Between October 1997 and July 2000, 101 feet of eighty-seven patients
(eighty-four women and three men) had a symptomatic hallux valgus deformity
requiring operative correction, other than a first metatarsophalangeal
arthrodesis. Fourteen patients underwent a bilateral procedure. Patients were
excluded if they were less than fifteen years old or more than sixty-five
years old, if they had rheumatoid arthritis or other inflammatory diseases, or
if they had had an operation on the affected foot. Also excluded were patients
with osteoarthritis of the first tarsometatarsal joint and those with moderate
or severe osteoarthritis of the first metatarsophalangeal joint (a total range
of motion of <50° and/or radiographic signs of grade-III or IV
osteoarthritis31).
Before the examination, all patients provided written informed consent and
the study was approved by the local medical ethical committee. All patients
were examined clinically by the same observer (F.W.M.F.). Routine examination
for a hallux valgus deformity was performed according to an established
protocol. This protocol consisted of assessment of pain with use of a visual
analog scale and determination of the score on the great toe
metatarsophalangeal-interphalangeal scale of the American Orthopaedic Foot and
Ankle Society32.
This assessment incorporates both subjective and objective factors into a
numerical score to describe pain (0 to 40 points), function (0 to 45 points),
and alignment (0 to 15 points), with a maximum possible score of 100 points.
Clinical measurements of the hallux valgus angle and forefoot width were made,
and deformities of the lesser toes were noted. Patient satisfaction was
measured on a 6-point scale (with 1 indicating very satisfied; 2, satisfied;
3, quite satisfied; 4, fairly satisfied; 5, dissatisfied; and 6, very
dissatisfied), and, at the two-year follow-up examination, the patients were
asked whether they would choose the same procedure again.
The first tarsometatarsal joint mobility
test4,12,28
was performed with the ankle in neutral position and the second through fifth
metatarsals stabilized with one hand. The other hand applied force under the
first metatarsal head causing dorsal displacement. Hypermobility of the first
tarsometatarsal joint was defined as displacement of >8 to 10 mm without a
firm end point, as described by
Klaue30. After the
clinical examination, standardized weight-bearing dorsoplantar radiographs
(tube angle, 15°) and lateral radiographs (tube distance, 100 cm) were
made. On the dorsoplantar radiograph, the first metatarsophalangeal angle,
which was defined as the angle between the mid-longitudinal axis of the first
metatarsal (represented by a line bisecting the diaphysis) and the line
connecting the midpoints of the proximal and distal articular surfaces of the
proximal phalanx, was measured. The intermetatarsal angle was defined as the
angle between the mid-longitudinal axes of the first and second metatarsal,
both represented by lines bisecting the
diaphyses33. The
distal metatarsal articular angle was not measured because the reliability and
reproducibility of this measurement has been
questioned34 and
has been found to be less reliable than the measurement of the first
metatarsophalangeal and intermetatarsal
angles35.
Randomization was guaranteed by preparing sealed envelopes (one for each
patient) containing the name of the procedure to be followed (Hohmann or
Lapidus) before the start of the study. After clinical and radiographic
examination of the patient, the relevant envelope was opened and the
randomized operation to be performed was communicated to the patient. Fourteen
patients with bilateral involvement had the procedures performed at different
times, and the randomization procedure was followed again for the second foot.
The operations were all performed by or under the supervision of the same
author (F.W.M.F.).
Description of the Procedures
Both procedures were performed with the patient under general or spinal
anesthesia and placed in the supine position with a tourniquet applied.
The Hohmann Procedure (Fig.
1)
A dorsomedial incision is centered over the first metatarsophalangeal
joint. The medial dorsal cutaneous nerve is protected. On the plantar-medial
side, the tendon of the abductor hallucis muscle is freed and cut distally.
