal osteotomy of the first metatarsal. Both approaches have some merit…you be the judge.

Reprinted with permission from the Winter 2011 issue of COA Bulletin

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Viewpoint 1: Tracy Rupke, MD, FRCSC

The Modified Lapidus Procedure for the Treatment of Moderate to Severe Hallux Valgus

The classically described Lapidus procedure consists of a fusion of the first tarsometatarsal joint and the bases of the first and second metatarsals and a distal soft tissue procedure. The purpose of this fusion is to reduce the intermetatarsal angle as well as to increase weight-bearing through the first ray, thereby decreasing the load on the lesser metatarsals. The original procedure was later modified by others, including Sangeorzan and Hansen, to include a biplanar bone resection to remove a wedge of bone from the medial cuneiform laterally and plantarly and the addition of rigid internal fixation with three screws.

The modified Lapidus procedure is a technically challenging procedure in that the surgeon must minimize bony resection to avoid excess shortening of the metatarsal, reduce the intermetatarsal angle, plantarflex the first metatarsal and still maintain excellent compression of the joint surfaces, and apply rigid internal fixation.

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Early results showed high rates of nonunion, revision, and failure. However, there are multiple subsequent publications by a variety of authors that demonstrate significantly improved outcomes. Rates of nonunion range from 0% to 5.3%>4,5,6 Over the years, there have been attempts to utilize plating techniques to improve union rates. The recent onset of locked plating has been applied to the first tarsometatarsal joint and has been shown in vitro to have a higher load to failure than crossed screws. In vivo, locked plates have improved fusion rates when compared with crossed screws (98.5% vs. 89.4%, respectively). Some surgeons feel that it may be safe to allow earlier weight-bearing with locked plating in order to reduce the traditional period of postoperative non-weight-bearing immobilization.

The modified Lapidus can be a very powerful tool for obtaining and maintaining significant correction. The fusion allows for limitless correction of the intermetatarsal angle, which is maintained over time. A retrospective review of 57 feet showed that the modified Lapidus procedure demonstrated improved maintenance of correction compared to a metatarsal closing wedge osteotomy with less radiographic recurrence.10


Figure 1. Preoperative AP showing increased hallux valgus and 1/2 intermetatarsal angle


Figure 2. Postoperative AP showing reduction in both hallux valgus angle and 1/2 intermetatarsal angle


Figure 3. Postoperative lateral demonstrating crossed screw technique.

According to a review by Toolan, current indications for the modified Lapidus procedure include correction of moderate to severe hallux valgus with metatarsus primus varus. It is also indicated for correction of hallux valgus in adolescents with generalized ligamentous laxity and for the correction of hypermobility of the first ray with or without concomitant clinical signs of deficient weight-bearing function of the first ray. These coexistent signs could include transfer metatarsalgia, synovitis of the second MTP joint, mechanical overload of the second ray, and as a salvage for recurrent hallux valgus after prior operative treatment. Contraindications include active infection, Charcot neuroarthopathy, anticipated noncompliance, open physes, first metatarsal phalangeal arthrosis, and a short first metatarsal unless an ancillary procedure is used to restore first ray length.11

The essential unanswered question around the modified Lapidus procedure is the role of hypermobility of the first ray: Is it necessary to resort to fusion for most patients? This question, in my opinion, remains unanswered based on the current literature. There is evidence to support increased first ray mobility in patients with hallux valgus versus control subjects.12,13 However, not all patients with hallux valgus demonstrate increased mobility of the first ray.

The modified Lapidus procedure stabilizes the first tarsometatarsal joint and theoretically decreases the load on the lesser metatarsals. Clinical results of the modified Lapidus procedure vary, but most agree that it is a powerful procedure that is essential to include in the armamentarium of every foot and ankle surgeon.

