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Role of First Ray Hypermobility in the Outcome of the Hohmann and the Lapidus ProcedureA Prospective, Randomized Trial Involving One Hundred and One Feet
Frank W.M. Faber, MD1; Paul G.H. Mulder, PhD2; Jan A.N. Verhaar, MD, PhD3
1 Department of Orthopaedic Surgery, Leyenburg Hospital, Postbox 40551, 2504 LN The Hague, The Netherlands. E-mail address: f.faber@leyenburg-ziekenhuis.nl
2 Department of Epidemiology and Biostatistics, Erasmus University Rotterdam, Postbox 1738, 3000 DR, Rotterdam, The Netherlands
3 Department of Orthopaedic Surgery, Erasmus Medical Center, Dr. Molewaterplein 60, 3015 GE, Rotterdam, The Netherlands
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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Leyenburg Hospital, The Hague, The Netherlands

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Mar 01;86(3):486-495
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Background: The role of hypermobility of the first tarsometatarsal joint in the etiology of hallux valgus deformity is controversial. Consequently, the need to include an arthrodesis of this joint in the surgical treatment of hallux valgus has been questioned. We designed a study to evaluate the role of arthrodesis of the first tarsometatarsal joint on the outcome of surgical treatment of hallux valgus.

Methods: A prospective, blinded, randomized study was performed to compare the results of a distal osteotomy of the first metatarsal (the Hohmann procedure) with those of an arthrodesis of the first tarsometatarsal joint combined with a soft-tissue procedure of the first metatarsophalangeal joint (the Lapidus procedure) for correction of a symptomatic hallux valgus deformity. One hundred and one feet of eighty-seven patients were included in the study. Fifty feet had a Hohmann procedure, and fifty-one had a Lapidus procedure. The mobility of the first tarsometatarsal joint was assessed in the preoperative clinical examination. On the basis of this examination, two subgroups were identified: sixty-eight feet with a hypermobile first tarsometatarsal joint and thirty-three feet with a nonhypermobile first tarsometatarsal joint. The patients were assessed clinically and radiographically at two years after the operation.

Results: There was a significant improvement in the score on the great toe metatarsophalangeal-interphalangeal scale of the American Orthopaedic Foot and Ankle Society and in the pain score following both procedures (p < 0.001). With the numbers available, no significant difference between the two procedures or between the subgroups of feet with a hypermobile first tarsometatarsal joint and those with a nonhypermobile joint could be identified. The patient satisfaction rating did not differ either between the two procedures or between the two subgroups. The radiographic results of the two methods were also similar, except for shortening of the first metatarsal, which was significantly greater (p < 0.001) in the Hohmann group, and plantar flexion of the first metatarsal, which was greater in the Lapidus group.

Conclusions: These short-term results were satisfactory and were comparable with those in previous isolated reports on these two procedures. As no significant differences between the two procedures or between the two subgroups (feet with a hypermobile first tarsometatarsal joint and those with a nonhypermobile joint) were found on clinical assessment, the theory that patients with hallux valgus and a hypermobile first tarsometatarsal joint should be managed with a Lapidus procedure was not supported.

Level of Evidence: Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Frank W.M. Faber
    Posted on April 14, 2004
    Dr. Faber responds:
    Leyenburg Hospital, Postbox 40551, 2504 LN The Hague, The Netherlands

    To the Editor:

    We thank Dr Digiovanni for his comments about our article. In contrast with the statement of Dr. DiGiovanni we did not presume that authors are generally performing the Lapidus procedure in every case of hypermobility. We agree with Dr. DiGiovanni that radiological signs of TMT 1 hypermobility should be taken into account. However, no previous study about the results of the Lapidus procedure with systematic evaluation of these radiographic criteria has been published, and thus far all authors have had to rely on clinical evaluation only.

    We performed a radiographic study on the relation between the mobility of the TMT 1 joint in the sagittal plane and the clinical test (1). The conclusion of this study was that this mobility differed significantly between clinically assessed hypermobile and non-hypermobile TMT 1 joints with a hallux valgus, but no sharp cut-off point could be defined to distinguish these groups.

