Back To Basics: Why The Proximal First Metatarsal Osteotomy Is Resurging
In 1928, McMensor noted that "in medical literature, ideas are frequently presented, forgotten and presented again.”1 In recent years, we have seen a resurgence of interest in proximal first metatarsal osteotomy procedures for the correction of bunion deformities. Numerous orthopedic suppliers now provide specific fixation devices for proximal first metatarsal closing and opening wedge osteotomies. This has been an interesting phenomenon, considering the enthusiasm for the Lapidus type of bunion correction over recent years.
It is interesting to consider the reasons why physicians abandoned the proximal metaphyseal osteotomy and similar proximal osteotomies in favor of the Lapidus procedure, and whether this abandonment was in fact grounded in fact or fiction.
Paradigms changed over the years. Residents and students today are grounded with an understanding that the Lapidus procedure is preferable to the base wedge osteotomy or similar procedures.
I believe that much of the criticism directed at the proximal first metatarsal osteotomy was based on factors not inherent to the osteotomy itself. During the 1970s and early 1980s, residency training in podiatric surgery was limited with most residencies consisting of a one-year surgical experience. Less than optimal equipment was available at that time for the performance of osteotomies. Additionally, fixation choices were generally limited and often consisted of monofilament wire or Kirschner wires, supplemented by non-weightbearing in a cast. In addition, physicians generally did not appreciate the role of hypermobility early on.
Distal metaphyseal osteotomies grew in popularity during the 1970s and 1980s. James Ganley, DPM, the great podiatric teacher, practitioner and scientist, questioned the indications for distal metaphyseal osteotomies. Dr. Ganley would show a radiograph of a first metatarsal and question where the deformity within the metatarsal existed to justify performance of a distal metaphyseal osteotomy. It was Dr. Ganley's position that the deformity, metatarsus primus adductus, existed at the metatarsocuneiform joint. He therefore advocated opening wedge osteotomies of the first cuneiform bone and secondarily the Lapidus procedure. With reference to distal metaphyseal osteotomy or, in fact, any osteotomy within the first metatarsal, Dr. Ganley would note that such procedures failed to correct the true deformity and created a second deformity in compensation for the first deformity. Dr. Ganley would state as a basic principle of surgery: "Correct that which is deformed."
Physicians have advocated Lapidus procedures for use with increased intermetatarsal angulation, the presence of ligamentous laxity, the presence of central metatarsal overload associated with a bunion deformity, ligamentous laxity and joint hypermobility syndrome, deformity of the metatarsocuneiform joint, revision surgery, bunion deformity in the presence of metatarsus abductus, hypermobility, and in the presence of pronation syndromes.
Criticisms of the proximal first metatarsal osteotomy included: performance in the presence of osteopenia; increased risk of delayed union and nonunion; the need for prolonged immobilization; the presence of an “atavistic cuneiform”; performance in the presence of joint hypermobility and joint laxity; the presence of poorly controlled pronation syndromes; contraindications to prolonged immobilization; and patients with anticipated poor postoperative adherence.
In the presence of recurrent deformity, supporters of the Lapidus procedure would note that such a recurrence was not likely to occur had one performed the Lapidus procedure.
Why Surgeons Started Favoring The Lapidus
Lapidus noted that operative correction of bunion deformity must include reduction of metatarsus varus primus, a position that Morton later supported.2,3 Lapidus noted that "in the majority of cases of congenital varus primus, the current popularity of the Lapidus procedure, in podiatry, appears to have started in the Pacific Northwest secondary to the instructions of the well known and recognized foot surgery and reconstruction.”2 Hansen noted in 1996 that "Morton and Lapidus were correct" on the necessity of correcting metatarsus varus primus.4
Three main issues appear to have encouraged practitioners to perform the Lapidus procedure over proximal first metatarsal osteotomies and related procedures.
The first issue is hypermobility. In the presence of hypermobility, Lapidus supporters maintain that procedures less than arthrodesis of the first metatarsocuneiform joint are doomed to failure with a high probability of recurrence. The second issue is that of shortening or elevation of the first metatarsal with associated transfer metatarsalgia. The third main issue is the incidence of delayed union and nonunion, often cited by critics as being unacceptably high with proximal metaphyseal osteotomies.
