Bunionectomy

Number: 0629

Policy

Simple Bunionectomy

(e.g., modified McBride, Silver Procedure)

Aetna considers simple bunionectomy with soft tissue removal of the bump only without bony correction medically necessary in members with either of the following conditions:

1. Members with clinical symptoms and a history of conservative management who meet the following criteria:
   
   
   1. Documentation of persistent pain and difficulty walking despite at least six months of conservative treatment under the direction of a healthcare professional which includes, but may not be limited to:
      
      
      1. Alternative or modified footwear
      2. Corticosteroid injections
      3. Debridement of hyperkeratotic lesions
      4. Foot orthotics (shoe inserts) (generally contractually excluded)
      5. Oral analgesics or nonsteroidal anti-inflammatory drugs (NSAIDS)
      6. Protective cushions/pads
   2. Radiographic confirmationFootnotes for Radiographic confirmation^* of a hallux valgus angle (HVA) (formed by the long axis of the proximal phalanx and the first metatarsal) of 15 degrees or more with no degenerative changes at the meta-tarso-phalangeal (MTP) joint, and
   3. Documentation of skeletal maturity; or
      
2. Members with diabetes who have an ulcer and/or infection stemming solely from the bunion.

Aetna considers simple bunionectomy experimental and investigational for all other indications because its effectiveness for indications other than the ones listed above has not been established.

Bony Correction Bunionectomy

(e.g., Akin, Chevron, Keller, Lapidus, Mitchell, proximal metatarsal osteotomy procedures, etc.)

Aetna considers bony correction bunionectomy medically necessary to treat symptomatic hallux valgus (bunion) in a skeletally mature individual (i.e., after epiphyseal closure) or an individual who is 18 years of age or older when the following criteria is met:

1. The member's pain and symptoms over the medial bony eminence or calluses persist, making walking difficult despite at least a 6-month trial of conservative treatment under the direction of a healthcare professional that includes the following:
   
   
   1. Protective cushions/pads,
   2. Shoe inserts (generally contractually excluded), 
   3. Corticosteroid injections,
   4. Debridement of hyperkeratotic lesions,
   5. Oral analgesics or non-steroidal antiinflammatory drugs (NSAIDs)
   6. Alternative or modified footwear that must include the following:
      
      
      1. Wearing well-fitting, low-heeled comfortable shoes made out of soft materials (e.g., canvas, cloth, soft leather) with wide toe box and padding; or
      2. Lace-ups or a combination last (front of the shoe is wider than the back of the shoe) that oconforms to the bunion and minimizes irritation; and
         
   7. Radiographic confirmationFootnotes for Radiographic confirmation^* of the most recent weight-bearing view X-ray demonstrating both of the following:
      
      
      1. An HVA of 30 degrees or greater; and
      2. An inter-metatarsal angle (IMA) (formed by the long axis of the first and second metatarsals) of 12 degrees or greater; and
   8. Documentation of skeletal maturity; and
   9. The member has one or more of the following:
      
      
      1. A neuroma secondary to the bunion
      2. Problems with a dorsiflexed second toe due to over-riding of the great toe (so-called cross-over toe deformity)
      3. Limited or painful range of motion at the first toe MTP joint
      4. Painful prominence of the dorsiflexed second toe due to pressure from the first toe
      5. Ulceration caused by bunion
      6. Recurrent bursitis
      7. Demonstration of osteoarthritis on X-ray, as evidenced by any of the following:
         
         
         1. Cysts in the metatarsal head; or
         2. Loss of the cartilage space between the bones; or
         3. Mild-to-moderate bony proliferative pathology.
      8. The need for relief of a predisposing factor, e.g., Achilles tendon contracture.

Aetna considers bony correction bunionectomy experimental and investigational for all other indications because its effectiveness for indications other than the ones listed above has not been established.

Footnotes for Radiographic confirmation ^* Radiographic confirmation must include interpretation and report of weight bearing anterior/ posterior and lateral views of the affected foot. 

Note: A bilateral bunionectomy done at the same time generally is not deemed medically necessary unless extenuating circumstances are present.

Aetna considers bony correction bunionectomy not medically necessary for the following indications:

• Foot ulcer(s) secondary to peripheral vascular disease; or
• Gangrene of the foot, ankle or lower leg; or
• Non-ambulatory individuals unless being performed to relieve ulceration due to prominence; or
• Open blisters, pressure sores, and skin ulceration overlying the bunion when the bunion is not the cause of the skin lesion (bony correction may lead to osteomyelitis); or
• Poor tissues at the operative site due to excessive scarring and multiple closely placed previous incisions; or
• Severe vascular insufficiency significantly impairing circulation to the foot (e.g., absent foot pulses, intermittent claudication, ankle/arm ratio less than 0.6); or
• To improve the appearance of the foot (cosmetic).

Surgical Correction of First Metatarsophalangeal (MTP) Joint

Aetna considers surgical correction of the first MTP joint (e.g., hallux rigidus) (including but not limited to arthrodesis (fusion), cheilectomy or the Keller procedure (resection arthroplasty)) medically necessary when the following criteria are met:

1. Radiographic Footnotes for Radiographic confirmation^*confirmation of osteoarthritis as evidenced by any of the following:
   
   
   1. Cysts in the metatarsal head; or
   2. Loss of the cartilage space between the bones; or
   3. Mild to moderate bony proliferative pathology; and
      
2. Documentation of persistent pain and difficulty walking despite at least six months of conservative treatment under the direction of a healthcare professional which includes, but may not be limited to:
   
   
   1. Alternative or modified footwear
   2. Corticosteroid injections
   3. Debridement of hyperkeratotic lesions
   4. Foot orthotics (shoe inserts)(generally contractually excluded)
   5. Oral analgesics or nonsteroidal anti-inflammatory drugs (NSAIDS)
   6. Orthotics (shoe inserts) (generally contractually excluded)
   7. Protective cushions/pads; and
      
