Maintenance of Correction of First Metatarsal Closing Base Wedge Osteotomies Versus Modified Lapidus Arthrodesis for Moderate to Severe Hallux Valgus Deformity

Maintenance of Correction of First Metatarsal Closing Base Wedge Osteotomies Versus Modified Lapidus Arthrodesis for Moderate to Severe Hallux Valgus Deformity Zachary Haas, DPM,1 Graham Hamilton, DPM,2 Daisy Sundstrom, DPM,3 and Lawrence Ford, DPM4 A retrospective radiographic review of 57 feet was conducted to compare maintenance of correction of the modified Lapidus arthrodesis with the first metatarsal closing base wedge osteotomy for moderate to severe hallux valgus deformity. Radiographic parameters were measured on the preoperative, early postoperative, and greater than 11-month postoperative weightbearing radiographs. These measurements included the intermetatarsal angle, the hallux abductus angle, and the tibial sesamoid position. The patients who underwent the closing base wedge osteotomy had an average initial intermetatarsal correction of 10.4°; for the modified Lapidus arthrodesis, it was 7.6°. The patients who underwent the closing base wedge osteotomy had an average loss of intermetatarsal correction of 2.55° from early to late postoperative radiographs; for the modified Lapidus arthrodesis, it was 1.08°. Our results demonstrated that the modified Lapidus arthrodesis maintains correction to a greater degree than the first metatarsal closing base wedge osteotomy with statistical significance (P ⫽ .0039). Both the modified Lapidus arthrodesis and the first metatarsal closing base wedge osteotomy are effective procedures with respect to degree of radiographic correction for moderate to severe hallux valgus deformities. ( The Journal of Foot & Ankle Surgery 46(5):358 –365, 2007) Key words: hallux valgus, lapidus arthrodesis, closing base wedge osteotomy, correction, radiographic analysis

S urgical treatment of hallux valgus deformity consists of selecting the most appropriate procedure to achieve a good to excellent long-term result. Many factors are considered in the selection of the appropriate procedure for the patient. Patients’ demographics and convalescence along with subjective, objective, and radiographic parameters must be Address correspondence to: Graham Hamilton, DPM, Kaiser Permanente, 280 W MacArthur Blvd, Oakland, CA 94611. E-mail: graham.a. [email protected]. 1 Post Graduate Year 3, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Permanente Medical Center, San Francisco, Oakland, Walnut Creek, CA. 2 Staff Podiatric Surgeon, Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Permanente Medical Center, Oakland, San Francisco, Walnut Creek, CA. 3 Staff Podiatric Surgeon, Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Permanente Medical Center, Oakland, San Francisco, Walnut Creek, CA. 4 Staff Podiatric Surgeon, Attending Staff, Residency Director, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Permanente Medical Center, Oakland, San Francisco, Walnut Creek, CA. Copyright © 2007 by the American College of Foot and Ankle Surgeons 1067-2516/07/4605-0006$32.00/0 doi:10.1053/j.jfas.2007.05.008

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equally weighed (1–7). For the treatment of moderate to severe hallux valgus deformity, several proximal bunionectomies have been proposed with accompanying debate regarding optimal necessity and efficacy (8). Two of these common procedures are the modified Lapidus arthrodesis (LA) and the first metatarsal closing base wedge osteotomy (CBWO). Loison in 1901 originally described the CBWO (9), with Balacescu later performing the operation in 1903 (10). Albrecht has been credited with initially describing the first tarsometatarsal joint arthrodesis in 1911 (11), with popularization by Paul Lapidus in 1934 (12). Once appropriate procedure selection has been made, outcome needs to be evaluated. Successful outcomes are determined by subjective and/or objective methods. Radiographic objective parameters include the angular correction after osteotomy or arthrodesis and the maintenance of angular correction. The measurements impart information regarding the ability to correct the initial deformity along with the ability to maintain this correction. There is a plethora of literature discussing short-term results of angular correction and patient satisfaction with various bunionectomies (1-3, 6, 7, 13-31). However, there is limited literature that evaluates

the maintenance of correction by looking at intermediate follow-up where changes in results may occur. To our knowledge no reports directly compare the modified LA to the first metatarsal CBWO. The purpose of this study is to evaluate objective radiographic parameters and compare the maintenance of correction of the modified LA versus the first metatarsal CBWO for moderate to severe hallux valgus deformity.

