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Lapidus Bunionectomy: First Metatarsal– Cuneiform Arthrodesis

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Lapidus Bunionectomy: First Metatarsal– Cuneiform Arthrodesis CHAPTER Lawrence A. DiDomenico 31 Mari Wargo-Dorsey Lapidus Bunionectomy: First Metatarsal– Cuneiform Arthrodesis Metatarsus primus varus and hallux abducto valgus (HAV) hypermobile when using Root’s technique (15). Roukis et al have been used to correct HAV since originally described by have promoted the “dynamic Hicks test,” in which the foot is Albrecht (1) in 1911. Truslow (2) followed with a version of tested with the hands positioned in the same manner as Root the procedure in 1925 that involved a wedged resection of described. The hallux is then fully dorsifl exed at the fi rst meta- bone from the fi rst metatarsocuneiform joint. The procedure tarsophalangeal joint, and dorsal and plantar pressures are then was later popularized by and named after Paul Lapidus. In applied to the metatarsal head. The results of the “dynamic 1930, he proposed a fi rst metatarsal–cuneiform arthrodesis Hicks test” are then compared with those of Root’s; they believe paired with arthrodesis of the second metatarsal as well as that true hypermobility of the fi rst ray exists when both tests resection of the dorsomedial eminence of the fi rst metatarsal show a positive result of hypermobility (16). Radiographically, head and distal soft tissue repositioning for metatarsus primus hypermobility is frequently distinguished on anteroposterior varus. He believed that metatarsus primus varus was the result radiograph as an increased fi rst to second IM angle with medial of an underdeveloped atavistic foot type. He hypothesized cortical thickening of the second metatarsal, which is believed that hypermobility of the fi rst metatarsal– cuneiform joint to be due to second metatarsal overload (17). Clinically, this combined with an increased fi rst to second intermetatarsal can be accompanied with a hyperkeratotic lesion plantar to the (IM) angle caused by an oblique joint axis predisposes the second metatarsal head (18). Some advocate the test for evalu- foot to HAV and metatarsus primus varus. Lapidus concluded ation of transverse plane hypermobility, which entails wrap- that the apex of the deformity, the fi rst metatarsal–cuneiform ping an ACE wrap across the forefoot while applying moderate joint, needed to be addressed or a “bayonet-shaped” deformity tightness (19,20). Radiographs with the ACE wrap applied are would result (3). compared with normal weight-bearing radiographs to assess if While many techniques have been described modifying the hypermobility of the joint occurs in the transverse plane, which original Lapidus procedure, all use arthrodesis of the metatar- can be seen with a decreased IM angle with the apex of deform- sal–cuneiform joint (4–11). The procedure allows for triplanar ity at the fi rst metatarsal–cuneiform joint. Hypermobility is correction of fi rst metatarsal pathology, increases the biome- frequently concomitant with a large HAV deformity, although chanical advantage of the peroneus longus, and has the ability mild to moderate cases of HAV have been treated successfully to stabilize the medial column. The fi rst metatarsal–cuneiform when fi rst ray hypermobility is present (5,12,21–23). The pro- arthrodesis, while controversial, is a versatile procedure that cedure is also indicated when generalized ligamentous laxity is can correct numerous pathologies. seen with HAV. Juvenile HAV frequently is accompanied by hypermobility at the fi rst metatarsal–cuneiform joint. Adolescent HAV dif- EVALUATION/DIAGNOSIS/ fers from adult HAV in that a smaller dorsomedial eminence is FUNCTIONAL ANATOMY present and less valgus rotation of the hallux occurs (24,25). If hypermobility is present and not addressed, recurrence of the Traditionally, the fi rst metatarsal–cuneiform arthrodesis has deformity may result, as juvenile HAV frequently is a structural been used to correct for a hypermobile fi rst ray. When the fi rst problem that can persist throughout adulthood and progress metatarsal possesses increased motion of the fi rst metatarsal– (12,22). It has been demonstrated that the angle created by the cuneiform joint, the metatarsal elevates during gait, mak- axis of the fi rst metatarsal and the distal surface of the medial ing the fi rst ray unstable and unable to maintain its position cuneiform is increased with statistical signifi cance in Juvenile against ground reaction forces throughout the gait cycle (12). HAV, supporting that varus angulation occurs proximal to the Numerous attempts have been made to defi ne hypermobility metatarsal at the level of the fi rst metatarsal–cuneiform joint. in both the sagittal and transverse planes although no stand- A positive correlation also exists between the angle created ardized values exist. Clinical assessment of the fi rst ray range by the distal surface of the medial cuneiform and the axis of of motion is still currently the most accepted method to diag- the second metatarsal and an increased IM angle (26). Lower nose hypermobility of the fi rst ray. Root described normal fi rst recurrence rates have been achieved with this procedure as ray motion as equal dorsal and plantar range of motion and it addresses the deformity at its apex and eliminates fi rst ray hypermobility as anything beyond equal motion in the sagittal hypermobility (17,22,27). Juvenile HAV corrected with other plane. He placed the ankle joint and subtalar joints in neutral procedures has been noted to have recurrence rates as high position and then stabilized metatarsal heads 2 to 5 with one as 35% (27,28). The procedure is an excellent option for cor- hand and the fi rst metatarsal head with the other hand, while rection of Juvenile HAV as it can be performed successfully taking the fi rst metatarsal through its range of motion (13,14). without resection of the medial eminence and distal soft tissue Later, one thumb’s breadth of dorsal motion was described as release (17). 322 SSoutherland_Chap31.inddoutherland_Chap31.indd 332222 88/18/2012/18/2012 22:48:39:48:39 AAMM Chapter 31 • Lapidus Bunionectomy: First Metatarsal–Cuneiform Arthrodesis 323 Moderate to severe HAV can be treated effectively with this Failed HAV procedures may also elicit the need of arthrode- procedure without the presence of hypermobility. IM angles rang- sis of the Lapidus procedure as it can maintain good functional ing from 14 to 30 degrees on anteroposterior radiograph have results (44). If the deformity returns following initial surgical been used as a baseline for the procedure (24,29). Etiology of an correction, hypermobility of the fi rst metatarsal–cuneiform increased IM angle may be due to the shape of the fi rst MC joint joint needs to be assessed as well as generalized ligamentous itself, as a positive correlation exists between the obliqueness of laxity to determine if excessive movement of the joint was etiol- the joint and increased fi rst to second IM angle (30). Surgical cor- ogy of recurrence. A bone graft may need to be incorporated rection of large IM angles needs to be addressed with proximal into the joint to maintain length and restore function as the procedures, as the long lever arm allows for a higher level degree prior procedure may have shortened the fi rst metatarsal. of correction as opposed to distal procedures. The procedure Hallux limitus and metatarsal primus elevatus may also be has the ability to restore fi rst metatarsophalangeal joint congru- corrected with this procedure (21,45). With intraoperative ency and realign the sesamoid apparatus in addition to correc- plantarfl exion of the fi rst metatarsal, decompression of the tion of the IM angle. The closing base wedge osteotomy (CBWO) fi rst metatarsophalangeal joint occurs, allowing for increased and the modifi ed Lapidus were compared and both procedures motion of the joint. demonstrated signifi cant fi rst to second IM correction, with the Lapidus maintaining a greater degree of correction postopera- tively, the CBWO losing an average of 2.55 degrees of correction CRITERIA/SELECTION OF and the Lapidus losing only an average of 1.08 degrees (31). PROCEDURE/CONTRAINDICATIONS More recently, the procedure has been used in conjunction with other procedures as a practical option for treatment of Inclusion criteria for the Lapidus procedure for HAV and meta- medial column insuffi ciency and fl atfoot deformity. Addressing tarsus primus varus include a pathologic hypermobile fi rst ray, the medial column for these pathologies is vital as the fi rst meta- moderate to severe HAV with or without the presence of hyper- tarsal can accommodate up to 50% of the stress experienced mobility with a fi rst to second IM angle greater than 15 degrees, through gait and provides a paramount role in stabilizing the HAV with concurrent generalized ligamentous laxity, adoles- medial longitudinal arch (32). It is important to note that the cent HAV (Fig. 31.1), or instability at the tarsal–metatarsal joint procedure is not advocated for primary correction of these in the sagittal, transverse, and/or frontal plane. The procedure pathologies. Morton described what has become known as a can be used as an adjunctive procedure for correction of pes “Morton’s foot” in which the fi rst metatarsal is anatomically or planovalgus deformity and hallux rigidus deformity, in patients functionally short, leading to rotation about the axis of the fore- who present with a sub–second metatarsal callous/lesion, or in foot causing pronation (33–37). The goal of surgical correction conditions where tarsal–metatarsal instability exists (Fig. 31.2). of a “Morton’s foot” is to stabilize the medial column and realign Arthrodesis of the fi rst metatarsal–cuneiform joint can be per- the parabola of the metatarsal heads to distribute weight-bearing formed in the presence of painful degenerative joint and for evenly. The peroneus longus muscle gains mechanical advan- decompression of the fi rst metatarsophalangeal joint seen with tage following a Lapidus procedure contributing to functional hallux limitus and metatarsus primus elevatus.
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