3. Documentation of skeletal maturity. 

Bunionette

Aetna considers correction of a bunionette deformity (tailor's bunion) (e,g., osteotomy or resection procedures) medically necessary in individuals with both of the following conditions:

1. Radiographic confirmationFootnotes for Radiographic confirmation^* of an IMA of 10 degrees or greater and the MTP angle is 16 degrees or greater; and
2. Documentation of persistent pain and difficulty walking despite at least six months conservative treatment under the direction of a healthcare professional, which includes, but may not be limited to:
   
   
   1. Alternative or modified footwear (shoe modifications to ones that fit comfortably with a soft upper and a roomy toe box)
   2. Corticosteroid injections
   3. Debridement of hyperkeratotic lesions
   4. Foot orthotics (shoe inserts)(generally contractually excluded)
   5. Oral analgesics or nonsteroidal anti-inflammatory drugs (NSAIDS)
   6. Protective cushions/pads; and
      
3. Documentation of skeletal maturity.

Aetna considers surgical correction of a bunionette deformity experimental and investigational for all other indications because its effectiveness for indications other than the ones listed above has not been established.

Cheilectomy

Aetna considers foot cheilectomy medically necessary for symptomatic relief of either of the following conditions:

1. Painful bony spurs in the earlier stages of an arthritic joint; or
2. Painful hallux rigidus meeting criteria for surgical correction of MTP joint noted above.

Aetna considers foot cheilectomy experimental and investigational for all other indications because its effectiveness for indications other than the ones listed above has not been established.

Arthrodesis

Aetna considers arthrodesis (fusion) of the foot medically necessary for any of the following conditions:

1. A hallux valgus deformity when the second toe is absent; or
2. Advanced hallux valgus (IMA greater than 20 degrees, HVA greater than 40 degrees); or
3. Failed bony correction bunionectomy (e.g., Keller bunionectomy); or
4. Failed cheilectomy; or
5. Painful symptoms secondary to hallux valgus with advanced degenerative joint disease; or
6. Painful symptoms secondary to hallux rigidus with advanced degenerative joint disease meeting criteria for MTP joint noted above: or
7. Severely subluxated or dislocated MTP joints.

Aetna considers arthrodesis of the foot experimental and investigational for all other indications because its effectiveness for indications other than the ones listed above has not been established.

Allograft

Aetna considers the use of allograft in bunion repair experimental and investigational because its effectiveness for this indication has not been established.

Continuous Wound Infiltration with Local Anesthetics After Hallux Valgus Surgery

Aetna considers continuous wound infiltration with local anesthetics after hallux valgus surgery experimental and investigational because the effectiveness of this approach has not been established. See CPB 607 -- Anesthetic and Antiemetic Infusion Pumps.

Background

Hallux valgus (bunion) is a common affliction of the adult foot caused by long-term irritation from poorly fitting shoes, arthritis, or heredity.  The deformity usually develops after the age of 35 years and is often bilateral. It consists of a lateral deviation of the great toe, outward angulation of the metatarsal toward the other foot, separation of the heads of the first and second metatarsals, and prominent soft-tissue thickening over the medial surface of the head of the first metatarsal, commonly referred to as a bunion.  Valgus posture of the great toe frequently causes a hammer toe-like deformity of the second toe.  In addition, the splaying of the forefoot makes the wearing of shoes more difficult.  With shoes that have a narrow toe box, corns often develop, as does bursal hypertrophy over the bunion.  With the presence of valgus subluxation of the first meta-tarso-phalangeal (MTP) joint for a prolonged time, osteoarthritis frequently develops.

The tissues surrounding the joint may become inflamed and painful. However, not all bunion deformities may cause symptoms. A bunion has many etiologies including, but not limited to arthritic conditions, heredity or trauma, and the deformity is aggravated by faulty foot mechanics or tight fitting shoe wear. This progressive deformity is not a single disorder but complex deformity of the first ray or the column of bones that form the medial border of the fore foot.

Most bunions are treatable without surgery.  Prevention is always best by choosing shoes that conform to the shape of the feet, have wide insteps, broad toes and soft soles.  Patients should avoid shoes that are short, tight, sharply pointed, or with heels higher than 2¼ inches.  If a bunion is already present, the patient should try protective pads to cushion the painful bunion and must wear well-fitting, low-heeled comfortable shoes that are roomy enough to not put pressure on it.

Surgery may be recommended to correct the deformity and reconstruct the bones and joints, restoring normal pain-free function to individuals having difficulty walking and/or experiencing pain despite accepted conservative treatments. Surgical repair of hallux valgus may include an osteotomy (cutting portions of bone on each side of the toe joint followed by realignment), shortening or lengthening tendons or ligaments, shaving tissue from the bunion, or arthrodesis (removing damaged portions of the joint and using screws, wires or a plate to hold the joint together). Several operative procedures and osteotomies have been devised and modified over time. The precise intervention employed depends on careful clinical and radiological evaluation and planning, as all hallux valgus deformities are unique and no single osteotomy procedure can treat them all. 

Hallux valgus (lateral deviation of the great toe) is not a single disorder, as the name implies, but a complex deformity of the first ray that frequently is accompanied by deformity and symptoms in the lesser toes.  Often, the intermetatarsal angle (IMA) formed by the long axis of the first and second metatarsals is more than the 8 to 9 degrees, which is usually considered to be the upper limits of normal.  The hallux valgus angle (HVA), which measures the relationship of the long axis of the proximal phalanx and the first metatarsal, also is more than the 15 to 20 degrees, which is considered to be the upper limits of normal.  If the hallux valgus angle of the first MTP joint exceeds 30 to 35 degrees, pronation of the great toe usually results.

In 2002, the Cochrane Library published its review on bunionectomy stating that an HVA of greater than 15 degrees is considered abnormal since at this angle the phalanx is no longer congruent with the metatarsal head.  The joint may not become symptomatic until larger angles are reached or when the formation of a bunion begins, which is when the metatarsal head becomes very prominent and swelling develops medially over the joint.

