SLR - December 2023 - Hemsted
Title: Changes in Radiographic Alignment Following Metatarsophalangeal Fusion, Distal Metatarsal Osteotomy, and LapidusReference: Dusch T, Guareschi A, Moore A, Hoch C, Gross CE, Scott DJ. Changes in Radiographic Alignment Following Metatarsophalangeal Fusion, Distal Metatarsal Osteotomy, and Lapidus. Foot Ankle Spec. 2023 Oct 16:19386400231203114. doi: 10.1177/19386400231203114. Epub ahead of print. PMID: 37846094.
Level of Evidence: Level III: Retrospective cohort study
Reviewed By: Dylan Hemsted, PGY-II
Residency Program: Cambridge Health Alliance, Cambridge MA
Podiatric Relevance: Hallux valgus deformity is a very common podiatric pathology with a multitude of ways to correct such deformity. It is imperative for the podiatric surgeon to pick the correct procedure for long term success and maintenance of correction. This article is important as it compares 3 common procedures and will help to address the radiographic outcomes postoperatively and measure of long-term success in regards to deformity correction between such groups.
Methods: Single center retrospective review identifying patients who underwent hallux valgus correction between December 2015 and October 2021. Procedures included distal metatarsal osteotomies (chevron/scarf), modified Lapidus, and first metatarsophalangeal joint arthrodesis (1st MTP fusion). Exclusion criteria: < 3 month follow up, minimally invasive procedures, and preoperative radiographic measurements less than 15o HAV or 9o IMA. Study consisted of 119 feet of 110 patients (MTP: 88, Chevron/scarf: 23, Lapidus: 8). Average age 60.49. Average follow up 1.2 yrs. Postoperative data points included complications, reoperations, readmission within 90 days post-op, time to joint union or time to osteotomy union, PROMs, and radiographic measurements. Weight bearing radiographs were obtained post up, six weeks, and final follow up. Primary outcome was to evaluate the differing effects of the first MTP arthrodesis and distal metatarsal osteotomies on radiographic first TMT alignment, as well as compared with a modified Lapidus in order to address the authors hypothesis that there would be no statistically significant difference in radiographic alignment measures among the three procedures in weightbearing images.
Results: In regards to superficial infection, deep infection, non union, 90 day readmission, and reoperation there was no statistical significant difference between the groups. The only radiographic measurement with significant difference preoperatively was the HVA angle (MTP = 33.33o, Chevron/scarf = 27.03o, Lapidus = 32.56o, P = .026). At the first follow up the distal metatarsal articular angle (DMMA) was significantly greatest among the Lapidus group (MTP = 10.14o, Chevron/scarf = 12.33o, Lapidus = 17.03o, P = .022) and it was significantly greatest at final follow up (MTP = 9.63o, Chevron/scarf = 13.51o, Lapidus = 17.45o, P = .005). The Lapidus group experienced the largest decrease in first metatarsal cuneiform angle between preoperative and follow up radiographs. The greatest significant increase in HVA and IMA from first to final follow up was noted to be with the Chevron/scarf osteotomy group. Regarding patient reported outcome measures the SSS-8 scores were significantly worse among patients undergoing chevron/scarf osteotomies. The FAOS quality of life the score was greatest in the Lapidus group.
Conclusion: The hypothesis that there would be no statistically significant difference in radiographic alignment measures between the three procedure groups was rejected by the authors as there was noted to be several statistical significant differences found on weightbearing radiographs. Notable findings from this study do suggest that 1st MTP fusion can maintain correction of a larger preoperative HAV as well as correct a DMAA better than a Lapidus. Additionally, the results show that a 1st MTP fusion and a Lapidus maintained correction better than a distal metatarsal osteotomy.