Reprinted with permission from the Winter 2011 issue of COA Bulletin

References

  1. Lapidus, P.W.: Operative correction of the metatarsus varus primus in hallux valgus. Surg. Gynecol. Obstet. 58:183– 191, 1934.
  2. Sangeorzan, B.J.; Hansen, S.T. Jr: Modified Lapidus procedure for hallux valgus. Foot Ankle 9:262– 266, 1989.
  3. Sangeorzan, B.J.; Hansen, S.T. Jr: Modified Lapidus procedure for hallux valgus. Foot Ankle 9:262– 266, 1989.
  4. Patel S., Ford L.A., Etcheverry J., Rush S.M., Hamilton G.A: Modified Lapidus arthrodesis: rate of nonunion in 227 cases. J Foot Ankle Surg. 2004;43(1):37-42.
  5. Coetzee J.C., Wickum D. The Lapidus procedure: a prospective cohort outcome study. Foot Ankle Int. 2004;25(8):526-31.
  6. Kopp F.J., Patel M.M., Levine D.S., Deland J.T. The modified Lapidus procedure for hallux valgus: a clinical and radiographic analysis. Foot Ankle Int. 2005;26(11):913-7.
  7. Scranton P.E., Coetzee J.C., Carreira D. Arthrodesis of the first metatarsalcuneiform joint: a comparative study of fixation methods. Foot Ankle Int. 2009;30(4):341-5.
  8. DeVries J.G., Granata J.D., Hyer C.F. Fixation of first tarsometatarsal arthrodesis: a retrospective comparison of two techniques. Foot Ankle Int. 2011;32(2);158-62.
  9. Sorensen M.D., Hyer C.F., Berlet G.C. Results of lapidus arthrodesis and locked plating with early weight bearing. Foot Ankle Spec. 2009;2(5):227-33.
  10. Haas Z., Hamilton G., Sundstrom D., Ford L. Maintenance of correction of first metatarsal closing base wedge osteotomies versus modified Lapidus arthrodesis for moderate to severe hallux valgus deformity. J Foot Ankle Surg. 2007;46(5); 358-65.
  11. Toolan B.C. Surgical Strategies: The Lapidus procedure. Foot Ankle Int. 2007;28(10);1108-1114.
  12. Glasoe, W.M.; Allen, M.K.; Saltzman, C.L.: First ray dorsal mobility in relation to hallux valgus deformity and first intermetatarsal angle. Foot Ankle Int. 22:98 – 101.
  13. Klaue, K.; Hansen, S.T.; Masquelet, A.C.: Clinical, quantitative assessment of first tarsometatarsal mobility in the sagittal plane and its relation to hallux valgus deformity. Foot Ankle Int. 15:9 – 13.

Viewpoint 2: Matthew Di Silvestro, MD, MSc, FRCSC

Medial Opening Wedge Osteotomy with Distal Soft Tissue Realignment Procedure for the Treatment of Moderate to Severe Hallux Valgus

The exact definition of what constitutes moderate or severe hallux valgus (HV) is not clear. However, an intermetatarsal angle between the first and second metatarsal (1-2 IMA) greater than 15 degrees and an HV angle above 40 degrees is often considered to be too great to be managed with a distal osteotomy.1-5 There have been numerous proximal procedures done in conjunction with distal soft tissue balancing to address more severe deformities.6-14 The proximal first metatarsal medial opening wedge osteotomy (PMOW) with distal soft tissue realignment and possible distal biplanar chevron osteotomy provides technical, biomechanical, and patient advantages.

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Technical Advantages

The procedure can be performed under general or regional anesthetic. An ankle block with sedation and the tourniquet placed around the ankle is often sufficient anesthesia. This operation can be done in a minor procedure room without an anesthetist. Performing the procedure in this setting helps to mitigate its impact on limited hospital resources. A mini C-arm is also beneficial. Surgical time is approximately 40 minutes with experience.

The osteotomy is relatively easy to learn and perform under image intensification.8,10 Care must be taken to ensure that the lateral cortex is preserved. A slightly oblique osteotomy can be used in order to add stability to the lateral cortical hinge by placing it within the first tarsometatarsal joint capsule. This also makes a lag screw across the osteotomy site a possibility. The plantar proximal screw is best suited as a lag screw as it tends to be less prominent when inserted obliquely.

