Original and Modified Lapidus Procedures: Proposals for a New Terminology.

In 1934, Paul W. Lapidus submitted a short report that he would later describe as “personal communication” and “preliminary communication.” It referred to a method of first tarsometatarsal (TMT) arthrodesis for the treatment of a congenital predisposition toward hallux valgus due to metatarsus primus varus[1]. Although the procedure was first advocated by Albrecht in 1911[2], it was Lapidus who popularized the method in the following years. Therefore, the technique righteously bears his name, without Lapidus himself claiming its originality. In his 1960 paper that reviewed the prior 3 decades of having performed the procedure, the author stated that his operative technique “remains essentially the same as described originally.”[3]

It is interesting to see how the Lapidus procedure currently is presented in 2 leading orthopaedic journals: The Journal of Bone & Joint Surgery and Foot & Ankle International (Table I). A content search for the terms “Lapidus” and “tarsometatarsal” that included all publication dates revealed a total of 339 papers with either term listed in the title, in the abstract, as a keyword, and/or in the full text. For the term “Lapidus” alone, the relevant number was 65 studies, which include 20 clinical studies of case series, 1 survey, 1 technique description, and 1 case report. The remaining studies were either cadaveric, biomechanical, or radiographic. Additionally, there were 7 review papers that did not have an original patient population. Modifications of the Lapidus procedure, as described in each clinical paper, are impressively broad (Table II). Indeed, it is hard to find 2 studies in which the exact same technique was used. Even within a single study, some authors reported that they modified their own technique during the study period.

A valid question is: What exactly did Lapidus describe in his original papers? Below is a step-by-step description of the technique in his own words[3]:

Anesthesia: general anesthesia.

Tourniquet use: an Esmarch bandage from the toes to the lower quarter of the leg, where it is bandaged tightly and used as a tourniquet.

Distal soft-tissue procedures: medial approach at the level of the first metatarsophalangeal (MTP) joint. Identification and separation of the muscle bellies and tendons of the abductor hallucis and flexor hallucis brevis plantarly. A U-shaped capsulotomy made with its base at the proximal phalanx. Subcutaneous tenotomy of the adductor hallucis and capsulotomy through a dorsal approach. Suturing of the U-shaped flap to the abductor hallucis longus with no. 0 chromic catgut with considerable tension, but not too tightly.

Bunionectomy: With the use of small wood-carving chisels at the level of the medial sagittal groove. Aiming at the metatarsal neck, with an effort to preserve the round shape of the head, with or without a dorsal cheilectomy.

TMT arthrodesis approach: Dorsal, between the extensor hallucis longus (EHL) medially and extensor hallucis brevis (EHB) laterally.

Joint preparation: Shaving of the articular surfaces of the base of the first metatarsal (MT) and medial cuneiform without wedge resection. Removal of cortex of the base of the first and second MTs, leaving the bone chips in situ after denuding them from soft tissues and cartilage.

Fixation: A bone tunnel is created at the dorsolateral part of the base of the first MT. A no. 0 chromic catgut is passed through it and sutured to the dorsal ligaments between the medial and intermediate cuneiforms.

Postoperative immobilization: A 12-cm-long and 7-mm-wide steel corset is used at the medial aspect of the first metatarsal over well-padded dressing for 3 to 4 weeks. Weight-bearing as pain allows, with or without crutches. Special canvas shoes or wool socks are worn in the first month postoperatively.

An easily drawn conclusion is that nowadays practically no one performs the “original” Lapidus procedure. Moreover, a number of authors have probably misquoted the original technique because, with the exception of the 1960 review, the original papers are hard to purchase. Additionally, a number of studies have provided reports on patients who underwent “Lapidus arthrodesis” without clarifying details about the modifications that the authors used in their series. In fact, in many circles, the term “Lapidus procedure” has become synonymous with a number of first TMT arthrodesis constructs, when in fact the original description was in reference to a hallux valgus correction.