Materials and Methods This was a retrospective cohort study, reviewing electronic databases and digital radiographs for 105 consecutive patients (119 feet) that underwent a modified LA from 1999 to 2005 by 2 surgeons (GH and LF), and 48 consecutive patients (51 feet) that underwent a first metatarsal CBWO from 1999 to 2005 by another surgeon (DS). The surgical technique, method of fixation, and postoperative management were applied similarly for each patient undergoing a modified LA by 2 different surgeons (GH and LF). Inclusion criteria included preoperative weight bearing radiographs, less than 6 month postoperative weight bearing radiographs, and greater than 11 month postoperative weight bearing radiographs. Patients were excluded who had simultaneous 2nd metatarsal, midfoot, rearfoot and / or ankle osseous procedures in order to eliminate variables that may have contributed to the radiographic evaluation and maintenance of correction. Additional hammertoe surgery on the ipsilateral foot was judged non-contributory to the radiographic evaluation and was not excluded. Based on our criteria, a total of 32 patients (37 feet) were evaluated that underwent a modified LA and a total of 19 patients (20 feet) were evaluated that underwent a first metatarsal CBWO. Secondary procedures in the first metatarsal CBWO group consisted of 9 hammertoe procedures. For the modified LA group 13 patients had an additional hammertoe repair. The radiographic angles were measured by the principal investigator (Z. H.) according to the guidelines accepted by the American Orthopaedic Foot and Ankle Society (32). The IMA was measured according to the Hardy and Clapham method (33), which bisects the shafts of the first and second metatarsals, and was shown to be the most accurate method for measuring the IMA (34). The HAA was measured by bisecting the shafts of the first metatarsal and the proximal phalanx of the hallux (32). The TSP was assessed relative to the first metatarsal head and measured based on the classification scheme presented by Haas (35), with a position of 4 representing the tibial sesamoid being midline with respect to the first metatarsal head. Measurements were conducted on digitized radiographs of the standardized anteroposterior view (Figure 1, A–C; Figure 2, A–C).

Surgical Technique Modified Lapidus Arthrodesis. The following description is adapted from Patel (5) with his permission. The operative technique, principles of joint preparation, method of fixation, and postoperative management were applied similarly for each patient by each of the operating coprincipal authors. A longitudinal incision is placed from the first cuneiform to the base of the proximal phalanx of the hallux. Proximally, the incision curves laterally to avoid the dorsomedial cutaneous nerve and to gain more central exposure over the first tarsometatarsal joint. The remainder of the incision lies medial to the extensor hallucis longus tendon. The first metatarsophalangeal joint is addressed first. The hypertrophic medial eminence, if present, is resected, and the conjoined adductor tendon and fibular sesamoid ligament in the first interspace are sectioned. The dorsomedial cutaneous nerve is identified and medially retracted. The first tarsometatarsal joint is exposed through a transverse capsulotomy and the use of a laminar spreader. The cartilage is denuded with an osteotome and a curette, leaving the subchondral plate intact. The subchondral bone is fenestrated and scalloped to promote bleeding. Preserving the peripheral rim of subchondral bone is important to maintain length and to provide added stability for internal fixation (36). The first metatarsal is then corrected to a near-anatomic position. In a foot with a medially angulated or atavistic cuneiform, the lateral aspect of the joint is planed or feathered to accommodate appropriate correction of the deformity. This can be performed with a sagittal saw, osteotome, curette, or burr. The joint is fixed with two 3.5-mm cortical screws placed across the fusion site in lag fashion. The first screw is placed axially from the dorsal surface of the first metatarsal base to the plantar surface of the medial cuneiform. The second screw is placed from the dorsal aspect of the medial cuneiform to the plantar lateral aspect of the first metatarsal. If the first ray continues to display either sagittal or transverse plane instability, a third lag screw is placed from the medial base of the first metatarsal to the second cuneiform or from the first cuneiform to the second cuneiform to provide further stability.

Postoperative Management Patients having the modified LA were placed into a modified Jones compression splint for 10 to 14 days, at which time sutures were removed. A short-leg, nonweightbearing cast was applied for an additional 4 weeks. The patients were routinely advanced to a removable walking boot and full weightbearing for 2 to 4 weeks. At 8 to 10 weeks postoperatively, the patients were advanced to regular supportive shoes with gradual return to regular activities as tolerated.

