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Moderate Bunions: Is The Metatarsal Osteotomy More Effective Than The Tarsometatarsal Arthrodesis?
Point
Yes. Noting the more aggressive nature of the Lapidus procedure and higher non-union rates, these authors say metatarsal osteotomies such as the Scarf osteotomy and closing base wedge osteotomy provide reliable long-term correction of moderate severity bunions with minimal complications.
By Hannah Khlopas, DPM and Lawrence M. Fallat, DPM, FACFAS
Metatarsal osteotomies are a traditional treatment for moderate bunion deformities but one emerging trend is the increased popularity of the Lapidus procedure.1 With so many surgical options available, it is tempting for the surgeon to go with what is currently in vogue. However, when assessing a bunion, you must evaluate multiple parameters and choose the procedure that best suits the patient.2 It is our stance that metatarsal osteotomies are more effective in the treatment of moderate severity bunions.
The definition of a moderate bunion deformity includes a hallux valgus angle of 21 to 39 degrees and intermetatarsal (IM) angle of 12 to 17 degrees.3 There are over 100 different techniques described in the literature for treatment of this condition. One can address multiple parameters and angles, and each procedure has its own advantages and disadvantages. Surgeons can perform metatarsal osteotomies at any level. However, the more proximal the osteotomy, the greater intermetatarsal angle correction one can achieve. While metatarsal osteotomies and the Lapidus procedure both correct hallux valgus deformities, metatarsal osteotomies preserve first ray range of motion in comparison to the Lapidus procedure. In our discussion, we will focus on two metatarsal osteotomies: the Scarf osteotomy and the closing base wedge osteotomy (CBWO).
Key Aspects Of The Scarf Osteotomy
The Scarf osteotomy utilizes a midshaft osteotomy to achieve correction. Biomechanically, it is structurally stable and resistant to compressive and tension forces.4,5 Modified Scarf osteotomies can also correct rotational deformities and address length discrepancies.6 Due to the inherent stability of this procedure, one may allow patients immediate guarded weightbearing in a postoperative shoe, which is an advantage in comparison to other bunion procedures.5
In a study of 101 patients who had a Scarf osteotomy with a mean nine-year follow up, Kilmartin and O’Kane demonstrated that 92 percent of patients had no foot-related activity restrictions, and 96 percent of patients reported better postoperative outcomes in comparison to preoperative conditions.7 Out of the 101 patients who followed up, there was only one revision.
One of the common misconceptions regarding the Scarf osteotomy is that there is a high complication rate associated with this procedure. However, in a study of 100 patients who underwent a Scarf osteotomy, Smith and colleagues demonstrated only six postoperative complications.8 The authors noted an apparent learning curve contributing to these complications, which all occurred within the first 30 operations.8 In a similar study, Hammel and team demonstrated a low complication rate of one percent in a large study of 475 patients.9
Weil and colleagues showed low rates of troughing and metatarsalgia, and only two percent loss of correction.5 The study authors also noted significant improvement in the intermetatarsal and hallux valgus angles, and 92 percent of patients said would have the surgery again without any reservation.5
The Scarf procedure has proven to be an excellent option with promising results, despite having a steep learning curve.
What You Should Know About The Closing Base Wedge Osteotomy
The proximal closing base wedge osteotomy is a wedge resection at the base of the first metatarsal with the base of the wedge facing laterally. Like the Scarf procedure, it preserves first ray range of motion while correcting hallux valgus deformities.
Many studies show the powerful correction and longevity of the procedure. Dreeben and Mann evaluated 28 patients who had a closing base wedge osteotomy and demonstrated a mean correction of intermetatarsal angle correction of 13.2 degrees.10 At a mean follow-up of 5.5 years, the study authors noted the mean loss of intermetatarsal angle correction was 1.4 percent.
