- Email: [email protected]
Modified lapidus arthrodesis for adolescent hallux abducto valgus
Modified Lapidus Arthrodesis for Adolescent Hallux Abducto Valgus David Grace, DPM, Rick Delmonte, DPM, Alan R. Catanzariti, DPM, and Mark Hofbauer, DPM The Lapidus arthrodesis was originally described for the surgical correction of hallux valgus associated with metatasus primus adductus. It was popularized on the adult patient with moderate to severe hallux valgus deformity. However, the authors present a retrospective review of 23 adolescents between the ages of 13 and 20 who underwent the procedures. Characteristics of adolescent hallux valgus include a smaller dorsal medial eminence, less valgus rotation of the hallux, and certain mechanical influences. These influences may include a generalized increase in motion at the first metatarsocuneiform joint. The modified Lapidus arthrodesis eliminates motion at the first metatarsocuneiform joint and therefore directly addresses an etiology of the deformity. Both preoperative and postoperative radiographs were evaluated for reduction in the 1-2 intermetatarsal angle. Patients were evaluated through either chart review or telephone interview for present activity level, comfortable footgear, and overall satisfaction of the procedure. Twenty-seven out of 30 feet (90%) had either a good or excellent result with only three complications and two recurrences over a mean follow-up of 61 months. (The Journal of Foot & Ankle Surgery 38(1):8-13,1999) Key words: adolescent, arthrodesis, hallux valgus, hypermobility, lapidus
T he
Lapidus procedure has been described for the adult patient with moderate to severe hallux valgus. This procedure includes a first metatarsocuneiform joint arthrodesis, resection of the dorsal medial eminence of the first metatarsal, and possible soft-tissue realignment at the first metatarsophalangeal joint (I, 2). Several authors have advocated first metatarsocuneiform joint arthrodesis for hallux valgus with associated metatarsus primus adductus (3-5). Paul Lapidus popularized this procedure for correction of hallux valgus associated with metatarsus primus adductus in the adult patient (I). These authors theorized that an "atavistic" foot and metatarsus primus adductus played a dominant role in the development of hallux valgus. They believed that by addressing the first metatarsocuneiform joint, one would truly correct the deformity (1-3). Characteristics of adolescent hallux valgus may include a generalized increase in motion at the first metatarsocuneiform joint (6, 7). Arthrodesis of the first metatarsocuneiform joint eliminates motion at this joint and therefore directly addresses one major etiological factor of adolescent hallux valgus. The majority of hallux valgus procedures chosen for the adolescent population From the Podiatry Hospital of Pittsburgh and the Western Pennsylvania Hospital, Pittsburgh, PA. Address correspondence to: David Grace, DPM, 198 Thomas Johnson Dr., Suite 4, Frederick, MD 21702. Received for publication March 1998; received in revised form for publication September 1998. The Journal of Foot & Ankle Surgery 1067-2516/99/3801-0008$4.00/0 Copyright © 1999 by the American College of Foot and Ankle Surgeons
8
THE JOURNAL OF FOOT & ANKLE SURGERY
are commonly based on radiographic findings, patient expectations, and comfort level of the surgeon performing the procedure. Historically, procedures for the adolescent patient with hallux valgus include head and base osteotomies. However, these osteotomies do not address the hypermobile first ray which may lead to a high rate of recurrence. Goldner and Gaines (6) and later Clark et al. (7) used the Lapidus arthrodesis for the adolescent patient with a hypermobile first my. Clark obtained 91 % excellent or good results with only one recurrence of deformity. The authors present a review of 23 adolescents who underwent the modified Lapidus arthrodesis for symptomatic hallux valgus and excessive motion of the first ray. Materials and Methods
The authors reviewed 30 modified Lapidus procedures performed on 23 patients between 1986 and 1995. There were 16 unilateral and seven bilateral procedures. Patients were between the ages of 13 and 20 with the average age of 16.5 years. There were 21 females and two males. Patient data are presented in Table I. Preoperative Evaluation
Preoperative evaluation was performed on each patient in a consistent manner. Patients had a chief concern of a symptomatic bunion, difficulty wearing shoes, and limited
TABLE 1 Age
Foot
Preop 1MAngle
Postop 1M Angle
Fixation
Growth Plate
1 2 3 4
18 17 13 14
Left Left Left Right
9° 16° 16° 10°
6° 9° 6° 5°
Steinmann pins (2) Steinmann pins (2) Steinmann pins (2) Plate and screws
Closed Closed Open Closed
64 42 30 80
5 6 7
18 14 15
Left Right Right
8° 9° 11°
5° 5° 6°
Closed Closed Closed
48 months 52 months 18 months
8 9 10 11 12
16 18 19 17 14
Right Left Right Left Right
14° 11° 10° 16° 9°
7° 0° 3° 5° 5°
Steinmann Screws (2) Screw (1) Steinmann Steinmann Steinmann Steinmann Screws (2) Screws (2)
Closed Closed Closed Closed Closed
32 79 74 74 74
13
17
Right
10°
8°
Steinmann pins (2)
Closed
74 months
14 15 16
13 14 15
Left Right Left
11° 11° 11°
6° 6° 6°
Steinmann pins (2) Steinmann pins (2) Steinmann pins (2)
Closed Closed Closed
77 months 74 months 73 months
17
15
Left
15°
5°
Screw (1) Steinmann Screw (1) Steinmann Steinmann Screw (1) Steinmann Steinmann Screw (1) Steinmann Screws (2) Screw (2) Screw (1) Steinmann Screw (1) Steinmann Steinmann Steinmann Screw (1) Steinmann Steinmann
Closed
72 months
Excellent result Excellent result Excellent result Excellent result Revision surgery 1 year later; fair result Limited shoegear; good result Excellent result Excellent result Limited activity, limited shoegear; fair result Excellent result
Closed
66 months
Excellent result
Closed Closed
91 months 79 months
Excellent result Excellent result
Closed Closed
75 months 40 months
Excellent result Excellent result
Closed Closed Closed
14 months 82 months 7 months
Excellent result Excellent result Excellent resuIt
Closed
35 months
Excellent result
Closed Closed Closed
55 months 47 months 40 months
Excellent result Excellent result Excellent result
Closed
161 months
Good results
#
18
18
Right
10°
r
19 20
