Original and Modified Lapidus Procedures

Abstract

In 1934, Paul W. Lapidus submitted a short report that he would later describe as “personal communication” and “preliminary communication.” It referred to a method of first tarsometatarsal (TMT) arthrodesis for the treatment of a congenital predisposition toward hallux valgus due to metatarsus primus varus1. Although the procedure was first advocated by Albrecht in 19112, it was Lapidus who popularized the method in the following years. Therefore, the technique righteously bears his name, without Lapidus himself claiming its originality. In his 1960 paper that reviewed the prior 3 decades of having performed the procedure, the author stated that his operative technique “remains essentially the same as described originally.”3 It is interesting to see how the Lapidus procedure currently is presented in 2 leading orthopaedic journals: The Journal of Bone & Joint Surgery and Foot & Ankle International (Table I). A content search for the terms “Lapidus” and “tarsometatarsal” that included all publication dates revealed a total of 339 papers with either term listed in the title, in the abstract, as a keyword, and/or in the full text. For the term “Lapidus” alone, the relevant number was 65 studies, which include 20 clinical studies of case series, 1 survey, 1 technique description, and 1 case report. The remaining studies were either cadaveric, biomechanical, or radiographic. Additionally, there were 7 review papers that did not have an original patient population. Modifications of the Lapidus procedure, as described in each clinical paper, are impressively broad (Table II). Indeed, it is hard to find 2 studies in which the exact same technique was used. Even within a single study, some authors reported that they modified their own technique during the study period. TABLE I - Search Results for the Terms Lapidus and Tarsometatarsal in JBJS and FAI* Search Term Title Abstract Keyword Full Text Lapidus TMT Lapidus TMT Lapidus TMT Lapidus TMT JBJS 3 14 0 3 NA NA 124 215 FAI 15 27 31 101 16 29 NA NA Combined 18 41 31 104 16 29 124 215 *JBJS = The Journal of Bone & Joint Surgery, FAI = Foot & Ankle International, TMT = tarsometatarsal, and NA = not applicable. TABLE II - Published Papers on Lapidus Procedures and Modifications* Study Level of Evidence No. of Patients with Follow-up No. of Surgeons Joints Stabilized or Fused Approach Fixation (in Sequence) Bone Graft Orthobiologics Distal Procedures Comments Aiyer et al. (2016)5 III: retrospective comparative series NR 4 TMT1 + IntCunMT1 NR Plates (dorsal-medial) and screws NR NR NR Comparative study of different methods; fixation technique derived from images/figures (not described in detail in the text) Bednarz and Manoli (2000)6 IV: case series 26 1 TMT1, MT1-2 (temporary) Dorsal (between 1st and 2nd rays) + stab medial incision Two 3.5-mm screws: Local cancellous No Bunionectomy Technique attributed to ST Hansen Jr. 1. MT1 base to MedCun 2nd screw removed at 13 weeks 2. MT1 to MT2 base Coetzee and Wickum (2004)7 IV: retrospective case series 91 NR TMT1, MT1-2 (temporary) Dorsal (between 1st and 2nd rays) + stab medial incision A. Two 3.5-mm screws: Medial eminence + local cancellous ±PRP Bunionectomy, release of AHL, ± Akin procedure 1. MedCun to MT1 base 2. MT1 to MT2 B. Modification with 4.0-mm screws Coetzee et al. (2004)8 IV: retrospective case series 24 NR TMT1, MT1-2 Dorsal (between the EHL and EHB) + distal incision in the first web space + medial incision A. Two 3.5-mm screws: Local cancellous No Soft-tissue release ±bunionectomy Revision surgery for failed HV correction 1. MedCun to MT1 base 2. MT1 to MT2 Conti et al. (2020)9,10 IV: case series 31 2 TMT1 Dorsal (1st TMT) 2 crossed screws: Cancellous autograft ± ±DBM Bunionectomy, ± Akin and/or modified McBride procedure The authors have reported on the same study population and technique in 2 separate publications 1. 4.0-mm MT1 to MedCun 2. 