According to the textbook Campbell's Operative Orthopaedics, bunion deformities are divided into 3 stages:

Stages of Campbell's Operative Orthopaedics, bunion deformities

Stage	Characteristics	IMA	HVA
Mild	small bunion big toe may abut the 2nd toe	< 12°	21 - 30°
Moderate	moderate or large bunion big toe abuts the 2nd toe or may push it to the side	12 -16°	31 - 40°
Severe	big toe may completely displace the 2nd toe 2nd toe may sit on top of the big toe or vice versa	> 16°	> 40°

Under accepted guidelines, surgery is recommended to correct the deformity, reconstruct the bones and joint, and restore normal, pain-free function when the bunion has progressed to a level where the patient has difficulty walking and/or experiences pain despite accommodative shoes and presents itself with angular deformities corresponding to a moderate to severe stage (see above).  In addition, the presentation of a number of complications directly related to bunion formation may cause need for either soft tissue correction of the hallux valgus complex and/or concomitant bony correction.  Inadequate vascularity or sensibility should be investigated thoroughly before any bunion surgery is considered.

There are many different surgical procedures available for treatment of hallux valgus, ranging from the very simple to the highly technical.  They have endured the clinical test of adequate numbers of patients, lengthy and detailed review, and reports by multiple observers using essentially the same techniques.

The usual candidate for the Silver Procedure, a simple exostectomy with removal of the bunion only, is a 30- to 50-year old woman with clinical symptoms from a prominent bunion, an IMA of less than 12 degrees, an HVA of 15 to 25 degrees with no degenerative changes at the MTP joint, and a history of conservative management failure.  Typically, this procedure is performed along with other hallux valgus reconstructive procedures such as Chevron, McBride, or proximal osteotomy.

In properly selected patients with stress (weight-bearing) view roentgenograms showing the medial capsule acting as a spring on stretch of the MTP joint, the modified McBride bunionectomy may be indicated.  It involves removal of the bunion as well as rebalancing of the big toe joint by releasing the tight tendons on the lateral side (side nearest to the 2nd toe) and tightening the joint capsule on the medial side and sometimes removing one of the sesamoid bones.  This procedure is utilized when there is a positional hallux valgus, i.e., the big toe is drifted over toward the 2nd toe but there are no significant bones or structural deformities other than the bunion bump.

Candidates for the Keller procedure, combined soft tissue release and removal of the medial eminence with resection of the proximal end of the proximal phalanx, are patients between 55 and 70 years of age with moderate-to-severe hallux valgus (30 to 45 degrees) and/or significant joint arthrosis (hallux limitus or rigidus), IMAs of 12 degrees or less, and pain over the medial or dorsal eminence with any shoe worn so that the variety of shoes the patient can wear is severely limited.  An incongruous first MTP joint caused by lateral subluxation of the phalanx on the metatarsal head, severe lateral displacement of the sesamoids, and any evidence of degenerative cartilage changes in the joint are all roentgenographic indications for the Keller procedure.

The Akin procedure is used for correction of hallux valgus interphalangeus when the deformity is located at the interphalangeal joint.  In this procedure, a medially based closing-wedge osteotomy of the proximal phalanx is performed, the medial eminence of the first metatarsal head is resected, and medial capsular reefing is done.  Usually the Aiken is performed along with a Silver or McBride procedure.

First metatarsal head osteotomies are probably the most commonly performed bunionectomy procedures today.  The choice of osteotomy performed is dependent upon both the perceived etiology of the condition and the amount of correction required.  In younger patients with no joint arthrosis, and with mild-to-moderate hallux valgus deformities (IMA angle less than 16 and HVA less than 30 to 35 degrees), a Chevron (Austin) osteotomy may be the procedure of choice.  It involves a "V" shaped osteotomy of the distal metatarsal, which allows the first metatarsal head to be shifted laterally, correcting the abnormal shape from long standing valgus drift.  According to the literature, a proximal metatarsal osteotomy for hallux valgus is indicated for patients with moderate-to-severe deformities (HVA of 13 to 20 degrees), and may be combined with other hallux valgus reconstructive procedures such as resection of medial eminence (Silver procedure) or a McBride type of soft tissue release.

The literature indicates that the Mitchell bunionectomy is applicable to moderate to severe deformities of the intermetatarsal angle and hallux valgus and consists of a metatarsal osteotomy that displaces metatarsal head laterally in order to correct hallux valgus deformity and metatarsus adductus.  This procedure is carried out more proximally than the Chevron osteotomy and can correct more severe deformities than Chevron.

Bunionette or tailor’s bunion is a bony prominence on the lateral side of the metatarsal head or the fifth toe. A bunionette is often combined with a bunion or hallux valgus known as "splay foot" or is seen congenitally or may be enlarged due to trauma. A painful callus or a localized keratosis may form beneath the fifth metatarsal head along with the bursa on the lateral side of the toe. Surgical repair may be necessary when severe pain limits an individual’s ability to walk.

Like a bunion, a bunionette deformity (tailor's bunion, overlapping or underlapping 5th toe deformity) may be created by a wide intermetatarsal angle between the 4th and 5th metatarsals.  The normal 4th and 5th IMA is approximately 6.2 degrees, and the normal 5th MTP angle is about 10 degrees.  Pathological angles are in the range of 10 degrees for the IMA and 16 degrees for the MTP angle.  Pressure placed on the head of the 5th metatarsal exacerbated by tight shoes forms a painful osseous prominence, hypertrophy, and/or signs of inflammation on the outside of the foot near the base of the little toe.  It may be associated with a symptomatic plantar callus, a hard corn and painful bursitis.  According to accepted guidelines, treatment should initially consist of conservative measures; this includes padding, debridement, NSAIDS, orthotic therapy, and shoe modifications to ones that fit comfortably with a soft upper and a roomy toe box.  In cases where non-operative treatment can no longer control the symptoms of persistent pain, surgical intervention is warranted.  Soft tissue surgery does not solve the problem as the offending agent is usually the head of the 5th metatarsal.  A proximal osteotomy is able to correct most deformities.  The literature indicates a distal osteotomy is recommended if medial translation of the head for 1/3 of the width of the metatarsal shaft produces a normal 4th to 5th IMA.  A partial ostectomy of the 5th metatarsal may be adequate if IMA reduction is not indicated.