The implications of this vague terminology and its endless modifications are many. From a scientific point of view, this wide variety practically renders any effort to conduct a valid meta-analysis on the subject obsolete. Multicenter studies also need to be interpreted with some caution. In a well-quoted survey by Pinney et al., 24% of 128 academic foot and ankle surgeons stated that they would perform a Lapidus arthrodesis for a hypothetical case of a patient with severe hallux valgus[4]. One can only wonder which of the numerous modifications of the Lapidus procedure each surgeon meant with his or her response.

Coding and billing for the procedure can be equally challenging. The range of operative costs, from 2 crossed 3.5-mm screws to dual-locking titanium plating plus an allograft or the use of orthobiologics, is staggering. Additionally, the term “Lapidoplasty,” which has recently been introduced, only seems to add to the confusion.

A better terminology is needed. The primary objective would be to improve the scientific quality of studies that report, combine, and compare groups of patients who undergo a first TMT arthrodesis procedure. Moreover, an improved terminology may aid in more precise coding and billing of the various modifications of the technique, which would benefit patients, health-care providers, and insurance companies. Finally, while eponyms are common in the orthopaedic lexicon, they can often lead to confusion and, therefore, an effort should be considered to avoid fostering eponyms at the expense of anatomic clarity.

This initiative can only succeed with the support of a leading scientific journal that will follow through with use of the amended terminology in its future publications. Our proposal is to use 5 main descriptive terms when referring to the modifications of the Lapidus procedure, assuming that the procedures are part of hallux valgus correction. These same 5 descriptive terms should be applied when using any combination of first TMT arthrodesis as part of an arch reconstruction or flatfoot correction (Figs. 1 through 5):

Fig. 1

Figs. 1 through 5 The new terminology for the arthrodesis of the first TMT joint. The solid parallel lines represent the joints that have been prepared for fusion; the dotted lines represent the usual direction that is used for fixation material. The dotted lines do not represent any suggestion on behalf of the authors with regard to the type, the volume, and the number of the fixation devices to be used (e.g., plates, screws, etc.). Fig. 1 Single first TMT arthrodesis.

Fig. 5

Four-corner TMT arthrodesis with inclusion of the first and second TMT joints and the intercuneiform joint.

First TMT arthrodesis: This would include all procedures where a single arthrodesis of the base of the first MT to the medial cuneiform is performed with any means of fixation, without including the intermediate cuneiform or the base of the second MT in the fixation (Fig. 1).

First TMT arthrodesis with 3-corner fixation: This term would refer to all procedures where an arthrodesis of the first TMT is combined with fixation of the intermediate cuneiform (Fig. 2-A) or the base of the second metatarsal (Fig. 2-B) without preparation of the joints for fusion.

Three-corner TMT arthrodesis: The same as number 2 above, but, in addition, either the intermediate cuneiform or the base of the second MT also is fused (Figs. 3-A and 3-B, respectively).

First TMT arthrodesis with 4-corner fixation: This would refer to all of the procedures that combine arthrodesis of the first TMT and fixation of the bases of the second MT and the intermediate cuneiform without preparation of the joints for fusion (Fig. 4).

Fig. 4

First TMT arthrodesis with 4-corner fixation to the intermediate cuneiform and the second MT.

Four-corner TMT arthrodesis: This would include all techniques where all of the joints between the base of the first and second MTs and the medial and intermediate cuneiforms are prepared for fusion (Fig. 5).

Figs. 2-A and 2-B Arthrodesis.

First TMT arthrodesis with additional fixation to the intermediate cuneiform.

First TMT arthrodesis with additional fixation to the second MT.

Figs. 3-A and 3-B Arthrodesis.

Three-corner TMT arthrodesis with inclusion of the intermediate cuneiform.

Three-corner TMT arthrodesis with inclusion of the base of the second MT.

With regard to the concomitant distal soft-tissue release procedure, a number of authors in recent studies do not include it as part of the described procedure. Therefore, we propose the addition of a capital “S” following each number for the type of procedure in order to clarify that the procedure is the combination of the arthrodesis and the distal soft-tissue release.

In 2021, we will celebrate the ninetieth anniversary of the first truly original Lapidus operation that was performed on April 8, 1931. The Journal of Bone & Joint Surgery, as the official journal of the American Orthopaedic Association (AOA) and a leading journal in the field for research and teaching purposes, can be a pioneer in redefining the terminology around this widely used technique and its modifications. We would ask readers of this Orthopaedic Forum article to express their views on the topic and the proposed new terminology of the various modifications of the Lapidus procedure.