3.5-mm MedCun to MT1 DeVries et al. (2011)11 III: retrospective comparative analysis 134 1 TMT1 ± IntCunMT1 NR A. 2 crossed TMT screws ± 3rd screw from MT1 to IntCun No ±DBM or BMA Various, not standard B. Dorsomedial locking plate ±crossed TMT screw Faber et al. (2004)12 I: therapeutic randomized controlled trial 51 1 TMT1 Dorsal, lateral to EHL + distal incision in the first web space + medial incision Two 3.5-mm crossed screws: NR No Bunionectomy + AHL release Number of feet reported, some of which are bilateral cases 1. MedCun to MT1 2. MT1 to MedCun Ellington et al. (2011)13 IV: retrospective case series 23 2 TMT1 ± MT1 to MT2 Dorsal (1st TMT) 2 crossed screws: Occasionally allograft/autograft No Bunionectomy, soft-tissue release Revision surgery for failed HV correction 1. MedCun to MT1 2. MT1 to MedCun ± 3rd screw MT1 to MT2 Habbu et al. (2011)14 IV: retrospective case series 268 2 TMT1 ± MT1-2 (temporary) NR Two 3.5-mm crossed screws: NR NR Soft-tissue release 1. MedCun to MT1 2. MT1 to MedCun ± 3rd screw MT1 to MT2 Jung et al. (2007)15 IV: retrospective case series 12 NR TMT1 Dorsolateral/medial Two 3.5-mm crossed screws: NR NR NR Primary diagnosis: TMT OA; fixation technique derived from images/figures (not described in detail in the text) 1. MedCun to MT1 2. MT1 to MedCun Kazzaz and Singh (2009)16 IV: retrospective case series 19 1 TMT1 Medial Two 3.5-mm or 4.0-mm crossed screws: NR NR Soft-tissue release + Akin 1. MedCun to MT1 2. MT1 to MedCun Klemola et al. (2017)17 III: case-control study 58 NR TMT1 NR Single, headless, variable-pitch compression screw NR NR No distal procedure Kopp et al. (2005)18 IV: retrospective case series 29 2 TMT1 Dorsal (1st TMT) Two 3.5-mm crossed screws: Local bone graft NR Soft-tissue release ±Akin 1. MedCun to MT1 2. MT1 to MedCun ± supplementary temporary Kirschner wire Langan et al. (2020)19 IV: retrospective case series 62 1 TMT1 + IntCunMT1 Dorsomedial, medial to the EHL Dorsomedial locking plate + 4.0-mm cannulated screw from base of MT1 to IntCun ± 4.0-mm cannulated screw from MT1 to MT2 NR NR Soft-tissue release ± bunionectomy ± Akin Lee and Manoli (2001)20 V: Case report 1 1 TMT1 + MT1MT2 NR Two 3.5-mm screws: NR NR Akin Method of fixation is derived from images/figures (not described in detail in the text) 1. MT1 to MedCun 2. MT1 to MT2 MacMahon et al. (2016)21 IV: retrospective case series 48 6 NR NR NR NR NR NR Ray et al. (2019)22 IV: retrospective case series 57 4 TMT1 Dorsomedial, medial to the EHL 2 small-profile, 4-hole titanium locking plates applied in biplanar 90°-90° fashion NR NR Soft-tissue release Rippstein et al. (2012)23 IV: retrospective case series 10 1 TMT1 Dorsomedial 2 crossed 3.5-mm screws: NR NR 1st MTP fusion 1. MedCun to MT1 2. MT1 to MedCun Sangeorzan and Hansen (1989)24 IV: retrospective case series 23 1 TMT1 ±MT1MT2 or MT1IntCun Dorsal, from the first web space to the TMT1 2 crossed 3.5-mm screws: Tricortical bone graft from iliac crest ± NR NR Authors state that their technique has changed during the study period 1. MedCun to MT1 2. MT1 to IntCun or MT2 Thompson et al. (2005)25 IV: retrospective case series 182 NR TMT1 Dorsal, from the first web space to the TMT1 ± medial MTP 2 crossed 3.5-mm screws: Local bone graft NR Soft-tissue release ± Akin Some of the procedures were part of a flatfoot reconstruction 1. MT1 to MedCun 2. MedCun to MT1 Toolan (2007)26 V: expert opinion surgical strategies NA NA TMT1 ± MT1MT2 Dorsal (1st TMT) Two 3.5-mm screws: Local bone graft NR Bunionectomy + AHL release 1. MT1 to MedCun 2. MedCun to MT1 or MT1 to MT2 *NR = not reported, MT = metatarsal, TMT = tarsometatarsal, IntCun = intermediate cuneiform, MedCun = medial cuneiform, PRP = platelet-rich plasma, ± = with or without, AHL = abductor hallucis longus, EHL = extensor hallucis longus, EHB = extensor hallucis brevis, HV = hallux valgus, DBM = demineralized bone matrix, BMA = bone marrow aspirate, OA = osteoarthritis, MTP = metatarsophalangeal, and NA = not applicable. A valid question is: What exactly did Lapidus describe in his original