18 19
Left Right
23° 24°
8° 10°
21 22
14 17
Right Left
13° 13°
3° 1°
23 24 25
15 20 19
Right Left Right
16° 15° 16°
5° 9° 5°
26
16
Left
17°
5°
27 28 29
19 19 16
Right Right Left
11° 10° 17°
6° 2° 3°
30
19
Right
16°
4°
activity due to pain. First-ray motion was assessed by holding the lesser metatarsals stable and manipulating the first ray in both the sagittal and transverse planes with the opposite hand (7) (Fig. 1). The subtalar joint was in its neutral position with the midtarsal joint maximally pronated. First-ray hypermobility and lateral forefoot overload were considered to be present when lesser metatarsal lesions existed. Preoperative radiographic assessment was performed for each patient. Both the dorsoplantar and lateral weightbearing views were evaluated. Preoperative 1-2 intermetatarsal angles ranged from 9° to 24° with an average of 13.3°. Radiographs were also studied for second metatarsal cortical hypertrophy which
pins (2)
pin (1) pins (2) pins (2) pins (2)
Follow-up
months months months months
months months months months months
Comments
Excellent result Excellent result Excellent result Revision surgery bone graft; good result Excellent result Bone graft; good result Excellent result
pin (1) pin (1) pins (2) pin (1) pins (2) pin (1)
pin (1) pin (1) pins (2) pins (2) pin (1) pins (2)
is indicative of first-ray hypermobility and insufficient weightbearing (8). This was noted in 60% of the x-rays reviewed. Outcomes
The results were graded by means of a modification of the criteria established by Bonney and MacNab (9). Patient results were either excellent, good, fair, or poor. An excellent result had to meet the following criteria: I) overall patient satisfaction, 2) no limitations with shoegear, 3) no limitations with activity, 4) absence of complications, and 5) complete elimination of pain. If one of VOLUME 38, NUMBER 1, JANUARY/FEBRUARY 1999
9
A
B
FIGURE 1 A and B, First-ray motion was assessed by holding the lesser metatarsals stable and manipulating the first ray in both the sagittal and transverse planes with the opposite hand. The subtalar joint was held in its neutral position with the midtarsal joint maximally pronated. First-ray hypermobility and lateral forefoot overload were considered to be present when lesser metatarsal lesions existed.
these criteria was missing, the patient was given a good result. If two criteria were missing, the patient was given a fair result and so on. Surgical Procedure Indications for the modified Lapidus arthrodesis include a moderate to high 1- 2 intermetatarsal angle and hypermobility of the first ray resulting in lateral forefoot overload. The authors modified the original Lapidus procedure. Unlike the original operation, the authors did not include arthrodesis of the first and second rays. Additional modifications included fixation and plantar transposition. Either 10
THE JOURNAL OF FOOT & ANKLE SURGERY
smooth pins or screws were used to fixate the arthrodesis site; the original procedure utilized suture. To avoid shortening only cartilaginous tissue was resected from the base of the first metatarsal. Furthermore, plantarflexion of the first metatarsal was obtained by plantarly translocating the first metatarsal on the medial cuneiform prior to fixation. Surgery was performed under IV sedation with a local nerve block. A pneumatic ankle tourniquet was used in all procedures. The surgery was performed with either one longitudinal incision from the first metatarsocuneiform joint to the first metatarsophalangeal joint or through two separate incisions. A complete soft-tissue release was performed at the first interspace consisting of a lateral caps ulotomy , adductor tendon release, and transection of the extensor hallucis brevis tendon. The dorsal medial eminence of the first metatarsal was then exposed through a linear or "L" -type capsular incision and resected flush with the medial edge of the metatarsal shaft. It should be noted that minimal bone was resected in most cases. Adolescents typically have a small dorsal medial eminence. The first metatarsocuneiform joint was then exposed and the cartilaginous base of the first metatarsal was resected. This was performed with curettage or use of an oscillating saw. Care was taken to avoid shortening by removing only cartilaginous tissue. The distal articular surface of the medial cuneiform was then resected. This consisted of a laterally based wedge to correct for the intermetatarsal angle. Occasionally, a section of the lateral base of the first metatarsal was resected to allow adequate lateralization for reduction in the 1- 2 intermetatarsal angle. The arthrodesis sites were then fenestrated prior to provisional fixation. The first metatarsal was then aligned on the distal cuneiform with care taken to obtain plantar displacement and lateralization. Provisional fixation was utilized and intraoperative radiographs were taken or fluoroscopy was utilized to evaluate position. Permanent fixation consisted of either crossing screws, percutaneous Steinmann pins, a combination of screws with a percutaneous Steinmann pin, or 1/4 tubular plate with screws. Small cortical or cancellous ASIF screws were placed in a lag fashion from dorsal-distal to plantar-proximal. Screw placement ranged from 1.0 to 1.2 em distal to the arthrodesis site and angled at 45° from the metatarsal shaft. Positioning of the screw in this manner allowed greater length to increase leverage and also ensured fixation to cross the plantar one third of the arthrodesis site (Fig. 2). Pin fixation was always utilized if the growth plate was open, which was the case in 10% of the procedures. A bone graft was used in two of the cases to avoid shortening of the first ray. These were fixed with a plate and screws. During the earlier years of performing the procedure, plantarflexion of the first metatarsal was obtained by angulating the cuts in the sagittal plane to remove a plantar wedge of bone. This was changed to trans locating the first metatarsal on the medial cuneiform
8
FIGURE 2 A, Intraoperative photograph demonstrating screws being placed approximately 1.5 cm proximal to the arthrodesis site. B, Radiograph demonstrating compression of screws placed distal-dorsal to plantar-proximal across the arthrodesis site.