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FIGURE 1 (A) Modified LA preoperative anteroposterior radiograph with an IMA of 16, HAA of 35, and TSP of 7. (B) Modified LA 12-week postoperative radiograph with an IMA of 11, HAA of 8, and TSP of 3. (C) Modified LA 20-month postoperative radiograph with an IMA of 11, HAA of 13, and TSP of 3.

First Metatarsal Closing Base Wedge Osteotomy. The CBWO is performed with similar anatomic dissection and similar attention to the first metatarsophalangeal joint and first interspace as the above-mentioned modified LA. Next, the first tarsometatarsal joint is identified, and a Kirschner wire is used as an axis guide (for proper planar positioning and for the apex of the wedge) on the medial cortex of the first metatarsal base approximately 5 mm distal to the joint. The obliquity of the axis guide determines the amount of sagittal plane correction one achieves. Next, a ruler is used to measure 2 cm from the axis guide to the lateral cortex of the first metatarsal distally before performing the distal osteotomy of the wedge. Using preoperative templates, the size of the lateral based wedge is determined and the proximal osteotomy is subsequently performed, leaving an intact medial hinge. After removal of the laterally based wedge and the axis guide, the osteotomy site is reduced with a bone clamp and fixated with one 3.5-mm or two 2.7-mm cortical screws inserted in lag fashion from distal medial to proximal lateral. 360

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Postoperative Management Patients who had the closing base wedge osteotomy were placed into a modified Jones compression splint for 10 to 14 days, at which time sutures were removed. A short-leg, nonweightbearing cast was applied for an additional 6 weeks. The patients were routinely advanced to a removable walking boot and full weightbearing for 2 to 4 weeks. At 10 to 12 weeks postoperatively, the patients were advanced to regular supportive shoes with gradual return to regular activities as tolerated.

Statistical Methods Six of the subjects studied (5 in the LA group and 1 in the CBWO group) had surgical procedures done on both feet, but at different times. For purposes of these analyses, we believe it is reasonable to treat these as independent observations. Three measurements were made on each patient:

FIGURE 2 (A) First metatarsal CBWO preoperative anteroposterior radiograph with an IMA of 15, HAA of 18, and TSP of 5. (B) First metatarsal CBWO 12-week postoperative radiograph with an IMA of 6, HAA of 9, and TSP of 3. (C) First metatarsal CBWO 42-month postoperative radiograph with an IMA of 6, HAA of 9, and TSP of 3.

preoperative, early postoperative, ⬎11 month postoperative. To determine if the surgical procedure was successful, the early postoperative measurement was compared to the preoperative measurement. To determine if the surgical correction was maintained over time, the early postoperative measurement was compared to the ⬎11 month postoperative measurement. Finally, to determine the overall correction, the ⬎11 month postoperative measurement was compared to the preoperative measurement. Each of these comparisons was made separately within each study group using a paired t-test. A paired t-test was used as we compared the means of two samples, matching an observation of one sample versus the same observation of the other sample. The Bonferroni correction was used to the Type I error rate, reducing it from 0.05 to 0.0167. The Bonferroni correction was used as a way to control the multiple comparisons made simultaneously on the same data sets. As we compared the preoperative and two postoperative values, our likelihood of obtaining a type I error was greater than 5%. To control for this, the type I error rate was divided by the number of tests performed, in our case 3, to use a new type I error rate of 1.67% or 0.0167. Finally, each of the three change scores listed above was compared between the groups using a

two-sample t-test. Again, the Bonferroni corrected Type I error rate was used.

Results The mean patient age was 48.9 years (range 14-64 years) for the modified LA group and 50.3 years (range 27-69 years) for the first metatarsal CBWO group. The mean radiographic follow-up for the modified LA group was 8.4 weeks (range 5.6-23.4 weeks) for the early postoperative radiographs, and 36.2 months (range 12.7-77.5 months) for the late postoperative radiographs. The mean radiographic follow-up for the CBWO group was 11.7 weeks (range 5.9-25 weeks) for the early postoperative radiographs, and 39.1 months (range 11.3-78.1 months) for the late postoperative radiographs. For all three measures (IMA-see Table 1 and Figure 3, HAA-see Table 2 and Figure 4, and TSP-see Table 3 and Figure 5), and in both treatment groups, there was a statistically significant (p⬍0.0001) decrease between the preoperative and early postoperative values. In addition for all three measures in both groups, there was still a statistically

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TABLE 1

Radiographic results of the intermetatarsal angle in degrees

Group

Baseline mean (SD)

