Taking A Closer Look At Lapidus Procedure Outcomes

"Don't believe the hype. I don't care how many number ones you have at the box office, I don't care how much they say you're great, don't believe it. Just stay in your lane and do what you're supposed to do."

- Tyler Perry¹

The Lapidus procedure hype is out-of-hand, but I understand it. The Lapidus is a complex procedure to do well and achieve consistent outcomes. Several steps during a Lapidus procedure are rife for potential errors and complications. Unfortunately, the industry-driven hype I’ve observed about the procedure would lead the foot and ankle surgeon to believe otherwise. A magical clamp is not a panacea for all the potential pitfalls of a Lapidus.

I believe the time has come for the device industry to have an honest discussion about the outcomes of the Lapidus. The misrepresentation of recurrence rates to foot and ankle surgeons and the public that I have observed must cease. Let's be genuine and honest about this excellent procedure and its authentic outcomes. Recurrence of deformity may not be a significant factor in patient satisfaction, but proper informed consent based on accurate data is mandatory preoperatively.^2,3

I perform the Lapidus procedure frequently, but it is not a one-procedure-fits-all hallux valgus deformities option for me. I believe hallux valgus is a triplanar deformity and that correction of all three planes is essential for anatomic reduction. Therefore, I utilize the SERI, Lapidus, and first metatarsal-phalangeal joint arthrodesis to correct hallux valgus, all of which allow for triplanar correction.

Recent, unbiased literature shined light on the truth about the recurrence of deformity with a Lapidus. For example, Galli and colleagues studied recurrence rates of the Lapidus procedure in a cohort of 127 operations.² The authors cite approximately a 15 percent recurrence rate based on literature review, which is substantially higher than some of the frequently referenced literature by industry.^2,4,5 The author's introduction stated, "Previous retrospective series have reported recurrence rates less than 15%, but our experience suggested recurrence rates were higher."²

The study used a Hallux Valgus Angle (HVA) greater than 20 degrees to define recurrence.² Other studies employed a more stringent 15 degrees HVA to determine recurrence.⁶ Therefore, and in my opinion, the Galli and colleagues study was generous on this topic. It is essential to note the average follow-up was significantly longer at 59-months compared to those studies with much lower recurrence rates.^2,4,5

The key take-home point of the study was a 38 percent recurrence rate.² This recurrence rate is more consistent with what I see in my own Lapidus patients and other surgeons' patients that come to me after a Lapidus procedure for a second opinion. I diligently correct all three planes during the procedure, and a recurrence of deformity is beyond frustrating. Of the 38 percent (48/127) experiencing recurrence, 24 percent (30/125) of the cohort perceived the recurrence. In addition,9.5 percent (12/126) of the patients required reoperation.² The authors noted, "AOFAS scores were lower with radiographic recurrence (p=0.01) and perceived recurrence (p=0.003)."² Finally, the study concluded, "Nonetheless, these results suggest radiographic and clinical outcomes are not as high as previously reported for the modified Lapidus procedure."

Interestingly, the intermetatarsal angle (IM) remained fully corrected while the HVA angle increased from the initial postoperative measurements in cases with recurrence. This finding begs the question of what is taking place with these recurrences. When I see recurrences, I will add that I see similar results where the IM angle maintains original correction, but the HVA angle is significantly worse than initially post-operatively. Could it be something to do with soft tissue balancing? I think an argument could easily be made that this is the case, as demonstrated by other studies.^7,8 Is metatarsal head shape a consideration in recurrence? For example, are those more rounded metatarsal heads more prone to recurrence? Ota and team detailed a potential torsional component to hallux valgus deformities occurring at the distal 1/3-proximal 2/3 junction.⁹ A torsional component to HAV would explain recurrence of the HVA while maintaining the IMA.

I look forward to more unbiased, evidence-based research on the Lapidus in this new "triplanar world." Then, hopefully, an open and honest discussion will take place outside of the influence of industry. It is time for industry to quit cherry-picking results to promote their products. Put out all the numbers, not just the pretty, glossy ones. Put it all out there and let surgeons and patients make informed choices, not hype-based choices.

Dr. DeHeer is the Residency Director of the St. Vincent Hospital Podiatry Program in Indianapolis. He is a Fellow of the American College of Foot and Ankle Surgeons, a Fellow of the American Society of Podiatric Surgeons, a Fellow of the American College of Foot and Ankle Pediatrics, a Fellow of the Royal College of Physicians and Surgeons of Glasgow, and a Diplomate of the American Board of Podiatric Surgery.

Dr. DeHeer discloses that he is a speaker for Paragon 28.

References

1. Tyler Perry Quotes. Brainy Quotes. Available at: https://www.brainyquote.com/quotes/tyler_perry_561225#:~:text=Tyler%20Perry%20Quotes&text=Please%20enable%20Javascript-,Don't%20believe%20the%20hype.,you're%20supposed%20to%20do. Accessed September 16, 2021.

2. Galli SH, Johnson N, Davis WH, Anderson RB, Jones III CP, Cohen BE. Patient-reported outcomes and recurrence following 127 primary lapidus surgeries for hallux valgus. Foot Ankle Orthop. 2020;5(4):2473011420S00222.

3. Matthews M, Klein E, Youssef A, et al. Correlation of radiographic measurements with patient-centered outcomes in hallux valgus surgery. Foot Ankle Int. 2018;39(12):1416-1422.

4. 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.

5. Dayton P, Santrock R, Kauwe M. Progression of healing on serial radiographs following first ray arthrodesis in the foot using a biplanar plating technique without compression.  J Foot Ankle Surg.  2019;58(3):427-433.

6. Pentikainen I, Ojala R, Ohtonen P, Piippo J, Leppilahti J. Preoperative radiological factors correlated to long-term recurrence of hallux valgus following distal chevron osteotomy. Foot Ankle Int. 2014;35(12):1262-1267.

7. Yammine K, Assi C. A meta-analysis of comparative clinical studies of isolated osteotomy versus osteotomy with lateral soft tissue release in treating hallux valgus. Foot Ankle Surg. 2019;25(5):684-690.

8. Dalmau-Pastor M. Percutaneous lateral release in hallux valgus. Advances in Minimally Invasive Surgery, An issue of Foot and Ankle Clinics of North America, EBook  2020;25(3): 373.

9. Ota T, Nagura T, Kokubo T, et al. Etiological factors in hallux valgus, a three-dimensional analysis of the first metatarsal. J Foot Ankle Res. 2017;10(1):1-6.