All patients were placed into a posterior splint for 2 weeks and then a below-knee fiberglass cast for another 4-5 weeks. All patients were nonweightbearing with the use of crutches for 6-8 weeks. Postoperative assessment consisted of both telephone conversation and chart review. Twenty patients were contacted and interviewed over the phone and three through chart review. Follow-up ranged from 7 to 161 months with an average of 61 months. The authors reviewed satisfaction of procedure, present activity level, and footgear with each patient. Preoperative and 6-week and 12-week postoperative radiographs were also evaluated for reduction in intennetatarsal angle.
exostosis, one symptomatic nonunion, and two recurrences of deformity. These patients required revisional surgery to obtain relief. The patient with a painful dorsal exostosis underwent an exostectomy 2 years following her original procedure. The individual with a symptomatic nonunion was pain free up to 20 months postoperatively when she started playing competitive soccer, at which point symptoms developed. She underwent revisional arthrodesis and healed without complications. One of the patients with a recurrence underwent global metatarsal base osteotomies to address a severe metatarsus adductus deformity. She went on to heal uneventfully and her symptoms resolved. Postoperative radiographic evaluation revealed an average reduction in the 1- 2 intermetatarsal angle to 5.4°. This ranged from 2° to 10°. There was an 8° average decrease in the intermetatarsal angle relative to the preoperative evaluation (see Table 1).
Results
Discussion
Preoperatively, 21 of the 23 patients who were female had difficulty wearing dress shoes before surgery. All patients had an increase in pain as their activity level increased. All patients were concerned with a painful bunion deformity. Postoperatively, 21 patients were able to wear fashionable footwear without discomfort. Two patients continued to have difficulty wearing dress shoes. The activity level was unlimited for 22 patients; however, one individual had discomfort when running long distances. The results were graded by means of a modification of the criteria established by Bonney and MacNab (9). Overall there were 25 excellent, three good, and two fair results. Complications of the procedure included one painful dorsal
There are significant differences that exist which differentiate adolescent from adult hallux valgus. Many authors have cited these differences, which include an absence of a thickened medial bursa of the first metatarsal head, smaller dorsal medial eminence, and less adduction and valgus rotation of the hallux (6, 10). Growth plates may often be open and the magnitude of the 1-2 intermetatarsal angle will be increased (11). Less erosion will have OCCUlTed at the first metatarsal phalangeal joint and there may be minimal deviation of the cartilage of the first metatarsal head (6, 10, 12). These differences must be taken into consideration when evaluating the adolescent with hallux valgus.