Preoperative/postoperative difference, mean (SD); P value

Preoperative ⬎1 y difference, mean (SD); P value

Postoperative ⬎1 y difference, mean (SD); P value

CBWO (N ⫽ 20) LA (N ⫽ 37) Between groups

14.8 (1.64) 14.1 (2.51) 0.7 (2.25)

–10.40 (2.23); P ⬍ .0001 –7.60 (2.76); P ⬍ .0001 –2.81 (2.59); P ⫽ .0003

–7.85 (3.51); P ⬍ .0001 –6.51 (3.39); P ⬍ .0001 –1.34 (3.43); P ⫽ .17

2.55 (2.11); P ⬍ .0001 1.08 (1.53); P ⫽ .0001 1.47 (1.76); P ⫽ .0039

Abbreviations: CBWO, closing base wedge osteotomy; LA, Lapidus arthrodesis; SD, standard deviation. 16 14 12

Preoperative IMA

10 8

Early Postoperative IMA

6

Late Postoperative IMA

4 2 0

CBWO

IMA

FIGURE 3 Radiographic results of the intermetatarsal angle (IMA) in degrees.

significant (p⬍0.0001) difference from preoperative values and the ⬎11 month follow-up. There was a statistically significant increase in almost all measurements in both groups between the early postoperative measurement and the ⬎11 month follow-up measurement (p⬍0.0007), the exception being the change in HAA in the CBWO group (p⫽0.046). For the IMA measurement, the preoperative to early postoperative change was significantly larger in the CBWO group than in the LA group (p⫽0.0003), the loss of correction was significantly less in the LA group (p⫽0.0039) (Figure 6), and the overall differences (preoperative to ⬎1 year follow-up) were not significantly different between the two treatment groups (p⫽0.17). For HAA, the preoperative to early postoperative change was significantly greater in the CBWO group (p⫽0.0026). The between-group difference in loss of correction was not statistically significant (p⫽0.94) (Figure 6), but the difference in changes over the entire study period remained significantly higher in the CBWO group (p⫽0.010). For TSP, there were no statistically significant changes between the groups during any of the three study periods: p⫽0.99 for the preoperative to early postoperative difference, p⫽0.62 for the loss of correction (Figure 6), and p⫽0.72 for the entire study period. Discussion Both the modified LA and the first metatarsal CBWO have shown to be effective procedures for the treatment of 362

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moderate to severe hallux valgus deformities (1, 2, 15, 17, 18, 20). The preoperative average IMA, HAA, and TSP for both the modified LA and the CBWO were comparable (P ⫽ .25, P ⫽ .13, and P ⫽ .26, respectively). The early postoperative average correction of the IMA and HAA was greater for the CBWO (10.4 and 23.2°, respectively) than for the modified LA (7.6 and 15.7°, respectively). The loss of IMA correction for the modified LA was less than the loss of correction for the first metatarsal CBWO (1.08 vs 2.55°, P ⫽ .004). These results suggest that a first tarsometatarsal joint arthrodesis and a near-anatomic first-ray position may have an additive effect on the inherent stability of the first ray. Sangeorzan and Hansen (18) retrospectively reviewed 32 patients in whom 40 modified LAs were performed. The average correction of the IMA and HAA were 8° and 15°, respectively. They stated that internal fixation of the first tarsometatarsal joint maintained the position of the first metatarsal, thus intraoperative positioning must be exact. Myerson et al (20) similarly reviewed 67 modified LAs and stated that hypermobility was present in only 29 of these cases. The average correction of the IMA and HAA were 8.5° and 21.5°, respectively. They also noted improvements in the TSP. Our results for the modified LA compare favorably with the above-mentioned studies, because the average initial postoperative IMA and HAA corrections were 7.6° and 15.7°, respectively. There have been several advocates for performing a modified LA for the correction of hallux valgus. Several indications have been described, including transverse or sagittal plane hypermobility, a medially orientated cuneiform metatarsal angle, and an IMA that is unable to reduce manually (1, 2, 18, 20, 37, 38). Although sagittal plane hypermobility is usually the most frequently listed indication for an LA (17, 18, 20, 37), most studies do not quantify mobility. Glasoe et al (39) demonstrated a poor correlation between manual estimates and mechanical testing of first ray mobility. Resch et al (19) retrospectively reviewed 27 patients in whom 29 first metatarsal CBWOs were performed. The average correction of the IMA and HAA were 3° and 13°, respectively. They stated improvements in 15 of 27 cases with regards to the sesamoid position. Trnka et al (7) evaluated greater than 10-year outcomes after a first metatarsal CBWO of 42 patients (60 feet). The average correc-

