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Symptomatic First Metatarsocuneiform Nonunion Revised by Arthroscopic Lapidus Arthrodesis
The Journal of Foot & Ankle Surgery 51 (2012) 656–659
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Symptomatic First Metatarsocuneiform Nonunion Revised by Arthroscopic Lapidus Arthrodesis Tun Hing Lui, MBBS (HK), FRCS (Edin), FHKAM, FHKCOS Consultant, Department of Orthopaedics and Traumatology, North District Hospital, Sheung Shui, New Territories, Hong Kong SAR, China
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4 Keywords: complication endoscopy fusion lag screw metatarsal surgery
Lapidus arthrodesis is indicated for painful, advanced hallux valgus and symptomatic first ray hypermobility with or without arthrosis of the joint. Nonunion of the first metatarsocuneiform joint fusion is the most frequent complication of attempted lapidus arthrodesis. We present a case of painful first metatarsocuneiform nonunion that was successfully treated using arthroscopic revision lapidus arthrodesis to describe this unusual approach to a known postoperative complication. Ó 2012 by the American College of Foot and Ankle Surgeons. All rights reserved.
The Lapidus procedure has evolved since 1934, when Paul Lapidus reported his experience with arthrodesis of the first metatarsocuneiform joint (1). The indications for metatarsocuneiform arthrodesis include (1) painful hallux valgus with moderate to severe deformity, (2) hallux limitus, (3) first ray hypermobility with transfer metatarsalgia resulting in second metatarsal overload and second metatarsophalangeal joint synovitis, (4) symptomatic degenerative arthritis of the first metatarsocuneiform joint, and (5) combined forefoot deformities requiring first ray stabilization, including splay foot and metatarsus adductus (2–5). The contraindications to this procedure include open growth plates at the operative site and preexisting shortening of the first ray resulting from a failed previous intervention or developmental defect (4). Nonunion of attempted first metatarsocuneiform joint fusion is the most frequent complication associated with the lapidus procedure, the rates for which have been reported to range from 3.3% to 12% (6). Another complication of the lapidus procedure is shortening of the first ray, which can lead to transfer metatarsalgia localized to the central metatarsals (7). Although radiographic nonunion is the most frequent complication, only about 25% of patients with this condition have associated clinical findings (5). In the case of symptomatic first metatarsocuneiform nonunion, revision arthrodesis is indicated. In the present report, a case of painful first metatarsocuneiform
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Tun Hing Lui, MBBS (HK), FRCS (Edin), FHKAM, FHKCOS, Consultant, Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China. E-mail address: [email protected]
nonunion successfully treated by arthroscopic lapidus arthrodesis (7,8) is presented. Case Report A 51-year-old female presented with a complaint of left forefoot pain on walking and standing. Clinically, she had callosities plantar to the second and third metatarsal heads and hypermobility of the first tarsometatarsal joint (Fig. 1). Accommodative insoles failed to relieve her symptoms. Open lapidus arthrodesis was performed in June 2006 (Fig. 2). Her postoperative course progressed unremarkably, and her left foot metatarsalgia was relieved. She resumed regular, full weightbearing ambulation by 12 weeks after surgery, but the postoperative radiographs failed to reveal radiographic consolidation of the fusion site. Because her left foot appeared clinically well aligned and she was not symptomatic, she was allowed to resume regular activities at her discretion. The first metatarsal to second metatarsal transfixation screw was removed 12 weeks after the lapidus procedure was performed. She progressed without clinical symptoms until January 2009, when she complained of pain and swelling at the site of the first metatarsocuneiform nonunion. Radiographs at that time revealed progressive loosening of the remaining lag screw (Fig. 3). Because of the duration of nonunion and her clinical symptoms, the decision was made to undertake revision arthrodesis of the nonunion using arthroscopic (endoscopic) lapidus arthrodesis in April 2009. Endoscopic Technique The patient was positioned supine on the operating table, and a pneumatic tourniquet was placed about her left thigh. Spinal
1067-2516/$ - see front matter Ó 2012 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2012.06.012
T.H. Lui / The Journal of Foot & Ankle Surgery 51 (2012) 656–659
657
Fig. 1. (A and B) Clinical examination showed hypermobility of the first tarsometatarsal joint of the patient’s left foot. (C) Radiographs did not show any significant hallux valgus deformity or difference in lengths of the first, second, or third metatarsals. (D) Some degree of dorsal shift and plantar opening of the first tarsometatarsal joint in the weightbearing lateral radiographs.