to obtain plantarflexion, thus limiting shortening associated with wedge resection. Postoperative Care
VOLUME 38, NUMBER 1, JANUARY/FEBRUARY 1999
11
The durability of the modified Lapidus arthrodesis makes it most suitabl e for addressing adolescents with hallux valgus associated with a truly hypermobile first ray. Hypermobility is defined as excessive range of motion of a jo int and has been used interchangeably with hyperlaxity, hyperextensibility, or hyperflexibility. When the motion in the joint is in excess of the normall y accepted limits for that joint, the joint is said to be hypermobile (13). One cause of this hypermobility is the presence of generalized laxity. Measurement of first-ray motion is performed with the subtalar joint in neutral position and the midtarsal joint maximall y pronat ed. The first metatarsal is manipulated with respect to the lesser metatar sals by holding the metatarsal heads between the thumb and forefinger. Hypermobility is usually an isolated finding of the foot, but is occasionally associated with generalized ligamentous laxity. This condition may render a patient prone to recurrent deformity if these factors are not taken into consideration when planning the appropriate procedure for correct ion of hallux abducto valgus in the adolescent. Females are more often affected with adolescent hallux valgus deformities. This has been shown to be present in all major reviews of adolescent bunion surgery (9, 14-20). This also proved to be true in our study where there were 2 1 female s and only two males. It appears that metatarsus primu s adductu s is a primary deforming force implicated in developing hallux valgus. This is the conclusion of severa l authors includin g Lapidus, Truslow, and others ( 1- 3, 9). Hardy and Clapham and later Piggot disputed this theor y when they conclude that hallux valgus leads to metatarsus primus adductus ( 10, 21). It has been suggested that in order to decrease the high recurrence rate of adole scent hallux valgus, hypermobility of the first ray must be addressed (6, 7). Early studies of adolescent hallux valgus have reported recurrence rates as high as 61% and 63% (9, 14). Scranton reported a 36% overall failure rate with 56% recurrence in those individuals with hypermobile flat feet (20). Geissele also reported a 52% recurrence rate of deformity (12). Das De and Helal reported overall good results, however, there was an abnormall y high amount of lesser metatarsalgia ( 16, 17). Procedure selection for these studies consisted of different types of distal metaphyseal osteotomies which did not address instability of the first ray. Clark and Myerson presented studies in which they performed a modified Lapidu s arthrodesis in the adolescent patient with hyperm obility of the first ray. Their recurren ce rate significantly decreased compared to earlier studies (7). Our popul ation of 30 feet demon strated a low recurrence rate of 10%. The modified Lapidu s arthrodesis accomplishes two major goals not attainable with metatarsal osteotomies. This procedure will restore stability to the first ray and eliminate disturbances in weightbearing patterns of the forefoot. Additionally, the 12
THE JOURNAL OF FOOT & ANKLE SURGERY
modified Lapidus arthrodesis will address the apex of the deformity, stabilizing the articulation and thereby preventing recurrent deformity, eliminating hypermobil ity of the first ray, and eliminating multiplanar instabil ity assoc iated with an increased tenden cy for the metatarsal to shift in both the sagittal and transverse planes.
Conclusion
Long-term studies eva luating the surgical management of adolescent hallu x valgus have demonstrated high failure rates, multiple compl ications, and a significant amount of recurrence (14-1 8, 20). Lapidus and others postulated that metatarsus primus adductus is associated with instability of the first ray. The authors have presented a review of the modified Lapidu s arthrodesis on 23 adole scent individuals with good results. There were few complications and only two recurrences (10%). The modified Lapidu s arthrodesis is a reasonable option for the adolescent patient with symptomatic hallux valgus and hypermobility of the first ray.
References I. Lapidus. P. The author's bunion operation from 1931-1 959. Clin. Orthop. 16:119-1 35, 1960. 2. Lapidus, P. The operative correction of metatarsus primus varus in hallux valgus. 1. Surg. Gynecol. Obstet. 58:183- 191, 1934. 3. Albrecht, G. The pathology and treatment of hallux valgus (in Russian). Russk. Vrach. 10:14-1 9, 1911. 4. Truslow, W. Metatarsus primus varus or hallux valgus? J. Bone Joint Surg. 7:98- 108, 1925. 5. Kleinberg, S. The operative cure of hallux valgus and bunions. Am. J. Surg. 15:75-8 1, 1932. 6. Goldner, J. L., Gaines R. Adult and juvenile hallux valgus: Analysis and treatment. Orthop. Clin. 7:863- 887, 1976. 7. Clark, H., Veith, R., Hansen, S. T. Adolescent bunions treated by the modified Lapidus procedure. Bull. Hosp. Joint Dis. Orthop. Inst. 47: 109-122, 1987. 8. Sangeorzan, B. J., Hansen, S. T. Modified Lapidus procedure for hallux valgus. Foot Ankle 9:262-266, 1989. 9. Bonney. G., MacNab. 1. Hallux valgus and hallux rigidity. 1. Bone Joint Surg. 33-B:376-382, 1951. 10. Piggot, II. The natural history of hallux valgus in adolescent and early adult life. J. Bone Joint Surg. 42-B:749-76O. 1960 I I. Coughlin, M. Juvenile bunions. In Surgery of the Foot and Ankle, PI' 297- 339, edited by Mann and Coughlin. Mosby-Year Book, St. Louis, 1993. 12. Geissele, A., Stanton, R. Surgical treatment of adolescent hallux valgus. J. Pediatr. Orthop. 10:642- 649, 1990. 13. McNerney. 1. E.• Johnston, W. B. Generalized ligamentous laxity. hallux abducto valgus and the first metatarsocuneiforrnjoint. J. Am. Podiatr. Med. Assoc. 69:69-82, 1979. 14. Ball, J.• Sullivan, J. A. Treatment of the juvenile bunion by the Mitchell osteotomy. Orthopedics 8:1249-1 252, 1985. 15. Carr, C. R., Boyd, M. B. Correctional osteotomy for metatarsus primus varus and hallux valgus. J. Bone Joint Surg. 50:1353- 1367, 1968.
16. Das De, S. Distal metatarsal osteotomy for adolescent hallux valgus. J. Pediatr. Orthop. 4:32-38, 1984. 17. Helal, B. Surgery for adolescent hallux valgus. Clin. Orthop. 157:50-63, 1981. 18. Luba, R., Rosman, M. Bunions in children: Treatment with a modified Mitchell osteotomy. 1. Pediatr. Orthop. 4:44-47, 1984.