    We did clinically assess post operative TMT 1 mobility in all the treated patients. However, we did not present this in the results of our paper, because we consider the differences we found not to be meaningful-- one procedure corrects TMT 1 hypermobility and the other does not. We were more interested in the end result. Are the results of one procedure better? With the present methods to test TMT 1 mobility, we could not find a difference in the outcome.

    Although transfer lesions and callosities under the second ray may be regarded to result from first ray hypermobility, this is unproven. The cause may be the hallux valgus itself. Also, Dr. DiGiovanni gives no references to support his statement that it takes ‘an average of four years to develop signs of 2nd metatarsal overload’. This is not according the guidelines of the AOFAS 2 , which consider a period of at least one year adequately. Our follow-up period is two years. However, we agree a repeated examination with a longer follow-up period could supply interesting results and we are planning to perform such a study in the future.

    We agree with Dr. DiGiovanni that there is no technique yet specifically demonstrating TMT 1 hypermobility. We respect his indications for performing a Lapidus procedure and we can add one-- a painful and arthritic TMT 1 joint in a symptomatic hallux valgus patient. However, these indications differ from other reports (3-6) . There is no general agreement about when to perform a Lapidus, except in case of TMT1 hypermobility. The definition of this hypermobility remains controversial.

    It is not our opinion that the Lapidus procedure should be abandoned. Our conclusion is that it probvides results that are similar to the Hohmann procedure, regardless of the pre-operative mobility of the TMT 1 joint, clinically assessed. In fact, we fully agree with the last remarks of Dr. DiGiovanni: it should be used on special indications. Dr. DiGiovanni states that the Lapidus procedure is ‘an optimal procedure for any patient determined to be hypermobile by current, collective standards’. This is exactly the problem that has to be solved. Since there are no such standards yet, an objective, simple, reliable and reproducible test for measuring TMT 1 hypermobility would be most welcome. Then, another prospective study could show that a Lapidus procedure might or might not give superior results in hypermobile patients.


    1. Faber FWM, Kleinrensink GJ, Mulder PGH, Verhaar JAN. Hypermobility of the first tarsometatarsal joint in hallux valgus patients: a radiographic analysis. Foot Ankle Int., 22: 965-969, 2001.

    2. Smith RW, Reynolds JC, Stewart MJ. Hallux valgus assessment: report of research of American Orthopaedic Foot and Ankle Society. Foot Ankle, 5: 92-103, 1984.

    3. Bednarz PA, Manoli A. Modified Lapidus procedure for the treatment of hypermobile hallux valgus. Foot Ankle Int., 21: 816-821, 2000.

    4. Mauldin DM, Sanders M, Whitmer WW.: Correction of hallux valgus with metatarsocuneiform stabilization. Foot Ankle 11: 59-66, 1990.

    5. Myerson M, Alan S, McGarvey W.: Metatarsocuneiform arthrodesis for management of hallux valgus and metatarsus primus varus. Foot Ankle, 13: 107-115, 1992.

    6. Sangeorzan BJ, Hansen ST.: Modified Lapidus procedure for hallux valgus. Foot Ankle, 9: 262-266, 1989.

    Christopher DiGiovanni
    Posted on April 01, 2004
    Hohmann and Lapidus Procedures for the Hypermobile First Ray
    Brown University School of Medicine

    To the Editor:

    I read with interest the recent article entitled “Role of First Ray Hypermobility and the Outcome of the Hohmann and the Lapidus Procedure” (2004:86:486-95). I congratulate Dr. Faber et al for completing one of the few prospective studies that compare bunion operations. I believe, however, that the article’s most basic premise--namely that the authors assume surgeons are generally performing Lapidus procedures in every instance of hypermobility of the 1st ray--deserves further comment. I also think the conclusions regarding these operations and their relationship to hypermobility raises question about how these determinations were made.