Elevation of the first ray is a concern with proximal procedures, thus the wedge may be placed slightly dorsally to facilitate plantar flexion of the first metatarsal. The contralateral wedge fixation plate often fits better in this situation.

Poor tracking of the first MTP joint often becomes evident after this powerful correction if the distal metatarsal articular angle (DMAA) is increased. A distal biplanar chevron may be done to correct this deformity. If residual HV interphalangeus or pronation persists, an Akin osteotomy may be added (Figures 1a-b).


Figure 1a. 24-year-old male with moderately severe hallux valgus


Figure 1b. Six weeks post PMOW, distal chevron biplanar, Aikin osteotomy

Stabilization of the osteotomy site is simplified with a low profile wedge plate designed for the procedure. The wedge comes in 0.5-mm increments, ranging from 1 to 7 mm. The correction can be checked with simulated weight-bearing under image intensification. Approximately 3 degrees of correction of the intermetatarsal angle can be expected per 1 mm of opening at the osteotomy site. The medial eminence is packed into the osteotomy site as bone graft.

Biomechanical Advantages

Lapidus suggested an association of HV with hypermobility of the first TMTJ. Hypermobility of the first ray is the most frequently listed indication for a Lapidus. Proximal osteotomy of the first metatarsal has been shown to reduce sagittal plane motion of the first ray by 50%.1,2 Coughlin hypothesized that increased sagittal mobility of the 1st ray occurs as a result of HV and is not a primary cause of the deformity. Realignment of the 1st ray with a joint-sparing proximal osteotomy restores the normal relationship of the intrinsic and extrinsic muscles, as well as the plantar aponeurosis that leads to a reduction in 1st ray motion.

A transfer lesion is a diffuse, clinically symptomatic callus that develops beneath the 2nd metatarsal head because of inadequate weight-bearing on the 1st metatarsal and great toe. Procedures that cause shortening or elevation of the first ray, such as the Lapidus procedure, may exacerbate this problem. In contrast, the PMOW has been shown to increase first metatarsal length by 2.3 mm. Positioning the wedge more dorsally can facilitate plantar flexion of the first ray and further offload the second metatarsal. Mann et al reported persistence of a transfer lesion in only five of 58 feet following a proximal crescentic osteotomy. The creation of a transfer lesion postoperatively is relatively rare.

Patient Advantages

Immediate heel weight-bearing in a postoperative sandal is permissible because of the stability of fixation. The average time to radiographic healing is 6 weeks(Figures 2a-b).10 Nonunion is relatively rare at approximately 1%.10 Other proximal procedures, such as the Lapidus procedure, require up to 6 weeks of non-weight-bearing and have a nonunion rate of up to 12% in some reports.15 A relatively early return to work at 6 weeks has been reported in 80% of patients undergoing a PMOW.10 This may be related to immediate weight-bearing and the short time to union. Patient satisfaction with the PMOW at 2.4 years has been reported to be good to excellent in 90% of patients.10


Figure 2a. Preoperative weight-bearing


Figure 2b. Osteotomy healed at 6 weeks postoperative

Disadvantages and Complications of PMOW

Some disadvantages and complications are associated with the PMOW as with all other hallux valgus surgery.

  • Symptomatic hardware despite the low-profile titanium plate and screws is the most common complication (10%) with PMOW.10 Placing the plate more dorsally and using the contra-lateral plate when necessary seems to make the hardware less problematic.
  • Nonunion and hallux varus at 1% and 2%, respectively, are relatively uncommon.10 Proper patient selection may improve the nonunion rate. A limited distal lateral release by avoiding an incision in the 1st web space may decrease the incidence of hallux varus.
  • The added cost of the procedure-specific wedge plate and screws may be a disadvantage. However, performing the surgery under an ankle block in a minor procedure room may offset this cost.