19. Pontious, 1., Mahan, K., Carter, S. Characteristics of adolescent hallux abducto valgus. J. Am. Podiatr. Med. Assoc. 84:208-- 212, 1994. 20. Scranton, P, Zuckerman, J. D. Bunion surgery in adolescents: Results of surgical treatment. 1. Pediatr. Orthop. 4(1):39-43, 1984. 21. Hardy, R. H., Clapham, 1. C. R. Observations on hallux valgus. J. Bone Joint Surg. 33-8:376-391, 1951.
VOLUME 38, NUMBER 1, JANUARY/FEBRUARY 1999
13
T he
Lapidus procedure has been described for the adult patient with moderate to severe hallux valgus. This procedure includes a first metatarsocuneiform joint arthrodesis, resection of the dorsal medial eminence of the first metatarsal, and possible soft-tissue realignment at the first metatarsophalangeal joint (I, 2). Several authors have advocated first metatarsocuneiform joint arthrodesis for hallux valgus with associated metatarsus primus adductus (3-5). Paul Lapidus popularized this procedure for correction of hallux valgus associated with metatarsus primus adductus in the adult patient (I). These authors theorized that an "atavistic" foot and metatarsus primus adductus played a dominant role in the development of hallux valgus. They believed that by addressing the first metatarsocuneiform joint, one would truly correct the deformity (1-3). Characteristics of adolescent hallux valgus may include a generalized increase in motion at the first metatarsocuneiform joint (6, 7). Arthrodesis of the first metatarsocuneiform joint eliminates motion at this joint and therefore directly addresses one major etiological factor of adolescent hallux valgus. The majority of hallux valgus procedures chosen for the adolescent population From the Podiatry Hospital of Pittsburgh and the Western Pennsylvania Hospital, Pittsburgh, PA. Address correspondence to: David Grace, DPM, 198 Thomas Johnson Dr., Suite 4, Frederick, MD 21702. Received for publication March 1998; received in revised form for publication September 1998. The Journal of Foot & Ankle Surgery 1067-2516/99/3801-0008$4.00/0 Copyright © 1999 by the American College of Foot and Ankle Surgeons
8
THE JOURNAL OF FOOT & ANKLE SURGERY
are commonly based on radiographic findings, patient expectations, and comfort level of the surgeon performing the procedure. Historically, procedures for the adolescent patient with hallux valgus include head and base osteotomies. However, these osteotomies do not address the hypermobile first ray which may lead to a high rate of recurrence. Goldner and Gaines (6) and later Clark et al. (7) used the Lapidus arthrodesis for the adolescent patient with a hypermobile first my. Clark obtained 91 % excellent or good results with only one recurrence of deformity. The authors present a review of 23 adolescents who underwent the modified Lapidus arthrodesis for symptomatic hallux valgus and excessive motion of the first ray. Materials and Methods
The authors reviewed 30 modified Lapidus procedures performed on 23 patients between 1986 and 1995. There were 16 unilateral and seven bilateral procedures. Patients were between the ages of 13 and 20 with the average age of 16.5 years. There were 21 females and two males. Patient data are presented in Table I. Preoperative Evaluation
Preoperative evaluation was performed on each patient in a consistent manner. Patients had a chief concern of a symptomatic bunion, difficulty wearing shoes, and limited
TABLE 1 Age
Foot
Preop 1MAngle
Postop 1M Angle
Fixation
Growth Plate
1 2 3 4
18 17 13 14
Left Left Left Right
9° 16° 16° 10°
6° 9° 6° 5°
Steinmann pins (2) Steinmann pins (2) Steinmann pins (2) Plate and screws
Closed Closed Open Closed
64 42 30 80
5 6 7
18 14 15
Left Right Right
8° 9° 11°
5° 5° 6°
Closed Closed Closed
48 months 52 months 18 months
8 9 10 11 12
16 18 19 17 14
Right Left Right Left Right
14° 11° 10° 16° 9°
7° 0° 3° 5° 5°
Steinmann Screws (2) Screw (1) Steinmann Steinmann Steinmann Steinmann Screws (2) Screws (2)
Closed Closed Closed Closed Closed
32 79 74 74 74
13
17
Right
10°
8°
Steinmann pins (2)
Closed
74 months
14 15 16
13 14 15
Left Right Left
11° 11° 11°
6° 6° 6°
Steinmann pins (2) Steinmann pins (2) Steinmann pins (2)
Closed Closed Closed
77 months 74 months 73 months
17
15
Left
15°
5°
Screw (1) Steinmann Screw (1) Steinmann Steinmann Screw (1) Steinmann Steinmann Screw (1) Steinmann Screws (2) Screw (2) Screw (1) Steinmann Screw (1) Steinmann Steinmann Steinmann Screw (1) Steinmann Steinmann
Closed
72 months
Excellent result Excellent result Excellent result Excellent result Revision surgery 1 year later; fair result Limited shoegear; good result Excellent result Excellent result Limited activity, limited shoegear; fair result Excellent result
Closed
66 months
Excellent result
Closed Closed
91 months 79 months
Excellent result Excellent result
Closed Closed
75 months 40 months
Excellent result Excellent result
Closed Closed Closed
14 months 82 months 7 months
Excellent result Excellent result Excellent resuIt
Closed
35 months
Excellent result
Closed Closed Closed
55 months 47 months 40 months
Excellent result Excellent result Excellent result
Closed
161 months
Good results
#
18
18
Right
10°
r
19 20
18 19
Left Right
23° 24°
8° 10°
21 22
14 17
Right Left
13° 13°
3° 1°
23 24 25
15 20 19
Right Left Right
16° 15° 16°
5° 9° 5°
26
16
Left
17°
5°
27 28 29
19 19 16
Right Right Left
11° 10° 17°
6° 2° 3°
30
19
Right
16°
4°