Some low level of evidence studies report high complication rates associated with closing base wedge osteotomies, such as first metatarsal elevatus and transfer lesions.11 Regarding elevatus, Mann and colleagues looked at proximal crescentic osteotomies and showed that dorsiflexion of the first metatarsal did not influence the presence of transfer lesions.12
Several studies found minimal complications in osteotomy healing after closing base wedge osteotomy with minimal incidence of delayed union or non-union.10,13,14 Laagay and colleagues compared the chevron osteotomy, closing base wedge osteotomy and the Lapidus osteotomy in their study of 646 patients.13 Only six out of the 646 patients had a non-union and all six patients had a Lapidus procedure. Another advantage of the closing base wedge osteotomy is a low recurrence rate.10 Assessing the combination of a proximal closing base wedge osteotomy with adductor tenotomy in 25 patients (27 procedures), Resch and coworkers only noted one case of recurrence of the hallux valgus deformity.14
When evaluating the literature, the closing base wedge osteotomy has proven to be a reliable and efficacious procedure.
Potential Pitfalls Of The Lapidus Procedure
There is no doubt that Lapidus is an effective procedure but it is not indicated for every patient. Fusion is an aggressive procedure, which permanently alters the joint mechanics. For moderate bunions, is it really necessary to violate the joint? Historically, surgeons reserved the Lapidus procedure for patients with hypermobility of the first ray. However, Coughlin and Jones concluded that stability of the first ray is based on its alignment, not intrinsically on the first tarsometatarsal joint.15 Furthermore, Dreeben and Mann concluded that fusion is not necessary for good long-term results in the correction of advanced hallux valgus deformities as there is an inherent stability of the first tarsometatarsal joint.10
Besides addressing hypermobility, other reported advantages of the Lapidus procedure include addressing frontal plane motion but surgeons can address this with other extracapsular osteotomies as well. However, the importance of frontal plane motion remains a subject of debate in the literature.16
Despite the popularity of the Lapidus procedure, it is not without risk of complications. The joint will forever be damaged and locked in the position the surgeon places it in. Furthermore, with a fusion, non-unions, delayed unions and malunions are more common than they are with metatarsal osteotomies. The literature reveals high rates of non-union for the Lapidus procedure up to 12 percent in comparison to other metatarsal osteotomies with minimal non-union rates.13,17
Delayed union can lead to an increased non-weightbearing period. Increased non-weightbearing increases risks of blood clots and other complications. Some argue that fusions have a lower bunion recurrence rate. However, if the surgeon achieves the correct osteotomy and proper correction, recurrence would not be an issue. Dreeben and Mann determined that if one corrects the intermetatarsal angle to below 10 degrees using a metatarsal osteotomy, patients would not have a bunion recurrence.10
With any surgery, there is risk of infection and iatrogenic damage to structures. It is significant to note with a Lapidus procedure, there is typically more dissection required in comparison to other osteotomies, especially if the surgeon wants to address the soft tissue or a hypertrophic first metatarsal head. Secondarily, by gaining exposure to the first metatarsocuneiform joint and ensuring adequate room for hardware, surgeons encounter more anatomical structures as they have to perform dissection closer to the neurovascular bundle. A cadaveric study by So and Hyer showed there is some anatomic risk to the neurovascular bundle when utilizing an intermetatarsal screw in a Lapidus procedure.18
Final Thoughts
There is no one universal procedure that is successful in all bunion patients and even technically well-performed procedures may result in complications. Determining the most optimal surgical technique depends on the degree of deformity and the extent of degenerative changes. It is our opinion that there is no need for an aggressive procedure such as the Lapidus procedure for bunions that are moderate in severity. The role of stability of the first tarsometatarsal joint in bunion correction is controversial as is frontal plane motion.
The literature demonstrates that metatarsal osteotomies are effective in treating moderate severity bunions. Researchers have shown that metatarsal osteotomies are dependable, achieve long-term correction and preserve the first metatarsocuneiform joint.
Dr. Khlopas is the Chief Resident with the Beaumont Health Wayne Podiatric Foot and Ankle Surgical Residency in Wayne, Mich.
Dr. Fallat is the Director of the Beaumont Health Wayne Podiatric Foot and Ankle Surgical Residency in Wayne, Mich. He is a Fellow of the American College of Foot and Ankle Surgeons.
Counterpoint
No. Sharing his experience along with evidence from the literature, this author advocates that triplanar correction capability, evolving improvements in technique and superior alignment make the tarsometatarsal arthrodesis the preferred procedure for moderate bunions over metatarsal osteotomies.
