Maintenance of Hallux Valgus Correction Treated with Modified Lapidus Procedure: Intermetatarsal Miniature Suture Button vs First Metatarsal to Intermediate Cuneiform Cross-Screw Fixation

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Over time our understanding of Hallux valgus deformity has continued to improve since Lapidus published his series in 1960, however, recurrence remains as high as 38%. Fixation of the first tarsometatarsal joint has been known to improve the rigidity of the construct and reduce recurrence. While some authors employ an inter-cuneiform screw between the medial and intermediate cuneiform others provide fixation using a suspensory fixation device (Arthrex mini tightrope). However, this is limited information comparing the modified Lapidus first metatarsal arthrodesis using the suture button fixation (MT1-2 SB) and the first metatarsal intermediate cuneiform screw (MT1C2 Screw). We hypothesize that the intermediate screw fixation would have better radiographic outcomes compared to the suture button fixation. Methods: This was a retrospective comparative study between patients who underwent surgical management of hallux valgus using the MT1-2 SB and the MT1C2 screw between January 2015 to January 2023. Exclusion criteria were as follows: revision or prior hallux valgus corrective surgery on the same foot, patients who received additional procedures (i.e. midfoot fusion, or flatfoot reconstruction), and incomplete medical records. Demographic variables including age, sex, body mass index (BMI), diabetes status, and smoking status were collected. Recurrence rate, union rate, hardware removal, infection rate, and patient-reported outcomes were also collected. The radiographic variables are first metatarsal declination angle (MTD), intermetatarsal angle (IMA), hallux valgus angle (HVA), and sesamoid station. Results: We had a total of 269 patients in the MT1-2 SB cohort and 93 in the MT1C2 Screw cohort. The MT1-SB group achieved a better radiographic correction for IMA (5.37 +/- 3.21 vs 6.65 +/- 3.36, p= < 0.001), HVA (16.03 +/-7.89 vs 19.81 +/- 8.47, p= < 0.001), and sesamoid stations (0.52 +/- 0.81 vs 0.76 +/- 0.90, p= 0.19). MT1-SB had a better correction at final follow-up. Diabetes status was associated with greater postoperative pain, while smoking status was associated with worse postoperative FAAM ADL score (p= 0.011 and 0.003 respectively). Smoking was associated with a greater postoperative and final HVA in addition to an increased revision rate (15.8% vs 3.5%, p=0.037). A greater recurrence rate was also seen among smokers (15.8% vs 4.4%, p=0.061). Conclusion: Suture button fixation and first metatarsal intermediate cuneiform screw fixation demonstrated similar clinical outcomes, union rates, deformity correction, and maintenance of correction at the final follow-up. Smoking was associated with a higher rate of recurrence, revision, and worse patient-reported outcomes.