Faber Frank W M, Mulder Paul G H, Verhaar Jan A N
Department of Orthopaedic Surgery, Leyenburg Hospital, Postbox 40551, 2504 LN The Hague, The Netherlands.
J Bone Joint Surg Am. 2004 Mar;86(3):486-95. doi: 10.2106/00004623-200403000-00005.
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.
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.
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.
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.
Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.
第一跖跗关节活动度过大在拇外翻畸形病因学中的作用存在争议。因此，在拇外翻手术治疗中是否有必要纳入该关节的关节融合术受到了质疑。我们设计了一项研究来评估第一跖跗关节融合术在拇外翻手术治疗结果中的作用。
进行了一项前瞻性、盲法、随机研究，比较第一跖骨远端截骨术（霍曼手术）与第一跖跗关节融合术联合第一跖趾关节软组织手术（拉皮德斯手术）矫正有症状拇外翻畸形的结果。87例患者的101只脚纳入研究。50只脚接受了霍曼手术，51只脚接受了拉皮德斯手术。在术前临床检查中评估第一跖跗关节的活动度。基于该检查，确定了两个亚组：68只第一跖跗关节活动度过大的脚和33只第一跖跗关节活动度正常的脚。在术后两年对患者进行临床和影像学评估。
美国矫形足踝协会的拇趾跖趾 - 趾间量表评分及两种手术后的疼痛评分均有显著改善（p < 0.001）。就现有数据而言，两种手术之间或第一跖跗关节活动度过大的脚的亚组与活动度正常的脚的亚组之间未发现显著差异。两种手术之间或两个亚组之间患者满意度评分也无差异。两种方法的影像学结果也相似，但第一跖骨缩短情况除外，霍曼组第一跖骨缩短明显更严重（p < 0.001），而拉皮德斯组第一跖骨跖屈更明显。
这些短期结果令人满意，与先前关于这两种手术的单独报告中的结果相当。由于在临床评估中未发现两种手术之间或两个亚组（第一跖跗关节活动度过大的脚和活动度正常的脚）之间存在显著差异，因此拇外翻且第一跖跗关节活动度过大的患者应采用拉皮德斯手术治疗的理论未得到支持。
治疗性研究，I - 1a级（随机对照试验[有显著差异]）。有关证据级别的完整描述，请参阅作者须知。