TABLE I

Search Results for the Terms Lapidus and Tarsometatarsal in JBJS and FAI*

Search Term	Title		Abstract		Keyword		Full Text
	Lapidus	TMT	Lapidus	TMT	Lapidus	TMT	Lapidus	TMT
JBJS	3	14	0	3	NA	NA	124	215
FAI	15	27	31	101	16	29	NA	NA
Combined	18	41	31	104	16	29	124	215

JBJS = The Journal of Bone & Joint Surgery, FAI = Foot & Ankle International, TMT = tarsometatarsal, and NA = not applicable.

TABLE II

Published Papers on Lapidus Procedures and Modifications*

Study	Level of Evidence	No. of Patients with Follow-up	No. of Surgeons	Joints Stabilized or Fused	Approach	Fixation (in Sequence)	Bone Graft	Orthobiologics	Distal Procedures	Comments
Aiyer et al. (2016)[5]	III: retrospective comparative series	NR	4	TMT1 + IntCunMT1	NR	Plates (dorsal-medial) and screws	NR	NR	NR	Comparative study of different methods; fixation technique derived from images/figures (not described in detail in the text)
Bednarz and Manoli (2000)[6]	IV: case series	26	1	TMT1, MT1-2 (temporary)	Dorsal (between 1st and 2nd rays) + stab medial incision	Two 3.5-mm screws:	Local cancellous	No	Bunionectomy	Technique attributed to ST Hansen Jr.
						1. MT1 base to MedCun				2nd screw removed at 13 weeks
						2. MT1 to MT2 base
Coetzee and Wickum (2004)[7]	IV: retrospective case series	91	NR	TMT1, MT1-2 (temporary)	Dorsal (between 1st and 2nd rays) + stab medial incision	A. Two 3.5-mm screws:	Medial eminence + local cancellous	±PRP	Bunionectomy, release of AHL, ± Akin procedure
						1. MedCun to MT1 base
						2. MT1 to MT2
						B. Modification with 4.0-mm screws
Coetzee et al. (2004)[8]	IV: retrospective case series	24	NR	TMT1, MT1-2	Dorsal (between the EHL and EHB) + distal incision in the first web space + medial incision	A. Two 3.5-mm screws:	Local cancellous	No	Soft-tissue release ±bunionectomy	Revision surgery for failed HV correction
						1. MedCun to MT1 base
						2. MT1 to MT2
Conti et al. (2020)[9,10]	IV: case series	31	2	TMT1	Dorsal (1st TMT)	2 crossed screws:	Cancellous autograft ±	±DBM	Bunionectomy, ± Akin and/or modified McBride procedure	The authors have reported on the same study population and technique in 2 separate publications
						1. 4.0-mm MT1 to MedCun
						2. 3.5-mm MedCun to MT1
DeVries et al. (2011)[11]	III: retrospective comparative analysis	134	1	TMT1 ± IntCunMT1	NR	A. 2 crossed TMT screws ± 3rd screw from MT1 to IntCun	No	±DBM or BMA	Various, not standard
						B. Dorsomedial locking plate ±crossed TMT screw
Faber et al. (2004)[12]	I: therapeutic randomized controlled trial	51	1	TMT1	Dorsal, lateral to EHL + distal incision in the first web space + medial incision	Two 3.5-mm crossed screws:	NR	No	Bunionectomy + AHL release	Number of feet reported, some of which are bilateral cases
						1. MedCun to MT1
						2. MT1 to MedCun
Ellington et al. (2011)[13]	IV: retrospective case series	23	2	TMT1 ± MT1 to MT2	Dorsal (1st TMT)	2 crossed screws:	Occasionally allograft/autograft	No	Bunionectomy, soft-tissue release	Revision surgery for failed HV correction
						1. MedCun to MT1
						2. MT1 to MedCun ± 3rd screw MT1 to MT2
Habbu et al. (2011)[14]	IV: retrospective case series	268	2	TMT1 ± MT1-2 (temporary)	NR	Two 3.5-mm crossed screws:	NR	NR	Soft-tissue release
