Maintenance of Correction of the Modified Lapidus Procedure With a First Metatarsal to Intermediate Cuneiform Cross-Screw Technique

Abstract

Background: Recurrence of deformity remains a concern when fusing the first tarsometatarsal joint for correction of hallux valgus (HV). A recently described construct adds an additional point of fixation from the plantar medial first metatarsal to the intermediate cuneiform. The purpose of this study was to determine the maintenance of correction of the first and second intermetatarsal angle, hallux valgus angle, and tibial sesamoid position after undergoing a first tarsometatarsal joint arthrodesis using the proposed construct. Methods: A radiographic review was performed of patients with HV treated with a first tarsometatarsal joint arthrodesis with the addition of a cross-screw intermediate cuneiform construct. Three observers reviewed radiographic data, including preoperative weightbearing, first weightbearing, and final weightbearing plain-film radiographs. Initial improvement and maintenance of intermetatarsal angle, hallux valgus angle (HVA), and tibial sesamoid position were evaluated radiographically. A total of 62 patients met inclusion criteria and were included in the study. Mean follow-up time was 9.3 months (SD 6.7). Results: Bony union was achieved in 60 of 62 patients (96.7%). Two of 62 patients required revision surgery as a result of recurrence (3.3%). Final mean improvement of the intermetatarsal angle (IMA) was 6.8 degrees (±2.9 degrees), HVA was 14.8 degrees (±7.5 degrees), and tibial sesamoid position was 2.4 (±1.4) positions. Mean loss of IMA correction was 1.5 degrees (±1.6), HVA was 2.9 degrees (±4.8 degrees), and tibial sesamoid position was 0.8 (±0.8). Conclusion: This study showed that the cross-screw intermediate cuneiform construct for first tarsometatarsal joint arthrodesis had a good union rate, a low complication rate, and maintained radiographic correction. Level of Evidence: Level IV, retrospective case series.

Normative Distribution of First Metatarsal Axial Rotation

“…Subsequently, reliable and reproducible 2D measures of HV severity such as the hallux valgus angle and intermetatarsal angle were developed and are still used ubiquitously today. 2,16,17,21,27,36,46 Further, numerous operations to normalize these quantitative measures of HV deformity also exist. 9,16,46 Despite the use of these 2D quantitative measures and operative correction of sagittal and transverse plane deformities, consistent rates of poor outcomes and HV recurrence persist with operative correction.…”

Recurrence of Hallux Valgus After Modified Lapidus Procedure With Successful Fusion of the Intermetatarsal and Intercuneiform Joints

“…Langan et al also included an intercuneiform fusion in order to improve foot stability. There was a significant reduction in the preoperative and postoperative IMA and HVA measurements, without a significant change postoperatively in cases of joint fusion [17]. Their study helps to validate the stability of the construct used by the senior author.…”

“…Possible benefits of this intercuneiform screw have conflicting support in the current literature. The intercuneiform screw has support from the aforementioned studies, which demonstrated the value of the additional construct stability more proximally [15][16][17]. However, a screw in this area has been studied biomechanically by Feilmeier et al [26] and does not increase stability of the first ray in the transverse or coronal planes in a TMT arthrodesis.…”

“…Additionally, the importance of successful IMT fusion in preventing deformity recurrence was further highlighted in our study by the fact that significant postoperative increase in HVA and IMA occurred in cases with nonunion. A study by Langan et al [17] evaluated a construct similar to that of the senior author. Langan et al also included an intercuneiform fusion in order to improve foot stability.…”

“…Galli et al [16] demonstrated in a cadaveric study that their crossed screw fixation, from the first metatarsal to the intermediate cuneiform, reduced sagittal mobility by an average of 1.3 mm compared to an isolated first TMT fixation. Building on that research, Langan et al [17] demonstrated with the same construct from Galli et al [16] that the bunion correction was maintained at a mean follow-up time of nine months.…”