BACKGROUND: Foot deformities and related problems of the forefoot are very common in patients with rheumatoid arthritis. The laxity of the medial cuneometatarsal joint and its synovitis are important factors in the development of forefoot deformity. The impaired joint causes the first metatarsal bone to become unstable in the frontal and sagittal planes. In this retrospective study we evaluated data of patients with rheumatoid arthritis who underwent Lapidus procedure. We evaluated the role of the instability in a group of patients, focusing mainly on the clinical symptoms and X-ray signs of the instability. METHODS: The study group included 125 patients with rheumatoid arthritis. The indications of the Lapidus procedure were a hallux valgus deformity greater than 15 degrees and varus deformity of the first metatarsal bone with the intermetatarsal angle greater than 15 degrees on anterio-posterior weight-bearing X-ray. RESULTS: Data of 143 Lapidus procedures of 125 patients with rheumatoid arthritis, who underwent surgery between 2004 and 2010 was evaluated. Signs and symptoms of the first metatarsal bone instability was found in 92 feet (64.3%) in our group. The AOFAS score was 48.6 before and 87.6 six months after the foot reconstruction. Nonunion of the medial cuneometatarsal joint arthrodesis on X-rays occurred in seven feet (4.9%). CONCLUSION: The Lapidus procedure provides the possibility to correct the first metatarsal bone varus position and its instability, as well as providing the possibility to achieve a painless foot for walking. We recommend using the procedure as a preventive surgery in poorly symptomatic patients with rheumatoid arthritis in case of the first metatarsal bone hypermobility.

1st Orthopaedic Clinic 1st Faculty of Medicine Charles University Prague 5 Úvalu 84 Prague 5 150 06 Czech Republic

See more in PubMed

Coughlin MJ, Jones CP. Hallux valgus and First Ray Mobility. J Bone Jt Surg. 2007;89-A:1887–1898. PubMed

Bednarz PA, Manoli A. Modified Lapidus procedur for the treatment of hypermobile hallux valgus. Foot and Ankle Int. 2000;21(10):816–821. PubMed

Greisberg J, Prince D, Sperber L. First Ray Mobility Increase in Patients With Metatarsalgia. Foot Ankle International. 2010;31(11):954–958. doi: 10.3113/FAI.2010.0954. PubMed DOI

Popelka S, Vavřík P, Pech J, Veigl D. Deformities of the forefoot in patients with rheumatoid arthritis – results of surgical treatment. Acta Chir. orthop. Traum. čech. 2003;70:336–342. PubMed

Popelka S, Vavřík P, Hromádka R, Sosna A. Lapidus Operation bei Patienten mit rheumatoider Arthritis – kurzfristig erreichte Ergenisse. Z Orthop Unfall. 2008;146:80–85. doi: 10.1055/s-2007-989439. PubMed DOI

Ravenell RA, Camasta CA, Powell DR. The Unreliability of the Intermetatarsal Angle in Choosing a Hallux Abducto Valgus Surgical Procedure. J Foot Ankle Surg. 2011;50(3):287–292. doi: 10.1053/j.jfas.2011.02.001. PubMed DOI

Rush SM, Christensen JC, Johnson CH. Biomechanic of the first ray. Part II: Metatarsus Primus Varus as a cause of Hypermobility. A Three-Dimensional Kinematic Analysis in a Cadaver Model. J. Foot and Ankle surg. 2000;39:68–77. doi: 10.1016/S1067-2516(00)80030-7. PubMed DOI

Morton DJ. Hypermobility of the first metatarsal bone: the interlinking factor between metatarsalgia and longitudinal arch strains. J. Bone Jt Surg. 1928;10-A:187–196.

Lapidus PW. The Author's Bunion Operation from 1931 to 1959. Clin. Orthop. 1960;16:119–135. PubMed

Lapidus PW. Operative correction in the metatarsus varus primus in hallux valgus. Surg. Gynecol. Obster. 1934;58:183–191.

Voellmicke KV, Deland JT. Technical Tip: Manual Examination Technique to Assess Instability of the First Ray. Foot and Ankle Int. 2002;23:1039–1041. PubMed

Jones CP, Coughlin MJ, Viladot P. The validity and reliability of the Klaue device. Foot and Ankle Int. 2005;26:951–956. PubMed

Klaue K, Hansen ST, Masquelet AC. Clinical quantitative assessment of first tarsometatarsal mobility in the sagital plane and its relation to hallux valgus deformity. Foot and Ankle Int. 1994;15:9–13. PubMed

Kim JY, Hwang KS, Lee KT, Young K, Jung JS. A Simple Device for Measuring the Mobility of the First Ray of the Foot. Foot and Ankle Int. 2008;29:213–218. doi: 10.3113/FAI.2008.0213. PubMed DOI

Lee KT, Young K. Measurement of First-Ray Mobility in Normal vs. Hallux Valgus Patiens. Foot and Ankle Int. 2001;22:960–964. PubMed