Degenerative joint disease may develop over the years and includes erosion of cartilage, joint space narrowing and varying amounts of bony spurs around the 1st MTP joint.  Milder cases may consist of slight limitation of motion and little pain.  More severe cases may consist of a rigid joint and considerable pain.  Cheilectomy is a procedure that may be utilized in earlier stages of an arthritic joint in which there are painful bone spurs.  The bony irregularities are shaved off and the cartilage may also be remodeled.

The great toe is stabilized in part by the presence of 2nd toe and, when it is absent, a hallux valgus deformity is best treated by arthrodesis of first MTP joint.  Another indication for arthrodesis includes a failed Keller bunionectomy.  Fusion is the procedure of choice for hallux valgus associated with advanced degenerative joint disease, and advanced hallux valgus (IMA greater than 20 degrees, HVA greater than 40 degrees), severely subluxated or dislocated MTP joints, or for failed hallux valgus surgery.  Cheilectomy is not the procedure of choice in presence of advanced degenerative joint changes.  The Lapidus procedure is indicated for patients with severe hallux valgus deformity accompanied by a hypermobile 1st ray.  The procedure involves arthrodesis of the metatarsalcuneiform joint.

Hallux rigidus is a progressive disorder characterized by limitation of movement along with a dorsal bunion at the MTP joint of the great toe most often caused in an adult by degenerative arthritis. An individual with hallux rigidus may have history of pain and stiffness in the first MTP joint increased with activity and aggravated by shoes. Many surgical procedures for hallux rigidus have been recommended including but not limited to arthrodesis (fusion), cheilectomy or the Keller procedure (resection arthroplasty).

Hallux limitus and hallux rigidus is, as their names imply, a loss of flexibility of the great toe as a result of osteoarthritic or degenerative changes at the first MTP joint.  This may be more disabling than hallux valgus, because the patient is unable to achieve relief even when not wearing shoes.  It is usually unilateral and is distinguished from hallux valgus by the lack of angular deformity (the alignment remaining normal) and by the prominence of the osteoarthritic changes at the dorsal surface of the joint, asymmetrical joint-space narrowing, subchondral sclerosis, marginal spurs, and, at times, rather large subchondral cysts.  Cheilectomy, which includes not only excision of the dorsal bone spur but also the dorsal third of the metatarsal head, gives long-term pain relief in most patients. Cheilectomy involves removal of the proliferative bone from the metatarsal head so as to remove the buttress preventing dorsiflexion of the proximal phalanx on the metatarsal head.  Arthrodesis or a Keller procedure is the generally accepted treatment of choice following failed cheilectomy or where advanced degenerative changes are present.

In a case-series study, Masquijo et al (2010) evaluated the results of a 5th metatarsal sliding osteotomy for the treatment of this deformity in patients under 18 years of age.  These researchers retrospectively evaluated 13 feet in 11 consecutive patients with bunionette deformity treated from January 2003 to January 2008 at 2 referral centers.  Mean age was 14.8 years (95 % confidence limit, SD 1.5 years); mean follow-up was 32.2 months (95 % confidence limit, SD 11.7 months); and clinical evaluation was made according to the modified AOFAS score and the Coughlin score.  The IV-V IMA ( IV-V IMA), the width of the forefoot (WF), lateral deviation angle (LDA), and 5th metatarsophalangeal angle (5 MPA) were also measured pre-operatively and post-operatively.  The average post-operative AOFAS score was 91 +/- 4.1 points.  Seven patients (8 feet) had an excellent outcome and 4 patients (5 feet) a good outcome according to the Coughlin scoring rate.  The IV-V IMA averaged 12.29 degrees +/- 1.5 degrees pre-operatively, while post-operatively it was 6.18 degrees +/- 1.4 degrees (p < 0.0001).  The LDA improved from 7.74 degrees +/- 1.7 degrees pre-operatively to 4.25 degrees +/- 1 degree after surgery (p < 0.0001).  The WF decreased from 8.01 +/- 1.3 mm to 7.05 +/- 1.3 mm (p < 0.0001).  The mean 5 MPA decreased from 21.7 degrees +/- 4.1 degrees pre-operatively to 7.63 degrees +/- 3.4 degrees at final follow-up (p < 0.0001).  One patient developed a superficial infection around a K-wire.  The authors concluded that metatarsal sliding osteotomy is a safe and effective method for the correction of symptomatic bunionette in patients below 18 years of age.  Moreover, they stated that further research is needed to compare this approach with other treatment methods in this specific age group.

Guha et al (2012) noted that the bunionette or tailor's bunion is a lateral prominence of the 5fth metatarsal head.  It is usually characterized by a wide IMA between the 4th and 5th metatarsals, varus of the MTP joint, pain and callus formation.  Various distal, shaft and basal osteotomies have been described in the literature.  These investigators have described a reverse scarf osteotomy for bunionette correction.  They have used a "reverse" scarf osteotomy in 12 cases (10 females: 2 males) with a mean follow-up of 12 months (range of 5 to 22 months) with radiographs and clinical scoring.  Post-operatively, mean IMA improved from 13.1 degrees to 7.27 degrees (range of 2.0 to 11.5); mean 5th MTP angle improved from 19.9 degrees to 6.36 degrees (range of  2.8 to 9.0) and post-operative mean AOFAS improved from 54.25 to 89.58 (range of 70 to 100).  The authors concluded that "reverse" scarf osteotomy in the correction of bunionette deformity offers promising results in the short-term.

An UpToDate review on “Hallux valgus deformity (bunion)” (Ferrari, 2013) does not mention the use of allograft as a therapeutic option.