By Scott Hoffman, DPM, FACFAS
A plethora of surgical procedures exist for the treatment of hallux valgus deformity. To proclaim that one procedure is universally more effective than the rest fails to appreciate that every patient, every foot and every deformity is unique. With this in mind, I advocate that surgeons should approach each patient with a fresh set of eyes and an individualized treatment course using the tools one acquires through training and experience. With the above in mind and considering the tools in my own toolbox with regard to bunion correction, I believe that, in general, the metatarsal osteotomy is not more effective than the first tarsometatarsal arthrodesis for the treatment of moderate bunion deformity.
The Lapidus bunionectomy, first described in 1934, has historically been a procedure of choice for the treatment of severe bunion deformity and/ or in patients with instability at the first tarsometatarsal joint.1 Surgeons have historically performed the metatarsal osteotomy to treat moderate bunion deformity with proponents noting a shorter recovery period and lower complication rates in comparison to the Lapidus procedure.2-5 Some surgeons cite the prevalence of complications as a deterrent with regard to the Lapidus bunionectomy. Many deem the procedure technically challenging and criticize its elevated rate of non-union. Historically, studies quote non-union rates of the modified Lapidus arthrodesis as high as 12 percent but more recent studies suggest an average rate between 2.2 to 5 percent.2-5
The original technique for the Lapidus procedure was rather rudimentary. However, as the surgical technique and fixation options evolved, the reported rate of non-union decreased as has the typical recovery period. In a recent systematic review of patients treated for hallux valgus deformity with first tarsometatarsal joint arthrodesis and a postoperative early weightbearing protocol of two weeks or less, the rate of non-union was 3.61 percent in 443 arthrodesis procedures.4 Thus, the traditional extended recovery associated with the procedure, including an initial six-week non-weightbearing period, is currently under challenge and does not appear necessary in most cases when employing appropriate surgical technique and fixation.
With regard to complication and reoperation following the Lapidus procedure in comparison to osteotomy procedures, Lagaay and colleagues analyzed 646 patients who received either a modified chevron/Austin osteotomy (270 patients), modified Lapidus arthrodesis (342 patients) or closing base wedge osteotomy (34 patients).6 The complication rates for each of the three distinctly different procedures were very similar. The reoperation rate for Austin/chevron-type osteotomies was only slightly less at 5.56 percent versus Lapidus at 8.19 percent and the closing wedge osteotomy at 8.82 percent.
Current Considerations In Addressing Deformity Recurrence In Hallux Valgus Surgery
One of the reported potential downsides to hallux valgus surgery is a high rate of deformity recurrence, especially with regard to those procedures that do not include arthrodesis. Bock and colleagues report a 30 percent recurrence rate after the Scarf procedure.7 In a randomized controlled trial, Jeuken and team report a 75 percent recurrence rate in patients who had either a chevron or Scarf procedure.8
In recent years, there has been much more focus on correcting the deformity in all three planes: transverse, sagittal and frontal. Addressing the deformity appropriately in all three planes will rebalance the soft tissues at the first metatarsophalangeal joint and first ray, decreasing those deforming forces that might lead to recurrence. Studies show that 87 percent of patients with hallux valgus have a frontal plane component to their deformity with an average rotation of 22 degrees.9,10
Where there is a multitude of first metatarsal osteotomy procedures, the most commonly utilized osteotomies (i.e. chevron, Scarf, closing base wedge) are unable to adequately address the deformity in all three planes. Many first metatarsal osteotomies allow for only uniplanar correction in the transverse plane with reduction of the intermetatarsal angle. Some osteotomies also allow for correction in the sagittal plane, which usually involves correction of a dorsiflexed first ray. However, the frontal plane component of the deformity is usually not adequately addressed.
There has been a link between recurrence and residual first ray frontal plane deformity (pronation of the first metatarsal), which one can visualize radiographically as an increased tibial sesamoid position during the postoperative period. In studies performed by Okuda and team, failure to address metatarsal rotation resulted in a 12-fold increased risk of deformity recurrence while failing to address sesamoid subluxation resulted in a tenfold increased risk.11,12 In a recent retrospective cohort study aimed at identifying predictors of postoperative recurrence (i.e. lateral deviation of the hallux of three degrees or more), Shibuya and colleagues revealed that tibial sesamoid position was the only variable associated with recurrence.13 Additionally, when the postoperative tibial sesamoid position was greater than four, the study authors found the recurrence rate was approximately 50 percent.