Subcapitally, a transverse incision is made in the transition zone of the
first metatarsophalangeal capsule and the periosteum. With an oscillating saw,
an osteotomy perpendicular to the shaft of the first metatarsal is performed
and a wedge-shaped piece of bone is removed. The size of the wedge depends on
the extent of the deformity. The base of the wedge must be medial (to achieve
correction of the valgus position of the great toe) and plantar in order to
keep the head of the first metatarsal in a weight-bearing position (to
compensate for the small amount of shortening and thus help to prevent
transfer metatarsalgia). The capital fragment is shifted 4 to 5 mm laterally,
and care is taken to ensure that it is tilted in a plantar direction. Fixation
is achieved with a Kirschner wire, which is drilled through the bone from the
distal-medial to the proximal-lateral aspect. The Kirschner wire is left
protruding through the skin distally, thus facilitating removal in the
outpatient clinic. The first metatarsophalangeal joint capsule (distal) is
sutured to the periosteum (proximal), and the tendon of the abductor hallucis
muscle is reattached dorsomedially to the capsule of the first
metatarsophalangeal joint. The skin is closed in a routine fashion. A
well-molded below-the-knee plaster-of-Paris splint is applied.
The Lapidus Procedure
A dorsal incision is made just lateral to the extensor hallucis longus
tendon. The cutaneous nerves are protected. In the first intermetatarsal
space, a lateral capsulotomy is performed. The oblique and transverse parts of
the adductor hallucis muscle are released from the base of the proximal
phalanx and the lateral sesamoid bone, and the transverse metatarsal ligament
is cut. A second incision is then centered over the medial eminence. The
cutaneous nerve is protected. The first metatarsophalangeal joint capsule is
incised longitudinally, and the medial eminence is resected with an
oscillating saw parallel to the medial cortex of the first metatarsal. A small
strip of capsule approximately 3 mm in width is excised, to enable reefing of
the medial capsule during closure of the wounds. The first tarsometatarsal
joint is then exposed proximally through the first incision, and the cartilage
is removed with an oscillating saw. Care is taken to remove as little bone as
possible, with most being removed from the lateral and plantar sides. This
enables the surgeon to tilt the first metatarsal in a lateral and plantar
direction. Multiple perforations of the subchondral bone of the first
metatarsal and the first cuneiform are performed with a small Kirschner wire
to enhance fusion. Fixation of the first tarsometatarsal arthrodesis is
performed with two 3.5-mm cortical lag screws. Closure of the medial capsule
is performed with interrupted sutures, and the subcutaneous tissue and skin
are closed in a routine fashion. A well-molded below-the-knee plaster-of-Paris
splint is applied.
Postoperative management of the patients was the same for the two
procedures. The patients wore a non-weight-bearing plaster-of-Paris splint for
two weeks and, after removal of the stitches, they wore a weight-bearing cast
for six more weeks. In this cast, movement of the great toe was allowed. When
the radiograph showed good bone-healing, which was usually evident at eight
weeks postoperatively, the patient was allowed unprotected weight-bearing and
ankle and toe exercises were begun. Physiotherapy was not a part of the
routine postoperative care. Measurements were made during the follow-up visits
at six months and at one and two years postoperatively. During these visits,
prior to the assessment, tape was applied to the dorsal and medial sides of
the foot by the nurse to hide the surgical scars so that the examiner was
blinded to the procedure that had been performed.
Statistics
Analysis of covariance was used to analyze the difference between the two
groups with respect to the mean scores on the American Orthopaedic Foot and
Ankle Society scale and the modification of this difference by the presence of
hypermobility in the first tarsometatarsal joint. In this analysis of
covariance, adjustment was made for the baseline score, which was included as
a covariable in a multiple linear regression model along with the dichotomous
treatment factor. The coefficient of this factor was the mean difference
between the two treatment groups with respect to the mean scores on the
American Orthopaedic Foot and Ankle Society scale, adjusted for the baseline
measurement of the score. Analysis of covariance was also used for the first
metatarsophalangeal joint angle, intermetatarsal angle, angle between the
first metatarsal and the floor, length of the first metatarsal, and forefoot
width, with each one adjusted for its own baseline measurement. In order to
test whether the baseline-adjusted mean difference in effect between the two
treatment groups varied across the two subgroups (those with a hypermobile
first tarsometatarsal joint and those with a nonhypermobile joint), a
treatment by subgroup interaction term was included in the multiple linear
regression model. The exact chisquare trend test in a four by two cross table
was used to test a difference in a categorical ordinal change from the
baseline sesamoid position between the two operations.
The Mann-Whitney test was used to compare the pain score (and its change
from baseline) and the postoperative satisfaction score for the two treatment
groups, which were also subdivided into hypermobile and nonhypermobile
subgroups. The paired t test was used to test changes from the baseline score
on the American Orthopaedic Foot and Ankle Society scale, first
metatarsophalangeal joint angle, intermetatarsal angle, angle between the
first metatarsal and the floor, length of the first metatarsal, and forefoot
width within each treatment group. The Wilcoxon signed-rank test was used to
test changes from the baseline pain score and the sesamoid position score for
each treatment group.