TABLE 2

Radiographic results of the hallux abductus angle in degrees

Group

Baseline mean (SD)

Preoperative/postoperative difference, mean (SD); P value

Preoperative/⬎1 y difference, mean (SD); P value

Postoperative/⬎1 y difference, mean (SD); P value

CBWO (N ⫽ 20) LA (N ⫽ 37) Between groups

30.45 (6.89) 27.24 (7.81) 3.21 (7.50)

–23.15 (7.65); P ⬍ .0001 –15.68 (8.95); P ⬍ .0001 –7.47 (8.53); P ⫽ .0026

–19.90 (10.17); P ⬍ .0001 –12.54 (9.90); P ⬍ .0001 –7.36 (9.99); P ⫽ .010

3.25 (6.82); P ⫽ .046 3.14 (5.17); P ⫽ .0007 0.11 (5.79); P ⫽ .94

Abbreviations: CBWO, closing base wedge osteotomy; LA, Lapidus arthrodesis; SD, standard deviation.

35 30

Preoperative HAA

25 20

Early Postoperative HAA Late Postoperative HAA

15 10 5 0

CBWO

IMA

FIGURE 4 Radiographic results of the hallux abductus angle (HAA) in degrees.

tion of the IMA and HAA was 9.4° and 19°, respectively. The average preoperative and postoperative TSP, on a scale of 0 to III, was 2.6 and 0.9, respectively. Our results for the CBWO compare favorably with the above-mentioned studies, because the average late (mean, 39.1 months) postoperative IMA and HAA corrections were 7.85° and 19.90°, respectively. Our average correction of the TSP was 2.20. Thordarson et al (31) evaluated 196 patients 2 years postoperatively who underwent 1 of 3 different types of hallux valgus corrective surgeries by using validated questionnaires along with radiographic evaluation and physical examination. They noted a correction in the HAA of 17.6° for patients undergoing a proximal metatarsal osteotomy with distal soft tissue realignment, and 16.3° for patients undergoing a modified LA. The degree of preoperative HAA and IMA did not affect any of the 15 outcome scores or the American Orthopaedic Foot and Ankle Society score. Postoperative residual HAA and the IMA, along with the overall change in hallux valgus and the IMA, did not show a consistent effect on the outcome scores. Contrary to this study, McInnes and Bouche (2) found a strong correlation between postoperative IMA and subjective scores, because patients had the highest subjective scores with postoperative intermetatarsal angles measured 6° and below. Rink-Brune (3) used a similar TSP score in analyzing longterm outcomes of modified LA. Her average amount of TSP correction was 4.0, with a mean postoperative TSP of 2.5. Our results compare favorably with those of this study, because our

average TSP correction was 2.35, with a mean early postoperative TSP correction of 3.05. Rink-Brune (3) demonstrated that TSP correlated with the amount of correction, because satisfactory cases corrected a mean of 5.5 positions and undercorrected cases corrected a mean of 2.5 positions. Seiberg et al (6) also used a similar TSP score in analyzing immediate postoperative and greater than 6-month postoperative outcomes of first metatarsal CBWO. Their average amount of immediate TSP correction was 3.5, with a mean position of 2.2. Their average amount of long-term (greater than 6 months) TSP correction was 2.7. Our results compare favorably with those of this study, because our early postoperative TSP correction was 3.05, with a mean position of 2.45. Our average amount of long-term (mean 39.1 months) TSP correction was 2.2, with a mean position of 3.3. Although several authors, including Lapidus, Sangeorzan and Hansen, Catanzariti, and Myerson (1, 12, 18, 20, 27, 38), state that an arthrodesis of the first tarsometatarsal joint stabilizes the hypermobility of the first ray and prevents recurrent deformity, others have demonstrated that only 10% of first ray mobility occurs at this level (39). Dreeben and Mann (28) showed there was inherent stability of the first tarsometatarsal joint, and an arthrodesis is not necessary for a good long-term result. Rush et al (40) demonstrated that an immediate decrease in sagittal mobility of the first ray occurs by restoring the first metatarsal to an anatomic position through a proximal osteotomy. Coughlin et al (41) also noted a significant decrease in first ray mobility (greater than a 50% decrease in sagittal plane motion of the first ray using the Klau device) after performing a proximal crescentic metatarsal osteotomy and distal soft tissue reconstruction in cadaveric specimens. These findings suggest that reduced first ray mobility is likely secondary to not only a first tarsometatarsal arthrodesis, but also correction of the angular deformity. Rush et al (40) demonstrated normalization of the first ray mobility by restoring the anatomy of the first metatarsal, which, in essence, improves the efficiency of the plantar aponeurosis. Saraffian (42) also discussed the importance of the plantar aponeurosis in providing stability of the first ray. Maintenance of correction seems to reflect the stability of the first ray, and Coughlin et al (41) believes that this “stability may be a function of first ray alignment and the plantar aponeurosis, not an intrinsic characteristic of the first