The Lapidus procedure, while technically challenging, allows for correction in all three planes, stabilization of the first tarsometatarsal joint and decreases the likelihood of residual forces that may lead to recurrence of deformity. Accordingly, it can provide for a more sustainable correction regardless of the severity of deformity.
In a 2019 multicenter study, Ray and coworkers assessed hallux valgus triplanar correction through the use of a first tarsometatarsal joint arthrodesis in 62 feet.14 The recurrence rate was 3.2 percent over a 13.5-month period. While a distal metatarsal osteotomy may allow for some improvement in alignment at the first metatarsophalangeal joint (MPJ), there is a limit to the amount of correction one can achieve.
Unlike metatarsal osteotomies, the Lapidus procedure addresses the deformity closer to the center of rotation and angulation (CORA), restoring anatomic alignment of the first ray. Many would agree that there is no intrinsic deformity to the first metatarsal in a bunion deformity but acknowledge the hallux and first metatarsal have deviated from their normal position. Employing an osteotomy procedure to the first metatarsal could then introduce a surgical deformity to the bone rather than restore the normal anatomic first ray alignment.15 In the event that revision surgery is necessary, this altered first metatarsal anatomy could present a significantly increased challenge to correct.
Other Key Benefits Of The Lapidus Procedure
By stabilizing the first ray and medial column of the foot through arthrodesis, the Lapidus procedure can also adequately address overload of the lesser metatarsals. This overload often occurs in patients with initial insufficiency/instability of the first ray. Additionally, one can address intercuneiform instability through placement of a stabilization screw at the time of procedure as warranted.
In Conclusion
Ultimately, one must tailor treatment to the individual patient and foot. While I do not believe that every bunion deformity requires a Lapidus procedure, if blindly given the choice between the Lapidus procedure and a first metatarsal osteotomy, I would feel more comfortable in general that the Lapidus procedure would provide surgeons the ability to best correct the triplanar deformity, better decrease the risk of recurrence and allow for a relatively similar recovery period.
Dr. Hoffman is a fellowship-trained reconstructive foot and ankle surgeon practicing with American Health Network in Indianapolis. He is board-certified by the American Board of Foot and Ankle Surgery, and is a Fellow of the American College of Foot and Ankle Surgeons.
Point
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2. Fraissler L, Konrads C, Hoberg M, Rudert M, Walcher M. Treatment of hallux valgus deformity. EFORT Open Rev. 2016;1(8):295- 302.
3. Menz HB, Munteanu SE. Radiographic validation of the Manchester scale for the classification of hallux valgus deformity. Rheumatology. 2005;44(8):1061–1066.
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6. Larholt J, Kilmartin TE. Rotational scarf and akin osteotomy for correction of hallux valgus associated with metatarsus adductus. Foot Ankle Int. 2010;31(3):220-228.
7. Kilmartin TE, O’Kane C. Combined rotation Scarf and Akin osteotomies for hallux valgus: a patient focused 9 year follow up of 50 patients. J Foot Ankle Res. 2010;3:2. Available at: https://jfootankleres.biomedcentral.com/articles/10.1186/1757-1146-3-2 . Published February 15, 2010. Accessed September 1, 2020.
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9. Hammel E, Abi Chala ML, Wagner T. Complications of first ray osteotomies: a consecutive series of 475 feet with first metatarsal Scarf osteotomy and first phalanx osteotomy. Rev Chir Orthop Reparatrice Appar Mot. 2007;93(7):710-719.
10. Dreeben S, Mann RA. Advanced hallux valgus deformity: long-term results utilizing the distal soft tissue procedure and proximal metatarsal osteotomy. Foot Ankle Int. 1996;17(3):142-144.
11. Jeremin PJ, DeVincentis A, Goller W. Closing base wedge osteotomy: an evaluation of twenty-four cases. J Foot Surg. 1982;21(4):316-323.
12. Mann RA, Rudicel S, Graves SC. Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy. A long-term follow-up. J Bone Joint Surg Am. 1992;74(1):124-129.
13. Lagaay PM, Hamilton GA, Ford LA, Williams ME, Rush SM, Schuberth JM. Rates of revision surgery using Chevron-Austin osteotomy, Lapidus arthrodesis, and closing base wedge osteotomy for correction of hallux valgus deformity. J Foot Ankle Surg. 2008;47(4):267-272.