anesthesia was used. First metatarsocuneiform arthroscopy was performed using dorsal and plantar portals, having first localized the sites with a needle under fluoroscopy. The 2.7-mm, 30 arthroscope was used. The soft tissue was stripped away from the nonunion with a small periosteal elevator to provide a working space for the arthroscopic instruments. The fibrous tissue of the nonunion was loosened with an arthroscopic probe and removed with an arthroscopic shaver (Fig. 4). The fusion surfaces were freshened with an
arthroscopic burr and arthroscopic awls, preserving the alignment of the residual partially threaded screw. The nonunion site was then packed with autologous cancellous bone graft, procured from the iliac crest, under arthroscopic guidance. A 2.5-mm drill guard was used to deliver the bone graft to the planned fusion interface (Fig. 5), after which an additional 4.0-mm cannulated lag screw was inserted from distally to proximally to provide additional stability to the fusion site.
Fig. 2. (A) Immediate postoperative dorsoplantar and oblique radiographs of the patient’s left foot. (B–D) Dorsoplantar, oblique, and lateral radiographs of the patient’s left foot after removal of the positioning screw.
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T.H. Lui / The Journal of Foot & Ankle Surgery 51 (2012) 656–659
Fig. 3. (A) Dorsoplantar and (B) oblique radiographs of the patient’s left foot immediately before the revision showed nonunion of the first tarsometatarsal joint with loosening of the screw.
Postoperatively, the patient was placed in a below-the-knee cast and instructed to avoid weightbearing on the left foot for the first 6 weeks, after which she was allowed weightbearing walking with the use of an orthopedic sandal. Bony union was observed radiographically by 8 weeks postoperatively (Fig. 6), and the pain that had been present before the revision arthrodesis had completely resolved. At the final follow-up examination, at 29 months after the revision surgery, the patient was fully functional in her desired shoes. Discussion Despite the applicability of first metatarsocuneiform arthrodesis, several potential complications can develop, including first metatarsal shortening, elevation, and nonunion. These have been attributed to various factors, including fixation failure, patient compliance issues, and the overall postoperative regimen (9). Preparation of the joint surfaces for fusion could be a significant factor that determines the outcome of the procedure (6). Classically, the symptomatic first
metatarsocuneiform nonunion is revised through an open surgical approach with adequate debridement of the nonunion site, surface preparation, and rigid fixation. Although radiologic evidence was found of screw loosening in our patient, the stability provided by the residual screw seemed to maintain the proper alignment in both the sagittal and the coronal planes, as well as the length of the first ray. Also, the patient’s metatarsalgia had subsided after the initial operation, and the clinical alignment of the foot remained satisfactory. For this reason, it was decided to keep the residual screw from the first lapidus operation and to revise the fusion arthroscopically. Because the screw was left in situ, the working space was limited, and the revision surgery was technically difficult. However, an experienced foot and ankle arthroscopist should be capable of performing this type of revision surgery. After preparation of the fusion surfaces and packing the interface with an autogenous bone graft, another interfragmental compression screw was added, from distally to proximally, in an effort to resist the cantilever loads applied to the first metatarsal during the midstance and propulsion phases of
Fig. 4. First tarsometatarsal arthroscopy was performed with dorsal and plantar portals. (A) The portals were identified with a needle under fluoroscopy. (B) The soft tissue was stripped away from the nonunion site with a small periosteal elevator to provide a (C) working space for the arthroscopic instruments. (D) The fibrous tissue of the nonunion site was loosened with an arthroscopic probe and removed with an arthroscopic shaver.