Chao and colleagues (2013) stated that the standard treatment for hallux valgus in rheumatoid arthritis (RA) has been arthrodesis of the first MTP joint.  There is limited literature regarding the results of hallux valgus procedures which preserve the first MTP joint in RA.  These researchers investigated the radiographic and clinical outcomes of joint-preserving surgery for hallux valgus in a series of RA patients to evaluate the result of non-arthrodesis reconstruction.  A total of 37 feet with hallux valgus in 27 patients with RA treated with a joint-preserving procedure of the first MTP joint were analyzed radiographically and clinically.  Average follow-up was 42 (range of 12 to 111) months; 20 feet had Ludloff osteotomies, 15 had scarf osteotomies, and 2 had chevron osteotomies.  Radiographs were evaluated pre-operatively and post-operatively for hallux valgus angle, 1-2 intermetatarsal angle, and degenerative narrowing of the first MTP joint based the Sharp score and the Larsen grade.  Narrowing of the first inter-phalangeal (IP) joint was based on a modification of the classification of Hattrup and Johnson.  Operative complications and required secondary surgeries were tabulated.  Clinical outcomes were measured using pre-operative and post-operative Short Form-36 (SF-36), AOFAS forefoot scale, and visual analog scale (VAS) pain questionnaires.  The average hallux valgus angle improved from 37 degrees pre-operatively to 15 degrees post-operatively.  The average 1-2 intermetatarsal angle improved from 14 degrees pre-operatively to 5 degrees post-operatively.  The average Sharp score of the first MTP joint was 0.9 pre-operatively and 1.6 post-operatively.  The average Larsen grade of the first MTP joint was 0.6 pre-operatively and 1.4 post-operatively.  Range of motion of the first MTP joint was essentially unchanged between pre-operative and post-operative measurements.  Seven of 37 feet had progression of first IP joint space narrowing, but none was symptomatic.  The AOFAS score improved from 45.2 pre-operatively to 82.6 at final follow-up (p < 0.01).  The VAS decreased from 4.8 pre-operatively to 1.5 at final follow-up (p < 0.02).  The SF-36 physical component score decreased from 40.3 pre-operatively to 37.4 at final follow-up, and the mental component score remained unchanged, and neither was statistically significant.  There were 7 feet (19 %) that required a return to surgery: 3 wound infections, 2 arthrodeses for progression of deformity, and 1 each for revision for recurrence and hardware removal.  The authors concluded that RA patients who undergo a bunionectomy rather than arthrodesis to preserve the first MTP joint have satisfactory clinical and radiographic outcomes.  This procedure appeared to be a reasonable alternative to first MTP arthrodesis in patients with relatively preserved joints.

Cheilectomy Versus Decompression Osteotomy in Early-Stage Hallux Rigidus

Cullen and colleagues (2017) noted that 2 commonly used procedures for early stage hallux rigidus are

1. cheilectomy and
2. decompression metatarsal osteotomy.  

However, although both procedures were first described several decades ago, a deficit exists in the published data comparing their effectiveness.  These investigators performed a retrospective comparative study to examine the results of surgical treatment of early-stage hallux rigidus.  A total of 423 subjects were included in this study.  Hallux limitus or rigidus had been diagnosed in all patients, who had undergone either cheilectomy or any variation of plantar-flexion decompression metatarsal head osteotomy.  Of the 423 procedures identified during the study period, 341 (80.6 %) were cheilectomy and 82 (19.4 %) were decompression osteotomy procedures.  The rate of revision procedures was significantly greater in the cheilectomy group (8.21 %) than in the osteotomy group (1.22 %).  Sex, laterality, and body mass index (BMI) played no role in the rate of revision.  The absence of research studies comparing the effectiveness of the 2 procedures has led many practitioners to favor cheilectomy for early-stage hallux rigidus.  Decompression metatarsal osteotomies are technically more difficult, involve more risks, and require greater restrictions on postoperative weight-bearing compared with cheilectomy.  The authors concluded that these findings demonstrated that within the first 5 post-operative years, decompression osteotomy resulted in a dramatically lower rate of revisional surgery for 1st MTP joint pathology compared with cheilectomy.

Continuous Wound Infiltration with Local Anesthetics After Hallux Valgus Surgery

Braito and colleagues (2018) noted that hallux valgus surgery is associated with significant early post-operative pain.  In a prospective, randomized, double-blind, and placebo-controlled, single-center trial, these investigators examined the use of continuous wound infiltration (CWI) with ropivacaine for pain management after hallux valgus surgery.  A total of 50 patients undergoing distal metatarsal osteotomy for idiopathic hallux valgus were allocated to CWI with ropivacaine 2 mg/ml at a rate of 2 ml/hr or placebo for 24 hours post-operatively.  Average and peak pain levels on the verbal numeric rating scale (NRS; 1 to 10) during the 1st 48 hours after surgery were recorded as primary outcome parameters.  Secondary outcome parameters included consumption of narcotics, clinical outcome, incidence of post-operative complications, and patient satisfaction.  No significant difference in mean (p = 0.596) and peak (p = 0.353) post-operative pain level was found for CWI with either ropivacaine (mean NRS 1.9 ± 0.8; peak NRS 3.5 ± 2.0) or placebo (mean NRS 2.0 ± 0.7; peak NRS 3.9 ± 1.7) during the early post-operative course.  Furthermore, no significant differences between both groups were detected regarding narcotic consumption (p = 0.354) and all other secondary outcome parameters; 2 severe complications (local dysesthesia with CWI, catheter accidentally fixed by a suture) and 5 catheter dislocations were observed.  The authors concluded that CWI with ropivacaine 2 mg/ml at a rate of 2 ml/hr for 24 hours after hallux valgus surgery did not reduce post-operative pain level in an in-patient setting.  Level of Evidence = I.

Furthermore, an UpToDate review on “Hallux valgus deformity (bunion)” (Ferrari, 2018) does not mention continuous wound infiltration as a tool for post-operative management.