						1. MedCun to MT1
						2. MT1 to MedCun ± 3rd screw MT1 to MT2
Jung et al. (2007)[15]	IV: retrospective case series	12	NR	TMT1	Dorsolateral/medial	Two 3.5-mm crossed screws:	NR	NR	NR	Primary diagnosis: TMT OA; fixation technique derived from images/figures (not described in detail in the text)
						1. MedCun to MT1
						2. MT1 to MedCun
Kazzaz and Singh (2009)[16]	IV: retrospective case series	19	1	TMT1	Medial	Two 3.5-mm or 4.0-mm crossed screws:	NR	NR	Soft-tissue release + Akin
						1. MedCun to MT1
						2. MT1 to MedCun
Klemola et al. (2017)[17]	III: case-control study	58	NR	TMT1	NR	Single, headless, variable-pitch compression screw	NR	NR	No distal procedure
Kopp et al. (2005)[18]	IV: retrospective case series	29	2	TMT1	Dorsal (1st TMT)	Two 3.5-mm crossed screws:	Local bone graft	NR	Soft-tissue release ±Akin
						1. MedCun to MT1
						2. MT1 to MedCun ± supplementary temporary Kirschner wire
Langan et al. (2020)[19]	IV: retrospective case series	62	1	TMT1 + IntCunMT1	Dorsomedial, medial to the EHL	Dorsomedial locking plate + 4.0-mm cannulated screw from base of MT1 to IntCun ± 4.0-mm cannulated screw from MT1 to MT2	NR	NR	Soft-tissue release ± bunionectomy ± Akin
Lee and Manoli (2001)[20]	V: Case report	1	1	TMT1 + MT1MT2	NR	Two 3.5-mm screws:	NR	NR	Akin	Method of fixation is derived from images/figures (not described in detail in the text)
						1. MT1 to MedCun
						2. MT1 to MT2
MacMahon et al. (2016)[21]	IV: retrospective case series	48	6	NR	NR	NR	NR	NR	NR
Ray et al. (2019)[22]	IV: retrospective case series	57	4	TMT1	Dorsomedial, medial to the EHL	2 small-profile, 4-hole titanium locking plates applied in biplanar 90°-90° fashion	NR	NR	Soft-tissue release
Rippstein et al. (2012)[23]	IV: retrospective case series	10	1	TMT1	Dorsomedial	2 crossed 3.5-mm screws:	NR	NR	1st MTP fusion
						1. MedCun to MT1
						2. MT1 to MedCun
Sangeorzan and Hansen (1989)[24]	IV: retrospective case series	23	1	TMT1 ±MT1MT2 or MT1IntCun	Dorsal, from the first web space to the TMT1	2 crossed 3.5-mm screws:	Tricortical bone graft from iliac crest ±	NR	NR	Authors state that their technique has changed during the study period
						1. MedCun to MT1
						2. MT1 to IntCun or MT2
Thompson et al. (2005)[25]	IV: retrospective case series	182	NR	TMT1	Dorsal, from the first web space to the TMT1 ± medial MTP	2 crossed 3.5-mm screws:	Local bone graft	NR	Soft-tissue release ± Akin	Some of the procedures were part of a flatfoot reconstruction
						1. MT1 to MedCun
						2. MedCun to MT1
Toolan (2007)[26]	V: expert opinion surgical strategies	NA	NA	TMT1 ± MT1MT2	Dorsal (1st TMT)	Two 3.5-mm screws:	Local bone graft	NR	Bunionectomy + AHL release
						1. MT1 to MedCun
						2. MedCun to MT1 or MT1 to MT2

NR = not reported, MT = metatarsal, TMT = tarsometatarsal, IntCun = intermediate cuneiform, MedCun = medial cuneiform, PRP = platelet-rich plasma, ± = with or without, AHL = abductor hallucis longus, EHL = extensor hallucis longus, EHB = extensor hallucis brevis, HV = hallux valgus, DBM = demineralized bone matrix, BMA = bone marrow aspirate, OA = osteoarthritis, MTP = metatarsophalangeal, and NA = not applicable.