papers? Below is a step-by-step description of the technique in his own words3: Anesthesia: general anesthesia. Tourniquet use: an Esmarch bandage from the toes to the lower quarter of the leg, where it is bandaged tightly and used as a tourniquet. Distal soft-tissue procedures: medial approach at the level of the first metatarsophalangeal (MTP) joint. Identification and separation of the muscle bellies and tendons of the abductor hallucis and flexor hallucis brevis plantarly. A U-shaped capsulotomy made with its base at the proximal phalanx. Subcutaneous tenotomy of the adductor hallucis and capsulotomy through a dorsal approach. Suturing of the U-shaped flap to the abductor hallucis longus with no. 0 chromic catgut with considerable tension, but not too tightly. Bunionectomy: With the use of small wood-carving chisels at the level of the medial sagittal groove. Aiming at the metatarsal neck, with an effort to preserve the round shape of the head, with or without a dorsal cheilectomy. TMT arthrodesis approach: Dorsal, between the extensor hallucis longus (EHL) medially and extensor hallucis brevis (EHB) laterally. Joint preparation: Shaving of the articular surfaces of the base of the first metatarsal (MT) and medial cuneiform without wedge resection. Removal of cortex of the base of the first and second MTs, leaving the bone chips in situ after denuding them from soft tissues and cartilage. Fixation: A bone tunnel is created at the dorsolateral part of the base of the first MT. A no. 0 chromic catgut is passed through it and sutured to the dorsal ligaments between the medial and intermediate cuneiforms. Postoperative immobilization: A 12-cm-long and 7-mm-wide steel corset is used at the medial aspect of the first metatarsal over well-padded dressing for 3 to 4 weeks. Weight-bearing as pain allows, with or without crutches. Special canvas shoes or wool socks are worn in the first month postoperatively. An easily drawn conclusion is that nowadays practically no one performs the “original” Lapidus procedure. Moreover, a number of authors have probably misquoted the original technique because, with the exception of the 1960 review, the original papers are hard to purchase. Additionally, a number of studies have provided reports on patients who underwent “Lapidus arthrodesis” without clarifying details about the modifications that the authors used in their series. In fact, in many circles, the term “Lapidus procedure” has become synonymous with a number of first TMT arthrodesis constructs, when in fact the original description was in reference to a hallux valgus correction. The implications of this vague terminology and its endless modifications are many. From a scientific point of view, this wide variety practically renders any effort to conduct a valid meta-analysis on the subject obsolete. Multicenter studies also need to be interpreted with some caution. In a well-quoted survey by Pinney et al., 24% of 128 academic foot and ankle surgeons stated that they would perform a Lapidus arthrodesis for a hypothetical case of a patient with severe hallux valgus4. One can only wonder which of the numerous modifications of the Lapidus procedure each surgeon meant with his or her response. Coding and billing for the procedure can be equally challenging. The range of operative costs, from 2 crossed 3.5-mm screws to dual-locking titanium plating plus an allograft or the use of orthobiologics, is staggering. Additionally, the term “Lapidoplasty,” which has recently been introduced, only seems to add to the confusion. A better terminology is needed. The primary objective would be to improve the scientific quality of studies that report, combine, and compare groups of patients who undergo a first TMT arthrodesis procedure. Moreover, an improved terminology may aid in more precise coding and billing of the various modifications of the technique, which would benefit patients, health-care providers, and insurance companies. Finally, while eponyms are common in the