T.H. Lui / The Journal of Foot & Ankle Surgery 51 (2012) 656–659
659
Fig. 5. After removal of the fibrous tissue, (A) the portion of the screw inside the nonunion site was exposed. (B) The fusion surfaces were freshened with an arthroscopic burr. The nonunion site was packed with autologous cancellous bone graft under arthroscopic guidance. (C and D) A small drill guard was used as the delivery instrument.
Fig. 6. (A) Dorsoplantar, (B) oblique, and (C) lateral views showing evidence of bony union of the patient’s left foot 8 weeks after revision.
gait (6,10). The present case has demonstrated the usefulness of small joint arthroscopy for the repair of a first metatarsal–medial cuneiform nonunion. The technique has the potential advantages of arthroscopic surgery, including adequate visualization and room to manipulate without the need for large incisions and, potentially, less risk of infection and scar formation (because of limited open dissection) (7,8). References 1. Lapidus PW. Operative correction of the metatarsus varus primus in hallux valgus. Surg Gynecol Obstet 58:183–191, 1934. 2. Blitz NM. The versatility of the lapidus arthrodesis. Clin Podiatr Med Surg 26:427–441, 2009.
3. Frankel JP, Larsen DC. The misuse of the lapidus procedure: re-evaluation of the preoperative criteria. J Foot Ankle Surg 35:355–361, 1996. rard R, Stern R, Assal M. The modified lapidus procedure. Orthopedics 31:2–8, 4. Ge 2008. 5. Myerson MS, Badekas A. Hypermobility of the first ray. Foot Ankle Clin 5:469–484, 2000. 6. 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. 7. Michels F, Guillo S, de Lavigne C, Van Der Bauwhede J. The arthroscopic lapidus procedure. Foot Ankle Surg 17:25–28, 2011. 8. Lui TH, Chan KB, Ng S. Arthroscopic lapidus arthrodesis. Arthroscopy 21:1516.e1–1516.e4, 2005. 9. Menke CRD, McGlamry MC, Craig A, Camasta CA. Lapidus arthrodesis with a single lag screw and a locking H-plate. J Foot Ankle Surg 50:377–382, 2011. 10. Ray RG, Ching RP, Christensen JC, Hansen ST Jr. Biomechanical analysis of the first metatarsocuneiform arthrodesis. J Foot Ankle Surg 37:376–385, 1998.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Symptomatic First Metatarsocuneiform Nonunion Revised by Arthroscopic Lapidus Arthrodesis Tun Hing Lui, MBBS (HK), FRCS (Edin), FHKAM, FHKCOS Consultant, Department of Orthopaedics and Traumatology, North District Hospital, Sheung Shui, New Territories, Hong Kong SAR, China
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4 Keywords: complication endoscopy fusion lag screw metatarsal surgery
Lapidus arthrodesis is indicated for painful, advanced hallux valgus and symptomatic first ray hypermobility with or without arthrosis of the joint. Nonunion of the first metatarsocuneiform joint fusion is the most frequent complication of attempted lapidus arthrodesis. We present a case of painful first metatarsocuneiform nonunion that was successfully treated using arthroscopic revision lapidus arthrodesis to describe this unusual approach to a known postoperative complication. Ó 2012 by the American College of Foot and Ankle Surgeons. All rights reserved.