For each test, the level of significance was set at p < 0.05.
Preoperatively, the two groups were comparable with respect to age, pain
score, American Orthopaedic Foot and Ankle Society score, and hypermobility of
the first tarsometatarsal joint measured clinically. Fifty-one feet were
managed with the Lapidus procedure, and fifty feet had the Hohmann procedure.
The median age of the patients was forty-three years (range, sixteen to
sixty-three years) in the Lapidus group and forty-four years (range, fifteen
to sixty-three years) in the Hohmann group. Preoperatively, the median pain
score was 6 (range, 1 to 10) in both groups. Preoperatively, the mean score
(and standard deviation) on the American Orthopaedic Foot and Ankle Society
scale was 57.6 ± 7.7 points in the Lapidus group and 56.2 ± 11.2
points in the Hohmann group. Hypermobility of the first tarsometatarsal joint
was seen in thirty-six (71%) of the fifty-one feet in the Lapidus group and in
thirty-two (64%) of the fifty feet in the Hohmann group. The preoperative
measurements of the first metatarsophalangeal angles and intermetatarsal
angles were also comparable (Table
I).
No patient was lost to follow-up, although one patient emigrated just
before the two-year follow-up visit. Therefore, the results for that patient
at the one-year follow-up visit were considered the end point.
Additional procedures included further correction of hammer-toe
deformities, performed at the same time as the hallux valgus correction, in
eighteen feet (eight toes in the Lapidus group and ten toes in the Hohmann
group) and an osteotomy of the fifth metatarsal in one foot in the Lapidus
group.
Clinical Results
All data presented as results were the scores before secondary procedures.
The mean score on the system of the American Orthopaedic Foot and Ankle
Society at the twenty-four-month follow-up evaluation was 88.6 points (range,
60 to 100 points) for the Lapidus group and 89.6 points (range, 55 to 100
points) for the Hohmann group. In both groups, this represented a significant
difference from the preoperative score (paired t tests, p < 0.001).
However, after adjustment for the baseline score, with use of analysis of
covariance, no significant difference was found between the two groups with
respect to the improvement in the mean score according to the American
Orthopaedic Foot and Ankle Society system (1.4 points [the score for the
Hohmann group less the score for the Lapidus group]; p = 0.48; 95% confidence
interval, —2.5 to 5.2), or between the hypermobile and nonhypermobile
subgroups (p = 0.34).
The median pain score on the visual analog scale improved to 0 (range, 0 to
8) for the Lapidus group (Wilcoxon test, p < 0.001) and 1 (range, 0 to 5)
for the Hohmann group (Wilcoxon test, p < 0.001). No significant difference
in pain reduction was found between the two procedures (Mann-Whitney test, p =
0.58) or between the hypermobile and non-hypermobile subgroups (p = 0.58 and
0.88, respectively).
The median satisfaction rate on the 6-point scale was 2 points (range, 1 to
4 points) for the Lapidus group and 1 point (range, 1 to 5 points) for the
Hohmann group. No significant difference was found between the two procedures
(Mann-Whitney test, p = 0.95) or between the hypermobile and non-hypermobile
subgroups (p = 0.37 and 0.46, respectively).
In the Lapidus group, forty-three procedures (84%) were considered so
satisfactory by the patients that they would choose to have the same procedure
again; four procedures (8%) were considered so unsatisfactory that the
patients would not have the procedure again; and, for four procedures (8%),
the patients were indecisive. In the Hohmann group, thirty-eight procedures
(76%) were considered satisfactory; nine procedures (18%) were considered
unsatisfactory; and, for three procedures (6%), the patients were
indecisive.
Radiographic Results
The results of the radiographic analysis are provided in
Table I.
The Hohmann procedure (Figs. 2-A,
2-B, and 2-C) and
the Lapidus procedure (Figs. 3-A,
3-B, and 3-C)
provided a significant reduction in the first metatarsophalangeal joint angle
and the intermetatarsal angle (paired t tests, p < 0.001). After adjustment
for baseline with use of analysis of covariance, the difference between the
groups (the findings in the Hohmann group less those in the Lapidus group) was
not found to be significant with respect to the improvement in the first
metatarsophalangeal angle (p = 0.28; 95% confidence interval, —5.1°
to 1.5°) or the intermetatarsal angle (p = 0.38; 95% confidence interval,
—2.0° to 0.8°).