orthopaedic lexicon, they can often lead to confusion and, therefore, an effort should be considered to avoid fostering eponyms at the expense of anatomic clarity. This initiative can only succeed with the support of a leading scientific journal that will follow through with use of the amended terminology in its future publications. Our proposal is to use 5 main descriptive terms when referring to the modifications of the Lapidus procedure, assuming that the procedures are part of hallux valgus correction. These same 5 descriptive terms should be applied when using any combination of first TMT arthrodesis as part of an arch reconstruction or flatfoot correction (Figs. 1 through 5): First TMT arthrodesis: This would include all procedures where a single arthrodesis of the base of the first MT to the medial cuneiform is performed with any means of fixation, without including the intermediate cuneiform or the base of the second MT in the fixation (Fig. 1). First TMT arthrodesis with 3-corner fixation: This term would refer to all procedures where an arthrodesis of the first TMT is combined with fixation of the intermediate cuneiform (Fig. 2-A) or the base of the second metatarsal (Fig. 2-B) without preparation of the joints for fusion. Three-corner TMT arthrodesis: The same as number 2 above, but, in addition, either the intermediate cuneiform or the base of the second MT also is fused (Figs. 3-A and 3-B, respectively). First TMT arthrodesis with 4-corner fixation: This would refer to all of the procedures that combine arthrodesis of the first TMT and fixation of the bases of the second MT and the intermediate cuneiform without preparation of the joints for fusion (Fig. 4). Four-corner TMT arthrodesis: This would include all techniques where all of the joints between the base of the first and second MTs and the medial and intermediate cuneiforms are prepared for fusion (Fig. 5). Fig. 1: Figs. 1 through 5 The new terminology for the arthrodesis of the first TMT joint. The solid parallel lines represent the joints that have been prepared for fusion; the dotted lines represent the usual direction that is used for fixation material. The dotted lines do not represent any suggestion on behalf of the authors with regard to the type, the volume, and the number of the fixation devices to be used (e.g., plates, screws, etc.). Fig. 1 Single first TMT arthrodesis. Figs. 2-A and 2-B Arthrodesis.Fig. 2-A: First TMT arthrodesis with additional fixation to the intermediate cuneiform.Fig. 2-B: First TMT arthrodesis with additional fixation to the second MT. Figs. 3-A and 3-B Arthrodesis.Fig. 3-A: Three-corner TMT arthrodesis with inclusion of the intermediate cuneiform.Fig. 3-B: Three-corner TMT arthrodesis with inclusion of the base of the second MT.Fig. 4: First TMT arthrodesis with 4-corner fixation to the intermediate cuneiform and the second MT.Fig. 5: Four-corner TMT arthrodesis with inclusion of the first and second TMT joints and the intercuneiform joint.With regard to the concomitant distal soft-tissue release procedure, a number of authors in recent studies do not include it as part of the described procedure. Therefore, we propose the addition of a capital “S” following each number for the type of procedure in order to clarify that the procedure is the combination of the arthrodesis and the distal soft-tissue release. In 2021, we will celebrate the ninetieth anniversary of the first truly original Lapidus operation that was performed on April 8, 1931. The Journal of Bone & Joint Surgery, as the official journal of the American Orthopaedic Association (AOA) and a leading journal in the field for research and teaching purposes, can be a pioneer in redefining the terminology around this widely used technique and its modifications. We would ask readers of this Orthopaedic Forum article to express their views on the topic and the proposed new terminology of the various modifications of the Lapidus procedure.

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