The Lapidus procedure has evolved since 1934, when Paul Lapidus reported his experience with arthrodesis of the first metatarsocuneiform joint (1). The indications for metatarsocuneiform arthrodesis include (1) painful hallux valgus with moderate to severe deformity, (2) hallux limitus, (3) first ray hypermobility with transfer metatarsalgia resulting in second metatarsal overload and second metatarsophalangeal joint synovitis, (4) symptomatic degenerative arthritis of the first metatarsocuneiform joint, and (5) combined forefoot deformities requiring first ray stabilization, including splay foot and metatarsus adductus (2–5). The contraindications to this procedure include open growth plates at the operative site and preexisting shortening of the first ray resulting from a failed previous intervention or developmental defect (4). Nonunion of attempted first metatarsocuneiform joint fusion is the most frequent complication associated with the lapidus procedure, the rates for which have been reported to range from 3.3% to 12% (6). Another complication of the lapidus procedure is shortening of the first ray, which can lead to transfer metatarsalgia localized to the central metatarsals (7). Although radiographic nonunion is the most frequent complication, only about 25% of patients with this condition have associated clinical findings (5). In the case of symptomatic first metatarsocuneiform nonunion, revision arthrodesis is indicated. In the present report, a case of painful first metatarsocuneiform
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Tun Hing Lui, MBBS (HK), FRCS (Edin), FHKAM, FHKCOS, Consultant, Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China. E-mail address: [email protected]
nonunion successfully treated by arthroscopic lapidus arthrodesis (7,8) is presented. Case Report A 51-year-old female presented with a complaint of left forefoot pain on walking and standing. Clinically, she had callosities plantar to the second and third metatarsal heads and hypermobility of the first tarsometatarsal joint (Fig. 1). Accommodative insoles failed to relieve her symptoms. Open lapidus arthrodesis was performed in June 2006 (Fig. 2). Her postoperative course progressed unremarkably, and her left foot metatarsalgia was relieved. She resumed regular, full weightbearing ambulation by 12 weeks after surgery, but the postoperative radiographs failed to reveal radiographic consolidation of the fusion site. Because her left foot appeared clinically well aligned and she was not symptomatic, she was allowed to resume regular activities at her discretion. The first metatarsal to second metatarsal transfixation screw was removed 12 weeks after the lapidus procedure was performed. She progressed without clinical symptoms until January 2009, when she complained of pain and swelling at the site of the first metatarsocuneiform nonunion. Radiographs at that time revealed progressive loosening of the remaining lag screw (Fig. 3). Because of the duration of nonunion and her clinical symptoms, the decision was made to undertake revision arthrodesis of the nonunion using arthroscopic (endoscopic) lapidus arthrodesis in April 2009. Endoscopic Technique The patient was positioned supine on the operating table, and a pneumatic tourniquet was placed about her left thigh. Spinal
1067-2516/$ - see front matter Ó 2012 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2012.06.012
T.H. Lui / The Journal of Foot & Ankle Surgery 51 (2012) 656–659
657
Fig. 1. (A and B) Clinical examination showed hypermobility of the first tarsometatarsal joint of the patient’s left foot. (C) Radiographs did not show any significant hallux valgus deformity or difference in lengths of the first, second, or third metatarsals. (D) Some degree of dorsal shift and plantar opening of the first tarsometatarsal joint in the weightbearing lateral radiographs.
anesthesia was used. First metatarsocuneiform arthroscopy was performed using dorsal and plantar portals, having first localized the sites with a needle under fluoroscopy. The 2.7-mm, 30 arthroscope was used. The soft tissue was stripped away from the nonunion with a small periosteal elevator to provide a working space for the arthroscopic instruments. The fibrous tissue of the nonunion was loosened with an arthroscopic probe and removed with an arthroscopic shaver (Fig. 4). The fusion surfaces were freshened with an
arthroscopic burr and arthroscopic awls, preserving the alignment of the residual partially threaded screw. The nonunion site was then packed with autologous cancellous bone graft, procured from the iliac crest, under arthroscopic guidance. A 2.5-mm drill guard was used to deliver the bone graft to the planned fusion interface (Fig. 5), after which an additional 4.0-mm cannulated lag screw was inserted from distally to proximally to provide additional stability to the fusion site.
Fig. 2. (A) Immediate postoperative dorsoplantar and oblique radiographs of the patient’s left foot. (B–D) Dorsoplantar, oblique, and lateral radiographs of the patient’s left foot after removal of the positioning screw.
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T.H. Lui / The Journal of Foot & Ankle Surgery 51 (2012) 656–659
Fig. 3. (A) Dorsoplantar and (B) oblique radiographs of the patient’s left foot immediately before the revision showed nonunion of the first tarsometatarsal joint with loosening of the screw.