The Lapidus Procedure / Lapiplasty System

Popelka and colleagues (2008) stated that the most frequent deformity of the big toe and fore-foot associated with a collapse of the transverse arch of the foot is a valgus deformity, which often develops due to a varus deviation of the 1st metatarsal (MT) bone when the intermetatarsal angle between the 1st and 2nd metatarsals is greater than 10 degrees.  When the intermetatarsal angle is larger than 10 degrees or the 1st ray is hypermobile, a Lapidus procedure is an therapeutic option.  These researchers evaluated the outcomes in patients with hallux valgus deformity treated by the Lapidus procedure.  The group comprised 61 patients, 49 women and 12 men, with an average age of 58.3 years at the time of surgery, who were treated at the authors’ department from 2002 to 2006; 15 patients had bilateral surgery.  The results of 76 operations were evaluated.  Indications for surgery were hallux valgus in 22 patients, RA in 36 and psoriatic arthritis in 3 patients.  Access was gained on the mediodorsal side of the foot through an incision medial to the extensor hallucis longus tendon, over the 1st tarsometatarsal joint up to the 1st MTP joint.  An arthrodesis was fixed with 2 Kirschner wires in 8 feet and with 2 screws in 15 feet.  Recently, the use of shape memory alloy staples (DePuy Mitek) was adopted and applied in 53 feet with good outcome.  In patients with RA the Lapidus procedure together with resection of the heads of the 2nd and 5fth metatarsals was used from the plantar approach.  The evaluation was focused on the patients' satisfaction and their subjective complaints.  No pain was reported on 56 (73 %) fore-feet, slight pain was experienced on the dorsal side in 10 feet (13 %) and pain in the transverse arch also in 10 feet (13 %).  Complications included slow healing of the wound in 7 feet of the patients with RA (9.2 %), and infection requiring revision surgery in 1 patient (1.3 %); 5 patients (6.5 %) reported persisting swelling of the foot dorsum for a period longer than 3 months.  Recurrence of hallux valgus was recorded in 9 feet.  The average AOFAS score, which was 48.1 points pre-operatively, improved to 89.2 points post-operatively.  In 1 patient, bony union was very slow and was achieved at 5 months following surgery.  The authors concluded that an exact evaluation of the results of a Lapidus procedure was not always possible, particularly in patients with RA in whom foot disorders are more complex.  A much discussed issue was first MT hypermobility.  In this group of 61 patients, this was found in 28.  Of these, 18 had RA and 10 had hallux valgus.  The rate of pseudo-arthrosis following a Lapidus procedure was reported to range from 3.3 % to 9 %.  In our group only 1 patient was affected (1.3 %).

So and co-workers (2019) stated that the Lapidus bunionectomy is performed for the treatment of hallux valgus; however, recurrence of the deformity remains a concern.  A transverse intermetatarsal screw spanning the base of the 1st metatarsal to the base of the 2nd can increase stability.  The neurovascular bundle is located within the proximity of this screw.  In this study, these researchers evaluated the structures at risks with the use of this technique.  In 10 specimens, a guide-wire was placed, and a 4.0-mm cannulated screw was inserted.  The neurovascular bundle was dissected and inspected for direct trauma to the neurovascular bundle, and the proximity of the screw was measured using a digital caliper.  A total of 10 cadaveric specimens were used.  The dorsalis pedis artery and deep peroneal nerve were free from injury in 9 of 10 specimens.  In those 9 specimens, the neurovascular bundle was located dorsal in relation to the screw.  The mean distance of the screw to the neurovascular bundle was 7.1 ± 3.3 mm.  The mean distance from the screw to the 1st tarsometatarsal joint (TMTJ) was 14.7 ± 4.3 mm.  The mean distance from the screw as it entered the 2nd metatarsal to the 2nd TMTJ was 18.0 ± 7.2 mm.  In 1 specimen, the screw was found to be traversing through the neurovascular bundle.  The distance from the screw to the 1st TMTJ was 15.0 mm.  The distance of the screw from where it entered the 2nd metatarsal to the 2nd TMTJ was 24.0 mm.  The authors concluded that although the intermetatarsal screw avoided the neurovascular cases in most instances, there is some anatomic risk to the neurovascular bundle.  These researchers stated that further study is needed to evaluate clinical results using the intermetatarsal screw for the modified Lapidus procedure.

Moerenhout and associates (2019) noted that the modified Lapidus procedure is a surgical option to treat moderate-to-severe hallux valgus deformity with good radio-clinical outcome.  However, comprehensive biomechanical outcome evaluation of this surgery at mid-term follow-up is missing.  These researchers evaluated and compared the radio-clinical and gait outcome at 6 and 12 months following modified Lapidus procedure.  A total of 10 consecutive female patients with moderate-to-severe hallux valgus who underwent modified Lapidus procedure participated in the study.  Comprehensive gait assessment was performed pre-operatively, at 6 and 12 months post-operatively.  Gait parameters including spatio-temporal, kinematics and plantar pressure were analyzed using pressure insoles and 3-D inertial sensors.  Outcome was evaluated using 2 clinical questionnaires, i.e. the AOFAS and the Foot and Ankle Ability Measure (FAAM), and X-rays; 3 spatio-temporal, 2 kinematics, and 7 plantar pressure parameters significantly improved between 6 months and 12 months post-operatively.  Significant improvement in radiological and clinical outcome was reported at 6 and 12 months.  The FAAM showed non-significant improvement at 12 months.  The authors concluded that the outcome of this study was consistent with the previously reported good clinical and radiological results at 1 year following Lapidus for moderate-to-severe hallux valgus; 12 gait parameters showed that outcome improved from 6 months to 12 months post-operative with room for further improvement at long-term.  These researchers stated that the gait outcome in this study confirmed the longer rehabilitation period following modified Lapidus procedure; studies with a larger sample size are needed to confirm these findings.

Furthermore, there is a clinical trial entitled “Early weight-bearing after the Lapiplasty procedure (ALIGN3D)” that is recruiting participants (last updated 4/4/2019; estimated study completion date = 12/31/2024).