Conclusion

Proximal first metatarsal procedures are often necessary to correct moderate to severe hallux valgus deformities. Many of these procedures are technically difficult to perform and have many associated complications that occur at an unacceptable rate. The proximal first metatarsal opening wedge osteotomy with a distal soft tissue realignment procedure and often a distal biplanar osteotomy is a reproducible and powerful correction for moderate to severe hallux valgus that allows early weight-bearing and is relatively simple to learn and perform. However, the surgeon must be cognizant of the risk of the hallux varus because of the power of this osteotomy.

Reprinted with permission from the Winter 2011 issue of COA Bulletin

References

  1. Coughlin M., Jones C. Hallux Valgus and First Ray Mobility. A Prospective Study. J Bone Joint Surg Am. 2007; 89: 1887-98.
  2. Coughlin M. et al. Hallux Valgus and First Ray Mobility: A Cadaveric Study. Foot & Ankle Int. 2004; 25: 537 – 544.
  3. Coughlin M., Jones C. Hallux Valgus: Demographics, Etiology, and Radiography. Foot & Ankle Int 2007; 28: 759 – 777.
  4. Coughlin et al. Hallux Valgus and First Ray Mobility. Surgical Technique. J Bone Joint Surg Am. 2008; 90: 153 – 170.
  5. Easley, Trnka. Current Concepts Review: Hallux Valgus Part II: Operative Treatment. Foot & Ankle Int. 2007; 28: 748 – 758.
  6. Okuda et al. Postoperative Incomplete Reduction of the Sesamoids as a Risk for Recurrence of Hallux Valgus. J Bone Joint Surg. 2009; 91: 1637 – 45.
  7. Mann et al. Repair of Hallux Valgus with a Distal Soft-Tissue Procedure and Proximal Metatarsal Osteotomy. J Bone Joint Surg Am. 1992; 74: 124 – 129.
  8. Saragas et al. Proximal Opening – Wedge Osteotomy of the First Metatarsal for Hallux Valgus Using a Low Profile Plate. Foot & Ankle Int. 2009; 30: 976 – 980.
  9. Okuda et al. Proximal Metatarsal Osteotomy for Hallux Valgus: Comparison of Moderate and Severe Deformities. Foot & Ankle Int. 2008; 29: 664 – 670.
  10. Shurnas et al. Proximal First Metatarsal Opening Wedge Osteotomy with a Low Profile Plate. Foot & Ankle Int. 2009; 30: 865 – 872.
  11. Trnka et al. Intermediate – Term Results of the Ludloff Osteotomy in One Hundred and Eleven Feet. J Bone Joint Surg Am. 2008; 90: 531 – 9.
  12. Coetzee et al. The Lapidus Procedure as Salvage After Failed Surgical Treatment of Hallux Valgus. J Bone Joint Surg Am. 2003; 85: 61 – 65.
  13. Coetzee et al. The Lapidus Pocedure: A Prospective Cohort Outcome Study. Foot & Ankle Int. 2004; 25: 526 – 531.
  14. Bednarz et al. Modofied Lapidus Procedure for the Treatment of Hypermobile Hallux Valgus. Foot & Ankle Int. 2000; 21: 816 – 821.
  15. Thompson et al. Fusion Rate of Tarsometatarsal Arthrodesis in the Modified Lapidus Procedure and Flatfoot Reconstruction. Foot & Ankle Int. 2005; 26: 698 – 703.
  16. Ellington et al. The Use of the Lapidus Procedure for Recurrent Hallux Valgus. Foot & Ankle Int. 2011; 32: 674 – 680.
  17. Perera et al. The Pathogenesis of Hallux Valgus. Current Concepts Review. J Bone Joint Surg Am. 2011; 93: 1650 – 61.
  18. Lee et al. Correction of Hallux Valgus Using Lateral Soft – Tissue Release and Proximal Chevron Osteotomy Through a Medial Incision. J Bone Joint Surg Am. 2007; 89: 82 – 89.
  19. Shima et al. Radiographic Measurements in Patients with Hallux Valgus Before and After Proximal Crescentic Osteotomy. J Bone Joint Surg Am. 2009; 91: 1369 -76.

 

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