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TABLE 3

Radiographic results of the tibial sesamoid position

Group

Baseline mean (SD)

Preoperative/postoperative difference, mean (SD); P value

Preoperative/⬎1 y difference, mean (SD); P value

Postoperative/⬎1 y difference, mean (SD); P value

CBWO (N ⫽ 20) LA (N ⫽ 37) Between group

5.50 (0.83) 5.84 (1.17) –0.34 (1.06)

–3.05 (1.00); P ⬍ .0001 –3.05 (1.13); P ⬍ .0001 0.004 (1.09); P ⫽ .99

–2.20 (1.44); P ⬍ .0001 –2.35 (1.55); P ⬍ .0001 0.15 (1.51); P ⫽ .72

0.85 (0.88); P ⫽ .0003 0.70 (1.15); P ⫽ .0007 0.15 (1.06); P ⫽ .62

Abbreviations: CBWO, closing base wedge osteotomy; LA, Lapidus arthrodesis; SD, standard deviation.

Early Postoperative TSP

3 2

Late Postoperative TSP

1 0

CBWO

FIGURE 5 (TSP).

IMA

Radiographic results of the tibial sesamoid position

metatarsocuneiform joint.” Although Lapidus, Sangeorzan, and Hansen have discussed the modified Lapidus procedure as providing a rigidly fixed corrected position (12, 18, 38), the studies performed by Rush et al (40) and Coughlin et al (41) have demonstrated that aligning the first ray to a near-anatomic position also imparts first ray stability. Thus, there may be 2 ways to impart stability to the first ray: an arthrodesis of the medial column and an anatomic position of the first ray restoring the windlass mechanism. Although Lapidus believed that a tarsometatarsal joint arthrodesis was necessary to correct the underlying primary etiologies of hypermobility and metatarsus primus varus (12), others including Coughlin et al (41), Rush et al (40), and Saraffian (42) suggest hypermobility may result from hallux valgus. Our loss of correction for a modified LA was significantly less (1.08° vs 2.55°, P ⫽ .004) than the loss of correction for a first metatarsal CBWO. These results seem to reflect the above-mentioned findings and indicate that a first tarsometatarsal joint arthrodesis and a near-anatomic first ray position may have an additive effect on the inherent stability of the first ray. Further research is needed to further quantify the stabilizing first ray influences of a near-anatomic reduction, a first tarsometatarsal arthrodesis, and a combination of these techniques. During our literature review, we only found 1 article (6) that analyzed both early postoperative radiographs and later (⬎6 months) postoperative radiographs to evaluate loss of correction with a proximal bunionectomy. We were unable to find a study that directly compared the efficacy of a modified LA with a first metatarsal CBWO. Further research and larger 364

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CBWO Loss of Correction LA Loss of Correction TSP (p=0.62)

4

HAA (p=0.94)

Preoperative TSP

5

3.5 3 2.5 2 1.5 1 0.5 0

IMA (p=0.0039)

6

FIGURE 6 Loss of correction (in degrees for the IMA and HAA, in position for the TSP) comparing early postoperative versus late postoperative radiographs.

