Do We Still Need Distal Procedures For First Metatarsocuneiform Arthrodesis?

The adage “old habits die hard” applies to surgery as equally as it does to life in general. During our training, we learn concepts that we often follow through our professional careers. When a conceptual change occurs regarding a specific procedure, diagnosis or therapy, it is often difficult to adjust our habits away from the old to the new.

This is an evolution that must occur when evidence-based medicine supports a conceptual change in philosophy. This is why it is imperative that foot and ankle surgeons stay current on relevant literature. One interesting emerging conceptual change occurring in foot and ankle surgery is the need for distal procedures with a first metatarsocuneiform arthrodesis.

The current literature is showing that the need for distal procedures with first metatarsocuneiform arthrodesis is at least limited to minimal soft tissue release and may not be required at all. The emerging concept of full deformity correction proximally resulting in distal soft tissue relaxation is gaining steam. The literature is showing there is no need for a McBride or distal osteotomy at the metatarsal head level. For many years, I have used a combination of first metatarsocuneiform arthrodesis, Reverdin-Green-Laird and Akin for what I term a “complex bunion” deformity. In going through relevant articles for lecture preparation and keeping up to date, I have had to rethink my approach for the “complex bunion.”

Dayton and coworkers described hallux abducto valgus as a triplane deformity.¹ The authors described this triplane deformity as fully correctable with first metatarsocuneiform arthrodesis at the deformity’s center of rotation of angulation. In this study, 25 patients had a first metatarsocuneiform arthrodesis with a limited soft tissue release distally. Surgeons can easily correct the sagittal and transverse planes with this procedure and we should take great care intraoperatively to reduce the deformities in these planes. The frontal plane deformity has been the neglected element, leading to inferior results. Dayton and coworkers described the varus rotation of the first metatarsal to correct this component of the deformity. The mean reductions in measured radiographic angles are as follows: intermetatarsal angle = 10.1 degrees, hallux abductus angle = 17.8 degrees, proximal articular set angle = 18.7 degrees and tibial sesamoid position = 3.8 degrees.

Dayton and coworkers further examined the frontal plane component of hallux abducto valgus and how surgeons correct it with varus rotation of the first metatarsal.² They radiographically evaluated the changes that occur in the first ray from 30 degree valgus to 30 degree varus in 10-degree increments. The authors measured intermetatarsal, hallux abductus and proximal articular set angles and tibial sesamoid position at each increment. They found that the tibial sesamoid position was directly related to rotation of the first metatarsal and that valgus rotation increased the tibial sesamoid position and intermetatarsal angle while varus rotation decreased the tibial sesamoid position. The conclusion was that the frontal plane rotation was required for complete anatomic reduction of hallux abducto valgus.

DiDomenico and colleagues additionally examined the frontal plane rotation of hallux abducto valgus and its relationship with first metatarsocuneiform arthrodesis.³ They described using ligamentotaxis at the metatarsophalangeal level to correct all three planes of hallux abducto valgus deformity after joint debridement of the first metatarsocuneiform prior to fixation. The authors corrected the frontal plane had correction by varus rotation of the hallux to bring the nail plate to neutral position, corrected the saggital plane by dorsiflexing the hallux and corrected the transverse plane by adducting the first metatarsal while maintaining the other two planes of correction. They first applied temporary fixation and followed this with final fixation.

Finally, Shinabarger and colleagues showed that with anatomic reduction, the distal soft tissues relaxed and allowed for the sesamoids to relocate into correct alignment.⁴ They discussed the arthrofibrosis that occurs with capsulotomy and cortical bone removal as described by Granberry, Lee and their respective colleagues.^5,6 They also referenced an article by Thordarson and Krewer that showed a statistically insignificant difference in metatarsal head width in patients with and without hallux abducto valgus, and that before and after dorsal medial prominence resection, there was no statistical change in forefoot width.⁷

This examination of the literature on this topic has caused me to change my opinion on distal procedures. I am much less likely to do a distal procedure now for complex bunions. I have adopted using extra large toe spreaders postoperatively to help stretch the lateral soft tissue structures and this has made a difference clinically in my opinion. When it comes to older patients, I do believe that more adaptive changes occur distally and this may require operative correction. However, for the younger patient, I believe distal procedures for complex bunions are unnecessary for the most part.

Old habits may indeed die hard but this discussion reemphasizes for me the importance of staying current on the literature to be the best foot and ankle physician you can be and provide the best care to your patients.

References

1. Dayton P, Feilmeier M, Kauwe M, Hirschi J. Relationship of frontal plane rotation of first metatarsal to proximal articular set angle and hallux alignment in patients undergoing tarsometatarsal arthrodesis for hallux abducto valgus: a case series and critical review of the literature. J Foot Ankle Surg. 2013; 52(3):348-354.

2. Dayton P, Feilmeier M, Kauwe M, at al. Observed changes in radiographic measurements of the first ray after frontal plane rotation of the first metatarsal in a cadaveric foot model. J Foot Ankle Surg. 2014; 53(3):274-278.

3. DiDomenico L, Fahim R, Rollandini J, Thomas ZM. Correction of frontal plane rotation of sesamoid apparatus during the Lapidus procedure: a novel approach. J Foot Ankle Surg. 2014; 53(2):248-251.

4. Shinabarger AB, Ryan MT, Dzurik M, Burns PR. Isolated first metatarsocuneiform joint fusion for correction of metatarsus primus varus deformity and literature review. J Foot Ankle Surg. 2014; 53(5):624-7.

5. Granberry WM, Hickey CH. Hallux valgus correction with metatarsal osteotomy: effect of a lateral distal soft tissue procedure. Foot Ankle Int. 1995; 16(3):132-138.

6. Lee HJ, Chung JW, Chu IT, Kim YC. Comparison of distal chevron osteotomy with and without lateral soft tissue release for the treatment of hallux valgus. Foot Ankle Int. 2010; 31(4):291-295.

7. Thordarson DB, Krewer P. Medial eminence thickness with and without hallux valgus. Foot Ankle Int. 2002; 23(1):48-50.