Neylon and colleagues concluded in 2001 that the Lapidus procedure was the procedure of choice in the presence of hypermobility.5 However, an examination of relevant literature does not support the proposition, suggesting that procedures performed within the first metatarsal will fail in the presence of hypermobility.
Faber and colleagues reviewed their results comparing the Hohmann procedure with the Lapidus procedure in the presence of both hypermobility and no hypermobility associated with bunion deformity.6 The authors noted no difference in radiographic or clinical outcome and performance of these procedures. Faber and colleagues said the suggestion that a Lapidus procedure is required in the presence of hypermobility was unsupported.
In a second randomized blinded study, Faber and colleagues reported on a follow-up of 101 feet having had either a Hohmann or Lapidus procedure and found no difference in outcome including those with “hypermobility.”7 This study included an 8- to 11-year follow-up. Certainly, one would expect recurrence of bunion deformity to be evident following a Hohmann procedure after such a long period of time.
Okuda and colleagues reviewed the results of proximal first metatarsal osteotomy at one and three years post-op.8 They found no change in intermetatarsal angulation or hallux valgus deformity following the initial correction.8
Rokkanen and coworkers reviewed 52 procedures in 36 feet with an average follow-up of 1.5 years.9 Study participants had maintained correction of metatarsus primus adductus and hallux valgus in the overwhelming majority of cases. The authors reported 41 good results, nine fair results and only one poor result after 1.5 years with the intermetatarsal angle maintained at an average of 9.3 degrees and an average hallux valgus angle of 17.7 degrees.
Abbuhl and coworkers reported on an average 4.2-year follow-up of 55 patients undergoing proximal first metatarsal osteotomy for bunion correction.10 The authors noted 82 percent had very good or good results, and only 4 percent had poor results.
Takao and colleagues reviewed the results of a proximal oblique dome osteotomy of the first metatarsal for bunion deformity.11 Follow-up at one year demonstrated improvement in AOFAS scores from 54.1 to 92.8 with maintenance of correction in intermetatarsal angulation. Interestingly, the authors also noted improvement in talar declination as well as calcaneal inclination, characteristics generally ascribed to the Lapidus procedure as helpful in the correction of pronation deformities.
Haapaniemi and colleagues reported on an eight-year follow-up of 167 feet undergoing proximal first metatarsal osteotomy for the correction of bunion deformity.12 The intermetatarsal angle remained reduced to 10 degrees and 86 percent of patients regarded the procedure as having been worthwhile.
Randhawa and Pepper noted the results of proximal first metatarsal opening wedge osteotomy with a one-year follow-up.13 Patients maintained correction with the use of a bone plate and screws. The study reported maintenance of the intermetatarsal angulation at 5.8 to 9.8 degrees.
Kumar and colleagues reported on the 12.2-month follow-up of proximal first metatarsal open wedge osteotomies with maintenance of intermetatarsal angular correction at 9.2 degrees and a hallux valgus angle of 14.1 degrees.14
Zettl and coworkers reviewed the results of proximal crescentic osteotomies in 114 feet with a 26 month follow-up.15 Patients maintained intermetatarsal angulation correction at 8.8 degrees and hallux valgus correction at 14.6 degrees.
In summary, available retrospective studies, most of them greater than one year in follow-up, do not support the proposition that distal or proximal first metatarsal osteotomy are associated with a significant rate of recurrent deformity.
Examining The Evidence On Nonunion Rates
A second criticism of the proximal first metatarsal osteotomy is that of an unacceptably high rate of nonunion. However, the Lapidus procedure has a reported average nonunion rate of 10 to 12 percent. This was noted in reports by Ellington (12 percent), McInnes (12 percent), Saffo (12 percent), Coetzee (11.5 percent), Catanzariti (10.6 percent), Sangeorzan (10 percent), and Metzdorf (8.8 percent) and their respective colleagues.16-22
However, a recent report by Choi and colleagues reviewed complications of the Lapidus procedure and found that nonunion — although the most common complication following the Lapidus procedure in addition to malunion — was symptomatic in only 25 percent of patients.23 However, the fact remains that follow-up studies of the Lapidus procedure demonstrate a significant nonunion rate.
What About Shortening Of The First Metatarsal?