    While medial column hypermobility may indeed be related to hallux valgus development, most foot and ankle surgeons to my knowledge do not consider as dogma that the presence of the former automatically necessitates 1st TMT fusion to treat the latter. Hypermobility remains an elusive concept, and as such there are currently many means employed (or misemployed) to determine its presence. Without agreement as to the most appropriate way to test for this entity, I think many of us trained in the Lapidus procedure have learned to apply it quite selectively--as opposed to using it in the more reflexive manner this paper implies. For example, I do not use the clinical definition of a ‘one centimeter difference’ between the 1st and lesser ray heads on physical exam to identify hypermobility, but rather prefer to check the lateral weight- bearing foot x-ray for 1st TMT dorsal translation or, more particularly, for plantar gapping of the 1st ray (break in the talo-1st metatarsal angle). This study entailed no radiographic evaluation of hypermobility and relied only on a single clinical exam. Furthermore, Dr. Faber’s group did not assess postoperative hypermobility and hence could not comment on their success in correcting the problem. Since much of this paper’s discussion is based on a comparison between two very different operations--one theoretically designed to treat hypermobility and the other not-- a post operative assessment would seem vital to accurately compare outcome and draw appropriate conclusions.

    Additionally, chronically hypermobile patients generally have enough medial column movement and peritalar subluxation on exam to lead to a transfer lesion under the second ray. The authors did not report, however, on the presence or absence of transfer metatarsalgia or callusing under the second metatarsal head preoperatively. These findings would have better identified those patients with true preoperative hypermobility and therefore those most apt to benefit from medial column stabilization via a Lapidus bunion reconstruction. Lack of such information casts doubt on the authors’ presumption that these initial groups were appropriately matched for hypermobility and thus also questions whether one can comment about the effects of either procedure on a ‘hypermobile’ patient. Since it takes an average of four years to develop signs of 2nd metatarsal overload and stress fracture a follow-up of only two years in these patients may not be sufficient to accurately assess an effect of hypermobility correction (or lack thereof) on such individuals.

    Although it is true that no technique has been found optimally sensitive and specific for the diagnosis of hypermobility, the use of these additional clinical and radiographic parameters both pre and post-operatively would have been less subjective and enabled more credible conclusions. Along with the presence of a very high intermetarsal angle, a very long 1st ray, or the need for a revision bunion procedure, these parameters arguably serve as our best relative indications for the Lapidus procedure. When performed correctly for a bunion, this operation serves any surgical armamentarium because it can effectively confer increased competence to the medial column, correct any IMA, and decompress the MTP joint of an excessively long 1st ray or even increase its motion a bit.

    It is curious that even more shortening was found with the Hohmann than with the Lapidus procedure in this study. Such a finding suggests that performing the Hohmann distal metatarsal osteotomy (without stabilization of the 1st TMT joint) could actually result in a long-term problem when this procedure is used to correct a hypermobile bunion.

    I would suggest that the authors’ conclusions might change with longer follow-up. Both the definition and identification of hypermobility continue to evolve today as we learn more about how to assess this problem, and as such I also believe most surgeons—even those primarily trained in the Lapidus--still proceed with caution in choosing the Lapidus correction for their bunions. While there is no doubt in my opinion that this operation is capable of powerful bunion correction with reasonable success and minimal complication if employed by capable hands, it is also true that the Lapidus is technically more demanding, obligatorily shortens the 1st ray, and requires a longer post-operative immobilization, weight-protection, and recovery period for bunion patients when compared to most alternative reasonable surgical approaches. Thus, I consider it a valuable operation when properly indicated and submit that most people choosing it today do so only occasionally and in keeping with the aforementioned principles. Since this study’s methodology has arguable shortcomings in its preoperative evaluation of hypermobility and also remains flawed in its postoperative assessment of whether or not the Lapidus procedure makes a difference for hypermobile patients, I believe it advances the Lapidus debate no closer to any answer. The Lapidus reconstruction should still be considered at least a reasonable—if not an optimal--procedure for any patient determined to be hypermobile by current, collective standards.


    Chris W. DiGiovanni, MD

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