activity due to pain. First-ray motion was assessed by holding the lesser metatarsals stable and manipulating the first ray in both the sagittal and transverse planes with the opposite hand (7) (Fig. 1). The subtalar joint was in its neutral position with the midtarsal joint maximally pronated. First-ray hypermobility and lateral forefoot overload were considered to be present when lesser metatarsal lesions existed. Preoperative radiographic assessment was performed for each patient. Both the dorsoplantar and lateral weightbearing views were evaluated. Preoperative 1-2 intermetatarsal angles ranged from 9° to 24° with an average of 13.3°. Radiographs were also studied for second metatarsal cortical hypertrophy which
pins (2)
pin (1) pins (2) pins (2) pins (2)
Follow-up
months months months months
months months months months months
Comments
Excellent result Excellent result Excellent result Revision surgery bone graft; good result Excellent result Bone graft; good result Excellent result
pin (1) pin (1) pins (2) pin (1) pins (2) pin (1)
pin (1) pin (1) pins (2) pins (2) pin (1) pins (2)
is indicative of first-ray hypermobility and insufficient weightbearing (8). This was noted in 60% of the x-rays reviewed. Outcomes
The results were graded by means of a modification of the criteria established by Bonney and MacNab (9). Patient results were either excellent, good, fair, or poor. An excellent result had to meet the following criteria: I) overall patient satisfaction, 2) no limitations with shoegear, 3) no limitations with activity, 4) absence of complications, and 5) complete elimination of pain. If one of VOLUME 38, NUMBER 1, JANUARY/FEBRUARY 1999
9
A
B
FIGURE 1 A and B, First-ray motion was assessed by holding the lesser metatarsals stable and manipulating the first ray in both the sagittal and transverse planes with the opposite hand. The subtalar joint was held in its neutral position with the midtarsal joint maximally pronated. First-ray hypermobility and lateral forefoot overload were considered to be present when lesser metatarsal lesions existed.
these criteria was missing, the patient was given a good result. If two criteria were missing, the patient was given a fair result and so on. Surgical Procedure Indications for the modified Lapidus arthrodesis include a moderate to high 1- 2 intermetatarsal angle and hypermobility of the first ray resulting in lateral forefoot overload. The authors modified the original Lapidus procedure. Unlike the original operation, the authors did not include arthrodesis of the first and second rays. Additional modifications included fixation and plantar transposition. Either 10
THE JOURNAL OF FOOT & ANKLE SURGERY
smooth pins or screws were used to fixate the arthrodesis site; the original procedure utilized suture. To avoid shortening only cartilaginous tissue was resected from the base of the first metatarsal. Furthermore, plantarflexion of the first metatarsal was obtained by plantarly translocating the first metatarsal on the medial cuneiform prior to fixation. Surgery was performed under IV sedation with a local nerve block. A pneumatic ankle tourniquet was used in all procedures. The surgery was performed with either one longitudinal incision from the first metatarsocuneiform joint to the first metatarsophalangeal joint or through two separate incisions. A complete soft-tissue release was performed at the first interspace consisting of a lateral caps ulotomy , adductor tendon release, and transection of the extensor hallucis brevis tendon. The dorsal medial eminence of the first metatarsal was then exposed through a linear or "L" -type capsular incision and resected flush with the medial edge of the metatarsal shaft. It should be noted that minimal bone was resected in most cases. Adolescents typically have a small dorsal medial eminence. The first metatarsocuneiform joint was then exposed and the cartilaginous base of the first metatarsal was resected. This was performed with curettage or use of an oscillating saw. Care was taken to avoid shortening by removing only cartilaginous tissue. The distal articular surface of the medial cuneiform was then resected. This consisted of a laterally based wedge to correct for the intermetatarsal angle. Occasionally, a section of the lateral base of the first metatarsal was resected to allow adequate lateralization for reduction in the 1- 2 intermetatarsal angle. The arthrodesis sites were then fenestrated prior to provisional fixation. The first metatarsal was then aligned on the distal cuneiform with care taken to obtain plantar displacement and lateralization. Provisional fixation was utilized and intraoperative radiographs were taken or fluoroscopy was utilized to evaluate position. Permanent fixation consisted of either crossing screws, percutaneous Steinmann pins, a combination of screws with a percutaneous Steinmann pin, or 1/4 tubular plate with screws. Small cortical or cancellous ASIF screws were placed in a lag fashion from dorsal-distal to plantar-proximal. Screw placement ranged from 1.0 to 1.2 em distal to the arthrodesis site and angled at 45° from the metatarsal shaft. Positioning of the screw in this manner allowed greater length to increase leverage and also ensured fixation to cross the plantar one third of the arthrodesis site (Fig. 2). Pin fixation was always utilized if the growth plate was open, which was the case in 10% of the procedures. A bone graft was used in two of the cases to avoid shortening of the first ray. These were fixed with a plate and screws. During the earlier years of performing the procedure, plantarflexion of the first metatarsal was obtained by angulating the cuts in the sagittal plane to remove a plantar wedge of bone. This was changed to trans locating the first metatarsal on the medial cuneiform
8
FIGURE 2 A, Intraoperative photograph demonstrating screws being placed approximately 1.5 cm proximal to the arthrodesis site. B, Radiograph demonstrating compression of screws placed distal-dorsal to plantar-proximal across the arthrodesis site.
