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

Tracy Rupke, M.D., FRCSC
Lakeshore Orthopaedics
Manitowoc, WI, USA

The classically described Lapidus procedure consists of a fusion of the first tarsometatarsal joint as well as the bases of the first and second metatarsals and a distal soft tissue procedure1. The purpose of this fusion is to reduce the intermetatarsal angle as well as to increase weight-bearing through the first ray thereby decreasing the load on the lesser metatarsals. The original procedure was later modified by others including Sangeorzan and Hansen to include a biplanar bone resection to remove a wedge of bone from the medial cuneiform laterally and plantarly and the addition of rigid internal fixation with three screws2.

 

rupke_fig1
Figure 1: Preoperative AP showing increased hallux valgus and 1/2 intermetatarsal angle.

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

Early results showed high rates of nonunion, revision and failure3. However, there are multiple subsequent publications by a variety of authors that demonstrate significantly improved outcomes. Rates of nonunion range from 0-5.3%4,5,6. Over the years there have been attempts to utilize plating techniques to improve union rates. The recent onset of locked plating has been applied to the first tarsometatarsal joint and has been shown in vitro to have a higher load to failure than crossed screws7. In vivo, locked plates have improved fusion rates (98.5%) vs. (89.4%) with crossed screws8. Some surgeons feel that it may be safe to allow earlier weight-bearing with locked plating in order to reduce the traditional period of postoperative non-weight-bearing immobilization9.

rupke_fig2

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

The modified Lapidus can be a very powerful tool for obtaining and maintaining significant correction. The fusion allows for limitless correction of the intermetatarsal angle which is maintained over time. A retrospective review of 57 feet showed that the modified Lapidus procedure demonstrated improved maintenance of correction compared to a metatarsal closing wedge osteotomy with less radiographic recurrence10.

According to a review by Toolan, current indications for the modified Lapidus procedure include correction of moderate to severe hallux valgus with metatarsus primus varus. It is also indicated for correction of hallux valgus in adolescents with generalized ligamentous laxity and for the correction of hypermobility of the first ray with or without concomitant clinical signs of deficient weight-bearing function of the first ray. Theses coexistent signs could include transfer metatarsalgia, synovitis of the second MTP joint, mechanical overload of the second ray and as a salvage for recurrent hallux valgus after prior operative treatment. Contraindications include active infection, charcot neuroarthopathy, anticipated noncompliance, open physes, first metatarsal phalangeal arthrosis and a short first metatarsal unless an ancillary procedure is used to restore first ray length11.

rupke_fig3

Figure 3:  Postoperative lateral demonstrating crossed screw technique.

The modified Lapidus is a powerful tool for hallux valgus correction. However, the essential unanswered question is the role of hypermobility of the first ray. Is it necessary to resort to fusion for most patients? This question, in my opinion, remains unanswered based on the current literature. There is evidence to support increased first ray mobility in patients with hallux valgus vs. control subjects12,13. However, not all patients with hallux valgus demonstrate increased mobility of the first ray.

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

References

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

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