The proximal first metatarsal osteotomy has been criticized as resulting in an unacceptable shortening of the first metatarsal. In recent years, greater enthusiasm has developed for proximal opening wedge osteotomies in order to compensate for shortening either as a result of first metatarsal osteotomy or preexisting first metatarsal shortening.
Banks reported an average of 1.7 mm shortening following proximal closing base wedge osteotomy, Nyska and colleagues reported an average of 2.9 mm shortening, Higgins showed an average of 2.3 mm shortening, and Seiberg found an average of 2.9 mm shortening.24-27 These figures compare favorably to reports of shortening without the use of a bone graft in the performance of the Lapidus procedure, including reports by McInnes (7.5 mm shortening), Catanzariti (4.7 mm shortening) and Sangeorzan (5.0 mm shortening).17,20,21 As surgeons can compensate for the shortening of a Lapidus procedure with the use of a bone graft, one may compensate for shortening associated with performance of a proximal first metatarsal osteotomy by using an opening wedge osteotomy.
An Overview Of Reported Complications With The Lapidus Procedure
The Lapidus procedure is not without its potential complications including shortening, delayed union/nonunion and inadvertent first ray elevation. In a review of 91 patients and 105 Lapidus procedures, Coetzee and Wickum noted seven nonunions, seven patients with continuing pain requiring revision surgery, and five patients with recurrent deformity and loss of all correction.19
Myerson, Allon and McGarvey, in a review of 53 patients and 67 Lapidus procedures, noted seven nonunions, three excessively elevated first rays with the symptomatic dorsal bunion deformity, an 8 percent failure of the Lapidus procedure to relieve pain and a 15 percent rate of only "partial relief" following the Lapidus procedure.28
In addition to proximal first metatarsal osteotomy and the Lapidus procedure, a variety of alternatives have increased in popularity. Opening wedge osteotomy of the first cuneiform bone (Joplin procedure), closing wedge osteotomy of the first cuneiform bone (Riedl procedure), the Ludloff osteotomy and the proximal metaphyseal V osteotomy (Kotenberg procedure) have seen increasing use by surgeons for the correction of bunion deformity. The utilization of improved fixation techniques has made the employment of these procedures increasingly attractive with decreased postoperative morbidity.
Perhaps McMensor was correct in that procedures are advocated, forgotten and then revised in popularity. Initially, there is random fact gathering and contending schools of thought (Lapidus good, base wedge bad). Over time, observation and science clarify the contending schools of thought. We identify problems (complications of both the Lapidus and base wedge osteotomy), and a new paradigm replaces the old paradigm. Improved understanding of the roles of the Lapidus procedure and proximal metaphyseal osteotomies as well as an improvement in fixation techniques, have allowed a return to the base of the first metatarsal for the correction of bunion deformities.
1. Kelikian H. Hallux Valgus: Allied Deformities of the Forefoot and Metatarsalgia. WB Saunders, Philadelphia, 1965.
2. Lapidus PW. A quarter century of experience with the operative correction of the metatarsus varus primus in hallux valgus. Bull Hosp Joint Dis. 1956; 17(2):404-21.
3. Morton D. The Human Foot: Its Evolution, Physiology And Functional Disorders. Columbia University Press, New York, 1937.
4. Hansen S. Hallux valgus surgery. Morton and Lapidus were right! Clin Podiatr Med Surg. 1996; 13(3):347-54.
5. Neylon TA, Johnson BA, Laroche RA. Use of the Lapidus bunionectomy in first ray insufficiency. Clin Podiatr Med Surg. 2001; 18(2):365-75.
6. Faber FW, Mulder PG, Verhaar JA. Role of first ray hypermobility in the outcome of the Hohmann and the Lapidus procedure. A prospective, randomized trial involving 101 feet. J Bone Joint Surg Am. 86-A(3):486-95.
7. Faber FW, van Kampen PM, Bloembergen MW. Long-term results of the Hohmann and Lapidus procedure for the correction of hallux valgus: a prospective, randomised trial with eight- to 11-year follow-up involving 101 feet. Bone Joint J. 2013; 95-B(9):122-6.
8. Okuda R, Kinoshita M, Morikawa J, et al. Proximal metatarsal osteotomy: relationship between one- to greater than three-years results. Clin Orthop Rel Res. 2005; 435:191-6.