All patients were placed into a posterior splint for 2 weeks and then a below-knee fiberglass cast for another 4-5 weeks. All patients were nonweightbearing with the use of crutches for 6-8 weeks. Postoperative assessment consisted of both telephone conversation and chart review. Twenty patients were contacted and interviewed over the phone and three through chart review. Follow-up ranged from 7 to 161 months with an average of 61 months. The authors reviewed satisfaction of procedure, present activity level, and footgear with each patient. Preoperative and 6-week and 12-week postoperative radiographs were also evaluated for reduction in intennetatarsal angle.
exostosis, one symptomatic nonunion, and two recurrences of deformity. These patients required revisional surgery to obtain relief. The patient with a painful dorsal exostosis underwent an exostectomy 2 years following her original procedure. The individual with a symptomatic nonunion was pain free up to 20 months postoperatively when she started playing competitive soccer, at which point symptoms developed. She underwent revisional arthrodesis and healed without complications. One of the patients with a recurrence underwent global metatarsal base osteotomies to address a severe metatarsus adductus deformity. She went on to heal uneventfully and her symptoms resolved. Postoperative radiographic evaluation revealed an average reduction in the 1- 2 intermetatarsal angle to 5.4°. This ranged from 2° to 10°. There was an 8° average decrease in the intermetatarsal angle relative to the preoperative evaluation (see Table 1).
Results
Discussion
Preoperatively, 21 of the 23 patients who were female had difficulty wearing dress shoes before surgery. All patients had an increase in pain as their activity level increased. All patients were concerned with a painful bunion deformity. Postoperatively, 21 patients were able to wear fashionable footwear without discomfort. Two patients continued to have difficulty wearing dress shoes. The activity level was unlimited for 22 patients; however, one individual had discomfort when running long distances. The results were graded by means of a modification of the criteria established by Bonney and MacNab (9). Overall there were 25 excellent, three good, and two fair results. Complications of the procedure included one painful dorsal
There are significant differences that exist which differentiate adolescent from adult hallux valgus. Many authors have cited these differences, which include an absence of a thickened medial bursa of the first metatarsal head, smaller dorsal medial eminence, and less adduction and valgus rotation of the hallux (6, 10). Growth plates may often be open and the magnitude of the 1-2 intermetatarsal angle will be increased (11). Less erosion will have OCCUlTed at the first metatarsal phalangeal joint and there may be minimal deviation of the cartilage of the first metatarsal head (6, 10, 12). These differences must be taken into consideration when evaluating the adolescent with hallux valgus.
to obtain plantarflexion, thus limiting shortening associated with wedge resection. Postoperative Care
VOLUME 38, NUMBER 1, JANUARY/FEBRUARY 1999
11
The durability of the modified Lapidus arthrodesis makes it most suitabl e for addressing adolescents with hallux valgus associated with a truly hypermobile first ray. Hypermobility is defined as excessive range of motion of a jo int and has been used interchangeably with hyperlaxity, hyperextensibility, or hyperflexibility. When the motion in the joint is in excess of the normall y accepted limits for that joint, the joint is said to be hypermobile (13). One cause of this hypermobility is the presence of generalized laxity. Measurement of first-ray motion is performed with the subtalar joint in neutral position and the midtarsal joint maximall y pronat ed. The first metatarsal is manipulated with respect to the lesser metatar sals by holding the metatarsal heads between the thumb and forefinger. Hypermobility is usually an isolated finding of the foot, but is occasionally associated with generalized ligamentous laxity. This condition may render a patient prone to recurrent deformity if these factors are not taken into consideration when planning the appropriate procedure for correct ion of hallux abducto valgus in the adolescent. Females are more often affected with adolescent hallux valgus deformities. This has been shown to be present in all major reviews of adolescent bunion surgery (9, 14-20). This also proved to be true in our study where there were 2 1 female s and only two males. It appears that metatarsus primu s adductu s is a primary deforming force implicated in developing hallux valgus. This is the conclusion of severa l authors includin g Lapidus, Truslow, and others ( 1- 3, 9). Hardy and Clapham and later Piggot disputed this theor y when they conclude that hallux valgus leads to metatarsus primus adductus ( 10, 21). It has been suggested that in order to decrease the high recurrence rate of adole scent hallux valgus, hypermobility of the first ray must be addressed (6, 7). Early studies of adolescent hallux valgus have reported recurrence rates as high as 61% and 63% (9, 14). Scranton reported a 36% overall failure rate with 56% recurrence in those individuals with hypermobile flat feet (20). Geissele also reported a 52% recurrence rate of deformity (12). Das De and Helal reported overall good results, however, there was an abnormall y high amount of lesser metatarsalgia ( 16, 17). Procedure selection for these studies consisted of different types of distal metaphyseal osteotomies which did not address instability of the first ray. Clark and Myerson presented studies in which they performed a modified Lapidu s arthrodesis in the adolescent patient with hyperm obility of the first ray. Their recurren ce rate significantly decreased compared to earlier studies (7). Our popul ation of 30 feet demon strated a low recurrence rate of 10%. The modified Lapidu s arthrodesis accomplishes two major goals not attainable with metatarsal osteotomies. This procedure will restore stability to the first ray and eliminate disturbances in weightbearing patterns of the forefoot. Additionally, the 12
THE JOURNAL OF FOOT & ANKLE SURGERY
modified Lapidus arthrodesis will address the apex of the deformity, stabilizing the articulation and thereby preventing recurrent deformity, eliminating hypermobil ity of the first ray, and eliminating multiplanar instabil ity assoc iated with an increased tenden cy for the metatarsal to shift in both the sagittal and transverse planes.