Smith WB, Coughlin MJ. The first metatarsocuneiform joint, hypermobility and hallux valgus. What does it all mean? Foot and Ankle surg. 2008;14:138–141. doi: 10.1016/j.fas.2008.05.006. PubMed DOI

Mitchell CL, Fleming JL, Allen R, Glenney C, Sanford GA. Osteotomy-bunionectomy for hallux valgus. J Bone Joint Surg Am. 1958;40(1):41–60. PubMed

Schneider W, Csepan R, Kasparek M, Pinggera O, Knahr K. Intra- and interobserver repeatability of radiographic measurements in hallux surgery. Acta Orthop Scand. 2002;3(6):670–673. PubMed

Hromádka R, Barták V, Popelka S, Pokorný D, Jahoda D, Sosna A. Ankle block implemented through two skin punctures. Foot Ankle Int. 2010;31:619–623. doi: 10.3113/FAI.2010.0619. PubMed DOI

Barouk LS. In: Forefoot Reconstruction. 2. Barouk LS, editor. Verlag; Springer, Paris; 2005. The Weil lesser metatarsal osteotomy; pp. 115–138.

Barouk LS. The Weil lesser metatarsal osteotomy in the treatment of metatarsalgia. Orthopade. 1996;25(4):338–344. doi: 10.1007/s001320050034. PubMed DOI

Vandeputte G, Dereymaeker G, Steenwerckx A. et al.The Weil osteotomy of the leader metatarsals: a clinical and pedobarographic followup study. Foot and Ankle Int. 2000;21(5):370–374. PubMed

Kitaoka HB, Alexander IL, Adelaar RS, Nunley JA, Myerson MS. Clinical Raiting Systems for the Ankle, Hindfoot, Midfoot, Hallux and Lesser Toe. Foot and Ankle Int. 1994;15:349–353. PubMed

Keller WL. The surgical treatment of union and hallux valgus. NY Med J. 1904;80:741.

Schneider W, Kadnar G, Kranzl A, Knahr K. Long-term results following Keller resection arthroplasty for hallux rigidus. Foot Ankle Int. 2011;32(10):933–939. doi: 10.3113/FAI.2011.0933. PubMed DOI

Akin OF. The treatment of hallux valgus: a new operative procedure and its results. Med. Sentinel. 1925;33:678–679.

Maestro M, Augoyard M, Barouk LS. et al.Biomécaniques et repéres radiologiques du sésamoide lateral de l’hallux par rapport á la palette métatarsienne. Méd.Chir.Pied. 1995;11(3):145–154.

Coughlin KV, Jones CP, Viladot R, Glano P, Grebing BR, Kennedy MJ, Shurnas PS, Alvares F. Hallux valgus and First Ray Mobility: A Cadaveic Study. Foot and Ankle Int. 2004;25:537–544. PubMed

Espinosa N, Wirth SH. Tarsometatarsal Arthrodesis for management of Unstable First Ray and Failed Bunion Surgery. Foot and Ankle Clinics. 2011;16(1):21–34. doi: 10.1016/j.fcl.2010.11.003. PubMed DOI

Faber FW, Kleinrensink GJ, Verhoog MW, Vijn AH, Snijders CJ, Mulder PG, Verhaar JA. Mobility of the first tarsometatarsal joint in relation to hallux valgus deformity: anatomical and biomechanical aspects. Foot Ankle Int. 1999;20:651–656. PubMed

Sarrafian SK. Functional Characteristics of the Foot and Planta Aponeurosis under Tibiotalar Loading. Foot and Ankle. 1987;8:4–17. PubMed

Grebing BR, Coughlin MJ. The Effect of Ankle Position on the Exam for First Ray Mobility. Foot and Ankle Int. 2004;25:467–475. PubMed

Ellington JK, Myerson MS, Coetzee LC, Stone RM. The use of the Lapidus procedure for recurrent hallux valgus. Foot and Ankle Int. 2011;32(7):674–680. doi: 10.3113/FAI.2011.0674. PubMed DOI

Fleming L, Savage TJ, Paden MH, Stone PA. Results of Modified Lapidus Arthrodesis Procedure Using Medial Eminence as an Interpositional Autograf. J Foot Ankle Surg. 2011;50(3):272–275. doi: 10.1053/j.jfas.2011.02.012. PubMed DOI

Shi K, Hayashida K, Tomita T. Surgical treatment of hallux valgus deformity in rheumatoid arthritis, clinical and radiographic evaluation of modified Lapidus technique. J Foot Ankle Surg. 2000;39:376–382. doi: 10.1016/S1067-2516(00)80073-3. PubMed DOI

Myerson MS, Badekas A. Hypermobility of the first ray. Foot-Ankle-Clin. 2000;5:469–484. PubMed

Patel S, Ford LA, Etcheverry J, Rush SM, Hamilton GA. Modified Lapidus arthrodesis: rate of nonunion in 227 cases. J Foot Ankle Surg. 2004;43:37–42. doi: 10.1053/j.jfas.2003.11.009. PubMed DOI