9. Rokkanen P, Isolauri J, Avikainen V, et al. Basal osteotomy of the first metatarsal bone in hallux valgus: experiences with the use of AO plate. Arch Orthop Trauma Surg. 1978; 92(4):233-5.
10. Abbuhl U, Morscher E, Wilson-MacDonald J. The modified Mayo procedure combined with basal valgus osteotomy of the first metatarsal for severe hallux valgus. Arch Orthop Trauma Surg. 1992; 111(6):309-13.
11. Takao M, Komatsu F, Oae K, et al. Proximal oblique-domed osteotomy of the first metatarsal for the treatment of hallux valgus associated with flatfoot: effect to the creation of the longitudinal arch of the foot. Arch Orthop Trauma Surg. 2007; 127(8):685-90.
12. Haapaniemi TM, Manninen MJ, Arajarvi EJ. Proximal osteotomy in hallux valgus, long-term results of 167 operated feet. A retrospective study. Arch Orthop Trauma Surg. 1997; 111(6-7):376-8.
13. Randhawa S, Pepper D. Radiographic evaluation of hallux valgus treated with opening wedge osteotomy. Foot Ankle Int. 2009; 30(5):427-31.
14. Kumar S, Konan S, Oddy MJ, et al. Basal medial opening wedge first metatarsal osteotomy stabilized with a low profile wedge plate. Acta Orthop Belg. 2012; 78(3):362-8.
15. Zettl R, Trnka HJ, Easley M, et al. Moderate to severe hallux valgus deformity: correction with proximal crescentic osteotomy and distal soft-tissue release. Arch Orthop Surg Trauma. 2000; 120(7-8):397-402.
16. Ellington JK, Myerson MS, Coetzee JC, Stone RM. The use of the Lapidus procedure for recurrent hallux valgus. Foot Ankle Int. 2011; 32(7):674-80.
17. McInnes BD, Bouche RT. Critical evaluation of the modified Lapidus procedure. J Foot Ankle Surg. 2001; 40(2):71-90.
18. Saffo G, Wooster MF, Stevens M, Desnouers R, Catanzariti AR. First metatarsocuneiform joint arthrodesis — a five-year retrospective analysis. J Foot Ankle Surg. 1989;28(5):459-65.
19. Coetzee JC, Wickum D. The Lapidus procedure: a prospective cohort outcome study. Foot Ankle Int. 2004; 25(8):526-31.
20. Catanzariti AR, Mendicino RW, Lee MS, Gallina MR. The modified Lapidus arthrodesis: a retrospective analysis. J Foot Ankle Surg. 1999; 38(5):322-32.
21. Sangeorzan BJ, Hansen ST Jr. Modified Lapidus procedure for hallux valgus. Foot Ankle. 1999; 9(6):262-6.
22. Metzdorf A, Strehle JK. Early complications of the modified Lapidus procedure for hallux valgus treatment in adults. The Foot. 2001;11(1):38-44.
23. Choi JH, Zide JR, Coleman SC, Brodsky JW. Prospective study of the treatment of adult primary hallux valgus with scarf osteotomy and soft tissue realignment. Foot Ankle Int. 2013;34(5):684-90.
24. Banks AS, Cargill RS 2nd, Carter S, Ruch JA. Shortening of the first metatarsal following closing base wedge osteotomy. J Am Podiatr Med Assoc. 1997;87(5):199-208.
25. Nyska M, Trnka HJ, Parks BG, Myerson MS. Proximal metatarsal osteotomies: a comparative geometric analysis based on sawbone models. Foot Ankle Int. 2002; 23(10):938-45.
26. Higgins KR, Shebetka KA, Lavery LA. Review of the effect of fixation on complication rate in the base wedge osteotomy. J Am Podiatr Med Assoc. 1996; 86(7):327-30.
27. Seiberg M, Felson S, Colson JP, et al. 1994 William J. Stickel Award. Closing base wedge versus Austin bunionectomies for metatarsus primus adductus. J Am Podiatr Med Assoc. 1994; 84(11):548-63.
28. Myerson M, Allon S, McGarvey W. Metatarsocuneiform arthrodesis for management of hallux valgus and metatarsus primus varus. Foot Ankle. 1992; 13(3):107-15.