Instability of the Lisfranc Joint After Lapidus Bunionectomy: A Case Report

The treatment of moderate to severe hallux valgus (HV) via fusion of the first metatarsocuneiform joint is an established procedure. Indications for the procedure include moderate to severe increase in the first intermetatarsal space, hypermobility of the first ray, metatarsus primus elevatus, juvenile hallux valgus, revisional/failed procedures, and arthritic first tarsometatarsal joint.

Arthrodesis of the first tarsometatarsal (TMT) joint to treat HV was popularized by Lapidus in 1934.¹ Lapidus modified his original surgical indication in 2 publications, later stating that the procedure was indicated for an intermetatarsal angle (IMA) > 15 degrees.^2,3 Multiple AO fixation methods are available: interfragmentary screws, staples, compression plates, plantar and medial locking plates, etc. The Lapidus procedure has been known to be a powerful corrective procedure with high technical demand.

A Guide to Surgical Technique

Incision placement varies per surgeon preference. Use either a single extensile incision from the distal first metatarsophalangeal joint proximally over the first metatarsocuneiform joint, or separate incisions over the two joints. Incise the first MPJ initially and perform lateral release.

Next, perform dissection over the first tarsometatarsal joint in preparation for joint exposure. Joint prep includes removing the articular surface (via most common saw resection) off the base of the first metatarsal perpendicular to its long axis.

Next, resect the medial cuneiform articular perpendicular to the axis of the second metatarsal bone in the coronal plane; that is, cut a lateral wedge of the medial cuneiform.⁴ Inspect the joint and remove any remaining articular surface. Perform subchondral drilling to encourage healthy bleeding of fusion site.

Achieve temporary fixation and utilize manipulation of site under fluoroscopy to achieve desired correction. Utilize your choice of fixation with some form of compression across the joint to obtain final correction.

At times one would perform adjunct procedures including proximal phalanx osteotomies or distal first metatarsal osteotomies followed by layered closure of the soft tissues.

A Closer Look at Patient Presentation

A 64-year-old woman with no significant past medical history presented to the office after having a Lapidus bunionectomy by another podiatrist with a complaint of pain to her midfoot arch collapse. The patient had undergone first metatarsocuneiform joint fusion via a new popular 3D correction technique 12 weeks prior. She was very adherent with her postoperative course including four weeks of complete non-weightbearing to the operative site followed by four weeks of protected weightbearing in a below-knee controlled ankle motion (CAM) walker boot. The patient did complete a two-week course of outpatient physical therapy to help her regain strength, proper gait training, and to transition to normal gym shoes with orthotics.

The patient’s symptoms began approximately two weeks before presentation which at this point she was about 10 weeks postoperative. She relates to progression of symptoms and presents for second opinion due to change in foot structure and increase in pain.

What You Should Know About Surgery on the Lisfranc Ligament

The Lisfranc ligament is a major stabilizer of the tarsometatarsal articulation that spans the articulation of the medial cuneiform and the second metatarsal base. The first tarsometatarsal joint has large variation in its anatomy due to intrinsic and extrinsic adaptation of the joint in response to biomechanical forces. New joint prep techniques include minimal invasive procedures and 3D manipulation of the first ray. Though these techniques may be allowing easier surgical reproducibility they lack stabilization of the Lisfranc joint.

Utilizing live fluoroscopy, the first web space compression stress test may identify instability. This test was described by Valderrabano: an initial x-ray centered over the base of first and second metatarsals is taken.⁴ Next, compress the first interspace with thumb and index finger and take a second image. If the IMA opens up excessively, this suggests a first–second ray instability.

What the Exam Revealed

The non-weightbearing exam revealed healed surgical cicatrix from distal first MPJ proximally over the first metatarsocuneiform joint. Edema medially along the course of surgical site was present. Vascular status showed excellent perfusion to the foot and good capillary fill time. Neurological exam revealed hypersensitivity over the medial dorsal cutaneous nerve course and more proximally over some of the medical cutaneous dermatomes. Motion of the first MPJ was within normal limits with no tracking or crepitus noted.

On stance the patient demonstrated a collapsed medial column in comparison to the non-operative side. She had pain to the first tarsometatarsal joint with overloading second ray.

In-office x-rays revealed some diastasis > 2 mm between the medial and intermediate cuneiforms and micromotion artifact at the Lisfranc joint.

The patient is currently undergoing physical therapy and using custom orthotics to help with her foot structure and pain. If pain does not reside at the six-month mark, revisional fusion of the first metatarsal cuneiform joint and stabilization of the Lisfranc joint are recommended.

In Conclusion

The Lapidus bunionectomy is a powerful procedure in correcting moderate to severe hallux valgus deformities. The procedure requires advanced technique by surgeons and newer approaches have improved rate of non-union and healing. The author believes that Lisfranc injury leading to instability of the tarsometatarsal joint is a commonly missed complication. Intraoperative compression of the first webspace under fluoroscopy should be a standard after fixation and additional fixation to stabilize the Lisfranc joint should be considered.

Dr. Palmieri is a Fellow of the American College of Foot and Ankle Surgeons and a Diplomate of the American Board of Podiatric Medicine. He practices at Alexian Brother’s Hospital in Elk Grove Village, IL.

References

1.  Lapidus PW. Operative correction of the metatarsus varus primus in hallux valgus. Surg Gynecol Obstet. 1934;58:16.

2.  Lapidus PW. A quarter of a century experience with the operative correction of the metatarsus primus varus in hallux valgus. Bull Hosp Joint Dis. 1956; 17:404–421.

3.  Lapidus PW. The author's bunion operation from 1931 to 1959. Clin Orthop. 1960;16:119–135.

4.  Alshalawi S, Teoh KH, Alrashidi Y, et al. Lapidus arthrodesis by an anatomic dorsomedial plate. Tech Foot Ankle Surg. 2020;19(2):89-95.