The difference between the two procedures with respect to the change in the
angle between the first metatarsal and the floor (the angle in the Hohmann
group less that in the Lapidus group), after adjustment for baseline with use
of analysis of covariance, was —3°, which was found to be
significant (p < 0.001; 95% confidence interval, —4.1 to
—1.9).
A significant improvement in the position of the sesamoids was reached
after both procedures (Wilcoxon test, p < 0.001). No significant difference
between the two procedures was found with respect to the improvement of the
sesamoid position (exact trend test, p = 0.46).
The mean shortening of the first metatarsal was calculated by subtracting
the preoperative measurement of the length of the first metatarsal from the
postoperative measurement. A correction for an artificial difference in length
due to a possible slight difference in the position of the x-ray beam was made
by multiplying the postoperative length of the first metatarsal by the ratio
of the preoperative length of the second metatarsal to the postoperative
length. The difference between the two procedures with respect to the mean
change in the length of the first metatarsal (the change in the Hohmann group
less that in the Lapidus group), adjusted for baseline with use of analysis of
covariance, was —0.46 cm, which was found to be significant (p <
0.001; 95% confidence interval, —0.56 to 0.37).
The mean reduction of forefoot width was calculated in the same manner by
subtracting the preoperative measurement of the distance between the first and
the fifth metatarsal from the postoperative measurement. A correction for bias
due to a possible slight difference in the position of the x-ray beam was made
by multiplying the postoperative measurement of the width of the first to the
fifth metatarsal by the ratio of the preoperative measurement of the length of
the second metatarsal to the postoperative measurement. With respect to the
reduction of forefoot width (that in the Hohmann Group less that in the
Lapidus group), no significant difference was found between the two procedures
(p = 0.42; 95% confidence interval, —0.42 to 0.34 cm).
Complications
Superficial wound infections occurred in two feet in the Lapidus group and
in seven feet in the Hohmann group. All of these patients were treated
successfully with oral antibiotics and, in six, with premature removal of the
Kirschner wire. No deep infections occurred.
Two patients, both in the Lapidus group, had reflex sympathetic dystrophy.
Both patients were readmitted; one was managed with intravenous administration
of mannitol combined with dimethylsulfoxide spray application, and the other
had dimethylsulfoxide spray application only. The latter patient had a good
result at the two-year follow-up visit (a score of 85 according to the system
of the American Orthopaedic Foot and Ankle Society and a patient satisfaction
rating of 1 [very satisfied]) and would choose the same procedure again. The
other patient had a fair result (a score of 82 points on the American
Orthopaedic Foot and Ankle Society system and a patient satisfaction rating of
4 [fairly satisfied]) but was indecisive about choosing the same procedure
again.
No neuromas of the dorsal-medial cutaneous nerve or the deep peroneal nerve
were observed. Transient hypoesthesia of one of these nerves occurred in
eighteen patients (eleven in the Hohmann group and seven in the Lapidus
group).
Delayed union, defined as questionable stability on manual testing and the
absence of callus formation at the osteotomy site on the eight-week
postoperative radiograph, occurred in four feet in the Hohmann group. Three
feet were treated successfully with prolonging the cast immobilization for
three weeks. One foot had a symptomatic nonunion (mobility at clinical testing
and the absence of radiographic signs of union six months after the operation)
that necessitated a reoperation. With autogenous cancellous bone-grafting and
repeat fixation with a memory staple, the osteotomy healed. However, the
patient had a bad result (a score of 55 points on the American Orthopaedic
Foot and Ankle Society system because of pain, hallux varus, shortening of the
first metatarsal, and transfer metatarsalgia). Nonunion (defined as the
absence of radiographic union six months after the operation) occurred in five
feet in the Lapidus group: four feet were completely asymptomatic and one foot
had a reoperation with autogenous cancellous bone-grafting and repeat fixation
with lag screws. This patient had a good result, with a score of 90 points on
the American Orthopaedic Foot and Ankle Society system and a patient
satisfaction rating of 2 (satisfied).