Conclusion
Long-term studies eva luating the surgical management of adolescent hallu x valgus have demonstrated high failure rates, multiple compl ications, and a significant amount of recurrence (14-1 8, 20). Lapidus and others postulated that metatarsus primus adductus is associated with instability of the first ray. The authors have presented a review of the modified Lapidu s arthrodesis on 23 adole scent individuals with good results. There were few complications and only two recurrences (10%). The modified Lapidu s arthrodesis is a reasonable option for the adolescent patient with symptomatic hallux valgus and hypermobility of the first ray.
References I. Lapidus. P. The author's bunion operation from 1931-1 959. Clin. Orthop. 16:119-1 35, 1960. 2. Lapidus, P. The operative correction of metatarsus primus varus in hallux valgus. 1. Surg. Gynecol. Obstet. 58:183- 191, 1934. 3. Albrecht, G. The pathology and treatment of hallux valgus (in Russian). Russk. Vrach. 10:14-1 9, 1911. 4. Truslow, W. Metatarsus primus varus or hallux valgus? J. Bone Joint Surg. 7:98- 108, 1925. 5. Kleinberg, S. The operative cure of hallux valgus and bunions. Am. J. Surg. 15:75-8 1, 1932. 6. Goldner, J. L., Gaines R. Adult and juvenile hallux valgus: Analysis and treatment. Orthop. Clin. 7:863- 887, 1976. 7. Clark, H., Veith, R., Hansen, S. T. Adolescent bunions treated by the modified Lapidus procedure. Bull. Hosp. Joint Dis. Orthop. Inst. 47: 109-122, 1987. 8. Sangeorzan, B. J., Hansen, S. T. Modified Lapidus procedure for hallux valgus. Foot Ankle 9:262-266, 1989. 9. Bonney. G., MacNab. 1. Hallux valgus and hallux rigidity. 1. Bone Joint Surg. 33-B:376-382, 1951. 10. Piggot, II. The natural history of hallux valgus in adolescent and early adult life. J. Bone Joint Surg. 42-B:749-76O. 1960 I I. Coughlin, M. Juvenile bunions. In Surgery of the Foot and Ankle, PI' 297- 339, edited by Mann and Coughlin. Mosby-Year Book, St. Louis, 1993. 12. Geissele, A., Stanton, R. Surgical treatment of adolescent hallux valgus. J. Pediatr. Orthop. 10:642- 649, 1990. 13. McNerney. 1. E.• Johnston, W. B. Generalized ligamentous laxity. hallux abducto valgus and the first metatarsocuneiforrnjoint. J. Am. Podiatr. Med. Assoc. 69:69-82, 1979. 14. Ball, J.• Sullivan, J. A. Treatment of the juvenile bunion by the Mitchell osteotomy. Orthopedics 8:1249-1 252, 1985. 15. Carr, C. R., Boyd, M. B. Correctional osteotomy for metatarsus primus varus and hallux valgus. J. Bone Joint Surg. 50:1353- 1367, 1968.
16. Das De, S. Distal metatarsal osteotomy for adolescent hallux valgus. J. Pediatr. Orthop. 4:32-38, 1984. 17. Helal, B. Surgery for adolescent hallux valgus. Clin. Orthop. 157:50-63, 1981. 18. Luba, R., Rosman, M. Bunions in children: Treatment with a modified Mitchell osteotomy. 1. Pediatr. Orthop. 4:44-47, 1984.
19. Pontious, 1., Mahan, K., Carter, S. Characteristics of adolescent hallux abducto valgus. J. Am. Podiatr. Med. Assoc. 84:208-- 212, 1994. 20. Scranton, P, Zuckerman, J. D. Bunion surgery in adolescents: Results of surgical treatment. 1. Pediatr. Orthop. 4(1):39-43, 1984. 21. Hardy, R. H., Clapham, 1. C. R. Observations on hallux valgus. J. Bone Joint Surg. 33-8:376-391, 1951.
VOLUME 38, NUMBER 1, JANUARY/FEBRUARY 1999
13