Postoperatively, the patient was placed in a below-the-knee cast and instructed to avoid weightbearing on the left foot for the first 6 weeks, after which she was allowed weightbearing walking with the use of an orthopedic sandal. Bony union was observed radiographically by 8 weeks postoperatively (Fig. 6), and the pain that had been present before the revision arthrodesis had completely resolved. At the final follow-up examination, at 29 months after the revision surgery, the patient was fully functional in her desired shoes. Discussion Despite the applicability of first metatarsocuneiform arthrodesis, several potential complications can develop, including first metatarsal shortening, elevation, and nonunion. These have been attributed to various factors, including fixation failure, patient compliance issues, and the overall postoperative regimen (9). Preparation of the joint surfaces for fusion could be a significant factor that determines the outcome of the procedure (6). Classically, the symptomatic first
metatarsocuneiform nonunion is revised through an open surgical approach with adequate debridement of the nonunion site, surface preparation, and rigid fixation. Although radiologic evidence was found of screw loosening in our patient, the stability provided by the residual screw seemed to maintain the proper alignment in both the sagittal and the coronal planes, as well as the length of the first ray. Also, the patient’s metatarsalgia had subsided after the initial operation, and the clinical alignment of the foot remained satisfactory. For this reason, it was decided to keep the residual screw from the first lapidus operation and to revise the fusion arthroscopically. Because the screw was left in situ, the working space was limited, and the revision surgery was technically difficult. However, an experienced foot and ankle arthroscopist should be capable of performing this type of revision surgery. After preparation of the fusion surfaces and packing the interface with an autogenous bone graft, another interfragmental compression screw was added, from distally to proximally, in an effort to resist the cantilever loads applied to the first metatarsal during the midstance and propulsion phases of
Fig. 4. First tarsometatarsal arthroscopy was performed with dorsal and plantar portals. (A) The portals were identified with a needle under fluoroscopy. (B) The soft tissue was stripped away from the nonunion site with a small periosteal elevator to provide a (C) working space for the arthroscopic instruments. (D) The fibrous tissue of the nonunion site was loosened with an arthroscopic probe and removed with an arthroscopic shaver.
T.H. Lui / The Journal of Foot & Ankle Surgery 51 (2012) 656–659
659
Fig. 5. After removal of the fibrous tissue, (A) the portion of the screw inside the nonunion site was exposed. (B) The fusion surfaces were freshened with an arthroscopic burr. The nonunion site was packed with autologous cancellous bone graft under arthroscopic guidance. (C and D) A small drill guard was used as the delivery instrument.
Fig. 6. (A) Dorsoplantar, (B) oblique, and (C) lateral views showing evidence of bony union of the patient’s left foot 8 weeks after revision.
gait (6,10). The present case has demonstrated the usefulness of small joint arthroscopy for the repair of a first metatarsal–medial cuneiform nonunion. The technique has the potential advantages of arthroscopic surgery, including adequate visualization and room to manipulate without the need for large incisions and, potentially, less risk of infection and scar formation (because of limited open dissection) (7,8). References 1. Lapidus PW. Operative correction of the metatarsus varus primus in hallux valgus. Surg Gynecol Obstet 58:183–191, 1934. 2. Blitz NM. The versatility of the lapidus arthrodesis. Clin Podiatr Med Surg 26:427–441, 2009.
3. Frankel JP, Larsen DC. The misuse of the lapidus procedure: re-evaluation of the preoperative criteria. J Foot Ankle Surg 35:355–361, 1996. rard R, Stern R, Assal M. The modified lapidus procedure. Orthopedics 31:2–8, 4. Ge 2008. 5. Myerson MS, Badekas A. Hypermobility of the first ray. Foot Ankle Clin 5:469–484, 2000. 6. 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. 7. Michels F, Guillo S, de Lavigne C, Van Der Bauwhede J. The arthroscopic lapidus procedure. Foot Ankle Surg 17:25–28, 2011. 8. Lui TH, Chan KB, Ng S. Arthroscopic lapidus arthrodesis. Arthroscopy 21:1516.e1–1516.e4, 2005. 9. Menke CRD, McGlamry MC, Craig A, Camasta CA. Lapidus arthrodesis with a single lag screw and a locking H-plate. J Foot Ankle Surg 50:377–382, 2011. 10. Ray RG, Ching RP, Christensen JC, Hansen ST Jr. Biomechanical analysis of the first metatarsocuneiform arthrodesis. J Foot Ankle Surg 37:376–385, 1998.