A reoperation for undercorrection and/or recurrence was necessary in one
patient in the Lapidus group and in two patients in the Hohmann group. The
patient in the Lapidus group was managed with a chevron osteotomy, and the end
result was excellent. In the Hohmann group, one patient had a soft-tissue
procedure about the first metatarsophalangeal joint and the other patient had
the same procedure combined with a proximal osteotomy of the first metatarsal.
The outcomes after both reoperations were good, with a score of 75 points on
the American Orthopaedic Foot and Ankle Society system and a high satisfaction
rating for one patient and a score of 85 points and a high satisfaction rating
for the other patient.
Despite countersinking of the screw heads, seven patients complained about
the screws, necessitating their removal under local anesthesia. One of these
patients also had correction of the scar, which had become unsatisfactory
after a superficial wound infection.
A hallux varus deformity developed in the patient in the Hohmann group who
had had a reoperation because of nonunion. It also developed in three patients
in the Lapidus group. The deformity was completely asymptomatic in two
patients and caused only cosmetic problems in the third patient, who did not
consider the matter serious enough for a reoperation.
Transfer metatarsalgia, defined as the development of pain and callosities
under the lesser metatarsal heads, occurred in four patients in the Hohmann
group and in two patients in the Lapidus group. All were treated
conservatively, with use of a shoe insert, and had a successful result.
No patient had deep venous thrombosis or osteonecrosis of the head of the
first metatarsal.
Recent reports have indicated that a painful hallux valgus deformity and
hypermobility of the first ray in the sagittal plane are
related1-5.
Consequently, hypermobility of the first tarsometatarsal joint could be a
relevant factor in the decision about which operative procedure to use to
correct the hallux valgus deformity: a Lapidus procedure or a different one,
without inclusion of an arthrodesis of the first tarsometatarsal joint. In the
present prospective study, the Lapidus procedure was compared with the Hohmann
procedure. Only patients without radiographic signs of arthritis of the first
tarsometatarsal joint were included.
Comparisons of the clinical results of the two procedures in the present
study with those in previous studies have to be made with some caution because
of differences in the duration of follow-up, the specific operative
techniques, and the postoperative treatment. In addition, the previous studies
on the Lapidus and Hohmann procedures did not use a universally acknowledged
system for the measurement of the outcome and they were retrospective.
Although there is a lack of repeatability and validity assessment studies for
outcome scores, presentation of the results of forefoot surgery with a
numerical score is now
advised36,37,
preferably combined with other criteria. In this way, the results of different
treatment procedures can be compared more reliably. In the present study, the
results of the Lapidus procedure were good, as indicated by an improvement in
the mean score on the American Orthopaedic Foot and Ankle Society system from
58 points to 89 points and by the finding that the outcome after 84% of the
procedures was considered by the patients to be so satisfactory that they
would undergo the same procedure again. These findings are in agreement with
those in previous studies, which have described a 73% to 96% rate of
satisfactory or good-to-excellent clinical
results11,13,15,28.
A comparison of our results with those in previous reports on the Hohmann
procedure provides a similar picture. In the present study, the mean American
Orthopaedic Foot and Ankle Society score improved from 56 points to 90 points
and the outcome after 76% of the procedures was considered by the patients to
be so satisfactory that they would undergo the same procedure again. Other
studies have described a 77% to 97% rate of satisfactory or good-to-excellent
clinical
results19,22-24,26.
Our results did not show a significant difference between the two
procedures with respect to the American Orthopaedic Foot and Ankle Society
score, pain score, or satisfaction. This finding is interesting because all of
the patients who met the inclusion criteria were enrolled in this one study,
whereas the Hohmann procedure is generally recommended for the treatment of
mild-to-moderate hallux valgus
deformity20,24,38
and the Lapidus procedure is chosen for a hallux valgus deformity with
hypermobility of the first tarsometatarsal
joint6-13,15,23.
However, the exact definition of hypermobility of the first tarsometatarsal
joint is still unclear, and all previous studies presenting the results of the
Lapidus procedure, as well as our study, have relied on the clinical diagnosis
of hypermobility of the first tarsometatarsal joint. We did not find a
significant difference in the clinical results between the feet with a
hypermobile first tarsometatarsal joint and those with a nonhypermobile joint,
for either type of procedure. A possible explanation for this finding could be
the imprecise definition of hypermobility of the first tarsometatarsal joint.