14. Resch S, Stenström A, Egund N. Proximal closing wedge osteotomy and adductor tenotomy for treatment of hallux valgus. Foot Ankle. 1989;9(6):272-280.
15. Coughlin MJ, Jones CP. Hallux valgus: demographics, etiology, and radiographic assessment. Foot Ankle Int. 2007;28(7):759- 777.
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18. So E, Van Dyke B, McGann MR, Brandao R, Larson D, Hyer CF. Structures at risk from an intermetatarsal screw for Lapidus bunionectomy: a cadaveric study. J Foot Ankle Surg. 2019;58(1):62-65.
Counterpoint
1. Lapidus PW. The operative correction of metatarsus primus varus in hallux valgus. Surg Gynecol Obstet. 1934;58:183.
2. Patel S, Ford LA, Etcheverry J, Rush SM, Hamilton GA. Modified Lapidus arthrodesis: rate of nonunion in 227 cases. J Foot Ankle Surg. 2004;43(1):37–42.
3. King CM, Richey J, Patel S, Collman DR. Modified Lapidus arthrodesis with crossed screw fixation: early weightbearing in 136 patients. J Foot Ankle Surg. 2015;54(1):69-75.
4. Crowell A, Van JC, Meyr AJ. Early weightbearing after arthrodesis of the first metatarsal-medial cuneiform joint: a systematic review of the incidence of nonunion. J Foot Ankle Surg. 2018;57(6):1204-1206.
5. Prissel MA, Hyer CF, Grambart ST, et al. A multicenter, retrospective study of early weightbearing for modified Lapidus arthrodesis. J Foot Ankle Surg. 2016;55(2):226- 229.
6. Lagaay PM, Hamilton GA, Ford LA, Williams ME, Rush SM, Schuberth JM. Rates of revision surgery using Chevron-Austin osteotomy, Lapidus arthrodesis, and closing base wedge osteotomy for correction of hallux valgus deformity. J Foot Ankle Surg. 2008;47(4):267-272.
7. Bock S, Kluger R, Kristen KH, Mittlbock M, Schuh R, Trnka H-R. The scarf osteotomy with minimally invasive lateral release for treatment of hallux valgus deformity: intermediate and long-term results. J Bone Joint Surg Am. 2015;97(15):1238-1245.
8. Jeuken RM, Schotanus MG, Kort NP, Deenik A, Jong B, Hendrickx RPM. Long-term follow-up of a randomized controlled trial comparing scarf to chevron osteotomy in hallux valgus correction. Foot Ankle Int. 2016;37(7):687-695.
9. Kim Y, Kim JS, Young KW, Naraghi R, Ki Cho H, Lee SY. A new measure of tibial sesamoid position in hallux valgus in relation to the coronal rotation of the first metatarsal in CT scans. Foot Ankle Int. 2015;36(8):944- 952.
10. Dayton P, Kauwe M, DiDomenico L, Feilmeier M, Reimer R. Quantitative analysis of the degree of frontal rotation required to anatomically align the first metatarsal phalangeal joint during modified tarsal-metatarsal arthrodesis without capsular balancing. J Foot Ankle Surg. 2016;55(2):220-225.
11. Okuda R, Kinoshita M, Yasuda T, Jotoku T, Kitano N, Shima H. Postoperative incomplete reduction of the sesamoids as a risk factor for recurrence of hallux valgus. J Bone Joint Surg Am. 2009;91(7):1637-1645.
12. Okuda R, Kinoshita M, Yasuda T, Jotoku T, Kitano N, Shima H: The shape of the lateral edge of the first metatarsal head as a risk factor for recurrence of hallux valgus. J Bone Joint Surg Am. 2007;89(10):2163-2172.
13. Shibuya N, Kyprios EM, Panchani PN, Martin LR, Thorud JC, Jupiter DC. Factors associated with early loss of hallux valgus correction. J Foot Ankle Surg. 2018;57(2):236-240.
14. Ray JJ, Koay J, Dayton PD, Hatch DJ, Smith B, Santrock RD. Multicenter early radiographic outcomes of triplanar tarsometatarsal arthrodesis with early weightbearing. Foot Ankle Int. 2019;40(8):955-960.
15. Paley D. Radiographic assessment of lower limb deformities. In: Principles of Deformity Correction. Berlin:Springer;2002:31-60.