population sizes are needed to analyze long-term maintenance of correction of various bunionectomies. We recognize that there are several limitations to this study, primarily related to its strictly radiographic design and absence of functional scores. Although this study was limited to radiographic review only, Kristen et al (30) and McInnes and Bouche (2) found a statistical significance in subjective postoperative scores with the postoperative intermetatarsal angle and the HAA. The preoperative examination, which included the severity of hypermobility and reducibility of deformity, was not included in the study. Also, our inclusion criteria of having at least 11-month postoperative radiographs severely diminished our population size. Conclusion The modified LA and the first metatarsal CBWO are popular methods for addressing moderate to severe hallux valgus deformity. The current radiographic retrospective study reports successful reduction and maintenance of correction of the IMA, HAA, and TSP. These results support previous reports that both techniques represent effective procedures verified by radiographic correction. Both procedures offer predictably successful radiographic results in the patient with a moderate to severe hallux valgus deformity, because long-term maintenance of correction may be achieved with an arthrodesis of the first tarsometatarsal joint and/or an anatomic position of the first ray. Our results show that a modified LA significantly (P ⫽ .004) maintains

correction to a greater degree than a CBWO. This may suggest that a tarsometatarsal joint arthrodesis and a nearanatomic first ray alignment may have an additive effect on the inherent stability of the first ray. Acknowledgment We thank Kaiser Permanente Division of Research Biostatistician and Investigator, Lynn Ackerson, MA, who provided statistical consultation and editorial review and assistance. References 1. Catanzariti AR, Mendicino RW, Lee MS, Gallina MR. The modified Lapidus arthrodesis: a retrospective analysis. J Foot Ankle Surg 38: 322–332, 1999. 2. McInnes BD, Bouche RT. Critical evaluation of the modified Lapidus procedure. J Foot Ankle Surg 40:71–90, 2001. 3. Rink-Brune O. Lapidus arthrodesis for management of hallux valgus—a retrospective review of 106 cases. J Foot Ankle Surg 43:290–295, 2004. 4. Palladino SJ. Preoperative evaluation of the bunion patient. In Textbook of Bunion Surgery, ed 3, pp 3–72, edited by J Gerbert, WB Sanders Company, Philadelphia, 2001. 5. Patel S, Ford LA, Etcheverry J, Rush SM, Hamilton GA. Modified lapidus arthrodesis: rate of nonunion in 227 cases. J Foot Ankle Surg 43:37– 42, 2004. 6. Seiberg M, Felson S, Colson JP, Barth AH, Green RM, Green DR. Closing base wedge versus Austin bunionectomies for metatarsus primus adductus. J Am Podiatr Med Assoc 84:548 –563, 1994. 7. Trnka HJ, Muhlbauer M, Zembsch A, Hungerford M, Ritschl P, Salzer M. Basal closing wedge osteotomy for correction of hallux valgus and metatarsus primus varus: 10- to 22-year follow-up. Foot Ankle Int 20: 171–177, 1999. 8. Mothershed RA, Catanzariti AR, Blitch EL. Proximal procedures of the first ray. In McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, ed 3, pp 529–556, edited by AS Banks, MS Downey, DE Martin, SJ Miller, Lippincott Williams & Wilkins, Philadelphia, 2001. 9. Loison M. Note sur le traitment chirurgical de hallux valgus d’apres l’etude radiographique de la deformation. Bull Mem Soc Chir 27:528, 1901. 10. Balacescu J. Un caz de hallux balgus simetric. Rev Cir 7:128, 1903. 11. Albrecht GH. The pathology and treatment of hallux valgus. Russ Vrach 10:14 –19, 1911. 12. Lapidus P. Operative correction of the metatarsus varus primus in hallux valgus. Surg Gynecol Obstet 58:183–191, 1934. 13. Chiodo CP, Schon LC, Myerson MS. Clinical results with the Ludloff osteotomy for correction of adult hallux valgus. Foot Ankle Int 25: 532–536, 2004. 14. Bar-David T, Trepal MJ. A retrospective analysis of distal Chevron and Basilar osteotomies of the first metatarsal for correction of intermetatarsal angles in the range of 13 to 16 degrees. J Foot Surg 30:450 – 456, 1991. 15. Grace D, Delmonte R, Catanzariti AR, Hofbauer M. Modified lapidus arthrodesis for adolescent hallux abducto valgus. J Foot Ankle Surg 38:8 –13, 1999. 16. Kopp FJ, Patel MM, Levine DS, Deland JT. The modified Lapidus procedure for hallux valgus: a clinical and radiographic analysis. Foot Ankle Int 26:913–917, 2005. 17. Bednarz PA, Manoli A 2nd. Modified lapidus procedure for the treatment of hypermobile hallux valgus. Foot Ankle Int 21:816 – 821, 2000. 18. Sangeorzan BJ, Hansen ST Jr. Modified Lapidus procedure for hallux valgus. Foot Ankle 9:262–266, 1989.

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