Table: CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
Simple bunionectomy:
CPT codes covered if selection criteria are met:
CPT codes not covered for indications listed in the CPB (not all-inclusive):
Continuous wound infiltration with local anesthetics - no specific code:
Other CPT codes related to the CPB:
11055 - 11057	Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus)
73620	Radiologic examination, foot; 2 views
73630	Radiologic examination, foot; complete, minimum of 3 views
Other HCPCS codes related to the CPB:
J0702	Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg
J1020	Injection, methylprednisolone acetate, 20 mg
J1030	Injection, methylprednisolone acetate, 40 mg
J1040	Injection, methylprednisolone acetate, 80 mg
J1094	Injection, dexamethasone acetate, 1 mg
J1100	Injection, dexamethasone sodium phosphate, 1 mg
J1700	Injection, hydrocortisone acetate, up to 25 mg
J1710	Injection, hydrocortisone sodium phosphate, up to 50 mg
J1720	Injection, hydrocortisone sodium succinate, up to 100 mg
J1741	Injection, ibuprofen, 100 mg
J1885	Injection, ketorolac tromethamine, per 15 mg
J2920	Injection, methylprednisolone sodium succinate, up to 40 mg
J3300	Injection, triamcinolone acetonide, preservative free, 1 mg
J3301	Injection, triamcinolone acetonide, not otherwise specified, 10 mg
J3302	Injection, triamcinolone diacetate, per 5 mg
J7312	Injection, dexamethasone, intravitreal implant, 0.1 mg
L3000 - L3100	Foot inserts and arch supports
L3201 - L3265	Orthopedic footwear
ICD-10 codes covered if selection criteria are met:
E10.51 - E10.59 E11.51 - E11.59 E13.51 - E13.59	Diabetes with circulatory complications [with ulcer and/or infection stemming solely from bunion]
L89.890 - L89.899	Pressure ulcer of other site [toes] [in diabetic members stemming solely from bunion]
L97.501 - L97.529	Non-pressure ulcer of other part of foot [toes] [in diabetic members stemming solely from bunion]
M20.10 - M20.12	Hallux valgus (acquired)
M21.611 - M21.619	Bunion
M86.071 - M86.079, M86.171 - M86.179 M86.271 - M86.279, M86.371 - M86.379 M86.471 - M86.479, M86.571 - M86.579 M86.9	Osteomyelitis, periositis, and other infections involving bone [stemming solely from bunion]
Bony Correction Bunionectomy (e.g., Akin, Chevron Osteotomy, Keller, Mitchell, proximal metatarsal osteotomy procedures, etc.):
Allograft for bunion repair - no specific code:
CPT codes covered if selection criteria are met:
28292	Correction, hallux valgus (bunion), with or without sesamoidectomy; Keller, McBride or Mayo type procedure
28294	Correction, hallux valgus (bunion), with or without sesamoidectomy; with tendon transplants (e.g., Joplin type procedure)
28295	Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal metatarsal osteotomy, any method
28296	Correction, hallux valgus (bunion), with or without sesamoidectomy; with metatarsal osteotomy (e.g., Mitchell, Chevron or concentric type procedures)
28297	Correction, hallux valgus (bunion), with or without sesamoidectomy; Lapidus type procedure
28298	Correction, hallux valgus (bunion), with or without sesamoidectomy; by phalanx osteotomy
28299	Correction, hallux valgus (bunion), with or without sesamoidectomy; by double osteotomy
CPT codes not covered for indications listed in the CPB (not all-inclusive):
Continuous wound infiltration with local anesthetics - no specific code:
Other CPT codes related to the CPB:
11055 - 11057	Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus)
73620	Radiologic examination, foot; 2 views
73630	Radiologic examination, foot; complete, minimum of 3 views
Other HCPCS codes related to the CPB:
A5512 - A5513	For diabetics only, multiple density inserts
J0702	Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg
J1020	Injection, methylprednisolone acetate, 20 mg
J1030	Injection, methylprednisolone acetate, 40 mg
J1040	Injection, methylprednisolone acetate, 80 mg
J1094	Injection, dexamethasone acetate, 1 mg
J1100	Injection, dexamethasone sodium phosphate, 1 mg
J1700	Injection, hydrocortisone acetate, up to 25 mg
J1710	Injection, hydrocortisone sodium phosphate, up to 50 mg
J1720	Injection, hydrocortisone sodium succinate, up to 100 mg
J1741	Injection, ibuprofen, 100 mg
J1885	Injection, ketorolac tromethamine, per 15 mg
J2920	Injection, methylprednisolone sodium succinate, up to 40 mg
J3300	Injection, triamcinolone acetonide, preservative free, 1 mg
J3301	Injection, triamcinolone acetonide, not otherwise specified, 10 mg
J3302	Injection, triamcinolone diacetate, per 5 mg
J7312	Injection, dexamethasone, intravitreal implant, 0.1 mg
L3000 - L3100	Foot inserts and arch supports
ICD-10 codes covered if selection criteria are met:
D21.20 - D21.22	Benign neoplasm of connective and other soft tissue of lower limb, including hip
G57.60 - G57.63	Lesion of plantar nerve [neuroma secondary to bunion]
M19.071 - M19.079	Primary osteoarthritis ankle and foot
M19.171 - M19.179	Post-traumatic osteoarthritis, ankle and foot
M20.10 - M20.12	Hallux valgus (acquired)
M20.5x1 - M20.5x9	Other deformities of toe(s) (acquired) [overriding of great toe or crossover toe deformity]
M21.611 - M21.629	Bunion
M67.00 - M67.02	Short Achilles tendon (acquired)
M71.171 - M71.179	Other infective bursitis, ankle and foot [recurrent]
M77.50 - M77.52	Other enthesopathy of foot [recurrent bursitis]
M85.671 - M85.679	Other cyst of bone, ankle and foot
Q66.89	Other specified congenital deformities of feet [overriding of great toe or crossover toe deformity]
ICD-10 codes not covered for indications listed in the CPB:
I73.9	Peripheral vascular disease, unspecified [severe vascular insufficiency impairing circulation]