The clinical test and its interpretation are subjective, and the validity is
unknown. Several studies have been performed to determine hypermobility in the
first tarsometatarsal joint in an objective and quantifiable
way1,2,4,5.
Special devices, which are not commonly available, have been
used2,4,5,
but, in those studies, the total mobility of the first ray was measured and
not the mobility of the first tarsometatarsal joint selectively. Also, a
lateral stress radiograph with use of a simple strut has been described, but a
specific radiographic value to define hypermobility of the first
tarsometatarsal joint has not been
found1. Thus,
although there are several indications of a relation between hypermobility of
the first tarsometatarsal joint and a symptomatic hallux valgus deformity,
there is no uniform, valid method to quantify it objectively. The clinical
test may be too unreliable to distinguish between first tarsometatarsal joints
that are truly hypermobile or nonhypermobile. This could explain the lack of
differences in the clinical results between the two subgroups in this
study.
The radiographic results of both procedures showed a significant reduction
of the first metatarsophalangeal angle and the intermetatarsal angle compared
with the preoperative values. These results are in line with those in other
reports on the radiographic results of the
Lapidus11-13,15,28
and Hohmann
procedures22,23,25-27,38
in separate analyses. With the number of interventions in the present study,
no significant difference was found between the two procedures with respect to
these two criteria. However, the Lapidus group demonstrated significantly less
shortening and more plantar tilt of the first metatarsal compared with the
Hohmann group. Shortening and elevation of the first metatarsal are related to
transfer metatarsalgia, which we observed in six feet (four in the Hohmann
group and two in the Lapidus group). The rate of occurrence of transfer
lesions in other studies has varied from 13% to 59% for the Hohmann
procedure23,25,26
and from 0% to 14% for the Lapidus
procedure11,13-15,28,39.
The higher prevalence of transfer lesions, which was noted in our study and in
previous reports, seems to be a disadvantage of the Hohmann procedure. In
addition, the duration of follow-up in our study was two years and the
prevalence of transfer lesions could increase with time.
An apparent difference was the rate of superficial infection of 3.9% in the
Lapidus group compared with 14% in the Hohmann group. The latter rate is also
considerably higher than the 2% rate reported for other
series25,27.
This was probably due to the use of the percutaneous Kirschner wire. Although
these superficial infections could easily be treated with oral antibiotics
and/or premature removal of the Kirschner wire, this finding has led us to
adjust the fixation method. We now use a 3.0-mm cannulated AO screw for
internal fixation.
Another evident difference between the two methods was the reoperation rate
for screw removal in the Lapidus group (seven patients; 13.7%), despite
countersinking of the screw heads. Although all screws were easily removed
under local anesthesia, this can be seen as a slight disadvantage of the
Lapidus procedure. Secure fixation with screws in the first tarsometatarsal
arthrodesis is considered essential to maintain the
position13,15,28,
and consequently we continue to use screw fixation.
The last apparent difference between the two methods was the prevalence of
hallux varus, which occurred in three patients in the Lapidus group compared
with one in the Hohmann group. Although no reoperation was necessary, this is
a possible disadvantage of the Lapidus procedure. In other series, the
prevalence of hallux varus has been reported to be between 1.5% and
15.7%11,13,15.
In general, we believe that the Hohmann procedure can be performed,
regardless of the amount of mobility of the first tarsometatarsal joint, for
the treatment of a hallux valgus deformity with an intermetatarsal angle of
<15°. With larger intermetatarsal angles, the distal fragment cannot be
shifted far enough laterally to achieve complete correction. It is better to
base the decision to perform a Lapidus procedure (or a proximal osteotomy of
the first metatarsal) on the existence of a large intermetatarsal angle
(=15°) than on clinically assessed hypermobility of the first
tarsometatarsal joint.
In conclusion, the short-term results of the Hohmann and the Lapidus
procedure for correction of a hallux valgus deformity were both satisfactory
and were comparable with those described in previous reports on these
procedures. There was no relevant difference in outcome between the two
methods in the total group of 101 feet. Although hypermobility of the first
tarsometatarsal joint can be seen as related to symptomatic hallux valgus
deformity, the results for the subgroups of feet with a hypermobile first
tarsometatarsal joint compared with those with a nonhypermobile joint, as
assessed clinically, were not significantly different. The theory that
patients with hallux valgus and a hypermobile first tarsometatarsal joint
should be managed with a Lapidus procedure is not supported by this study.