I96	Gangrene, not elsewhere classified [of the foot, ankle or lower leg]
L89.890 - L89.899	Pressure ulcer of other site [toes] [Open blisters, pressure sores, and skin ulceration overlying the bunion when the bunion is not the cause of the skin lesion or secondary to peripheral vascular disease]
L97.501 - L97.529	Non-pressure ulcer of other part of foot [toes] [Open blisters, pressure sores, and skin ulceration overlying the bunion when the bunion is not the cause of the skin lesion or secondary to peripheral vascular disease]
M24.671 - M24.676	Ankylosis, ankle and foot [excessive scarring]
Z74.01	Bed confinement status [non-ambulatory individuals]
Bunionette:
CPT codes covered if selection criteria are met:
28110	Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure)
Other CPT codes related to the CPB:
11055 - 11057	Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus)
73620	Radiologic examination, foot; 2 views
73630	Radiologic examination, foot; complete, minimum of 3 views
Other HCPCS codes related to the CPB:
J0702	Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg
J1020	Injection, methylprednisolone acetate, 20 mg
J1030	Injection, methylprednisolone acetate, 40 mg
J1040	Injection, methylprednisolone acetate, 80 mg
J1094	Injection, dexamethasone acetate, 1 mg
J1100	Injection, dexamethasone sodium phosphate, 1 mg
J1700	Injection, hydrocortisone acetate, up to 25 mg
J1710	Injection, hydrocortisone sodium phosphate, up to 50 mg
J1720	Injection, hydrocortisone sodium succinate, up to 100 mg
J1741	Injection, ibuprofen, 100 mg
J1885	Injection, ketorolac tromethamine, per 15 mg
J2920	Injection, methylprednisolone sodium succinate, up to 40 mg
J3300	Injection, triamcinolone acetonide, preservative free, 1 mg
J3301	Injection, triamcinolone acetonide, not otherwise specified, 10 mg
J3302	Injection, triamcinolone diacetate, per 5 mg
J7312	Injection, dexamethasone, intravitreal implant, 0.1 mg
L3000 - L3100	Foot inserts and arch supports
L3201 - L3265	Orthopedic footwear
ICD-10 codes covered if selection criteria are met:
M20.10 - M20.12	Hallux valgus (acquired)
Cheilectomy:
CPT codes covered if selection criteria are met:
28289	Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint
Other CPT codes related to the CPB:
11055 - 11057	Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus)
73620	Radiologic examination, foot; 2 views
73630	Radiologic examination, foot; complete, minimum of 3 views
Other HCPCS codes related to the CPB:
J0702	Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg
J1020	Injection, methylprednisolone acetate, 20 mg
J1030	Injection, methylprednisolone acetate, 40 mg
J1040	Injection, methylprednisolone acetate, 80 mg
J1094	Injection, dexamethasone acetate, 1 mg
J1100	Injection, dexamethasone sodium phosphate, 1 mg
J1700	Injection, hydrocortisone acetate, up to 25 mg
J1710	Injection, hydrocortisone sodium phosphate, up to 50 mg
J1720	Injection, hydrocortisone sodium succinate, up to 100 mg
J1741	Injection, ibuprofen, 100 mg
J1885	Injection, ketorolac tromethamine, per 15 mg
J2920	Injection, methylprednisolone sodium succinate, up to 40 mg
J3300	Injection, triamcinolone acetonide, preservative free, 1 mg
J3301	Injection, triamcinolone acetonide, not otherwise specified, 10 mg
J3302	Injection, triamcinolone diacetate, per 5 mg
J7312	Injection, dexamethasone, intravitreal implant, 0.1 mg
L3000 - L3100	Foot inserts and arch supports
L3201 - L3265	Orthopedic footwear
ICD-10 codes covered if selection criteria are met:
M20.20 - M20.22	Hallux rigidus
M25.774 - M25.776	Osteophyte, ankle and foot [painful bony spurs]
Arthrodesis:
CPT codes covered if selection criteria are met:
28750	Arthrodesis, great toe; metatarsophalangeal joint
Other CPT codes related to the CPB:
11055 - 11057	Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus)
73620	Radiologic examination, foot; 2 views
73630	Radiologic examination, foot; complete, minimum of 3 views
Other HCPCS codes related to the CPB:
J0702	Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg
J1020	Injection, methylprednisolone acetate, 20 mg
J1030	Injection, methylprednisolone acetate, 40 mg
J1040	Injection, methylprednisolone acetate, 80 mg
J1094	Injection, dexamethasone acetate, 1 mg
J1100	Injection, dexamethasone sodium phosphate, 1 mg
J1700	Injection, hydrocortisone acetate, up to 25 mg
J1710	Injection, hydrocortisone sodium phosphate, up to 50 mg
J1720	Injection, hydrocortisone sodium succinate, up to 100 mg
J1741	Injection, ibuprofen, 100 mg
J1885	Injection, ketorolac tromethamine, per 15 mg
J2920	Injection, methylprednisolone sodium succinate, up to 40 mg
J3300	Injection, triamcinolone acetonide, preservative free, 1 mg
J3301	Injection, triamcinolone acetonide, not otherwise specified, 10 mg
J3302	Injection, triamcinolone diacetate, per 5 mg
J7312	Injection, dexamethasone, intravitreal implant, 0.1 mg
L3000 - L3100	Foot inserts and arch supports
L3201 - L3265	Orthopedic footwear
ICD-10 codes covered if selection criteria are met:
M19.071 - M19.079	Primary osteoarthritis ankle and foot [advanced degenerative joint disease]
M19.171 - M19.179	Post-traumatic osteoarthritis, ankle and foot [advanced degenerative joint disease]
M20.10 - M20.12	Hallux valgus (acquired)
Q72.30 - Q72.33	Congenital absence of foot and toe(s) [absent second toe]
S93.121+ - S93.129+ S93.141+ - S93.149+	Dislocation and subluxation of metatarsophalangeal (joint) [severely subluxated or dislocated MTP joints]
Z89.421 - Z89.429	Acquired absence of other toe(s) [absent second toe]

The above policy is based on the following references: