Early Weightbearing After Lapidus: Is It Possible?
Yes, Neal Blitz, DPM, says it is possible in certain cases. In assessing the literature and his own experience, he emphasizes proper patient selection and key surgical tips for facilitating optimal outcomes. The Lapidus arthrodesis is an excellent procedure to correct metatarsus primus adductus. The procedure, which allows one to realign and stabilize the first metatarsal at the apex of the deformity, was first described by Albrecht in 1911 and subsequently popularized by Lapidus.1-4 Yet it was later abandoned by many surgeons because of the high nonunion rate and postoperative course of nonweightbearing. However, in recent years, the Lapidus arthrodesis has evolved and regained popularity due to improved technique and better fixation methods.5,6 With the use of rigid internal fixation, some surgeons have initiated an early weightbearing protocol to decrease the prolonged convalescence associated with the procedure.7-10 Obviously, one may achieve full weightbearing after bony consolidation has been identified on radiographs, a process that takes six to eight weeks. The immediate postoperative weightbearing protocol varies among surgeons, institutions and even geographic regions. Some surgeons advocate a strict nonweightbearing period of eight weeks while others allow gentle weightbearing as early as two weeks postoperatively.7,9 The postoperative protocol utilized by Lapidus involved immediate weightbearing as tolerated in a special shoe with a metal plate inserted medially. Patients were able to ambulate on “their heels on the second or third postoperative day” and “few patients required crutches for the first week or two.”4 He secured the fusion site with a heavy chromic catgut suture, which is considered primitive by today’s standards. This inadequate fixation and immediate weightbearing have been suggested as the causes for the early failures.11 It was not until 1974 when Rutherford first utilized single screw fixation.12 Sangeorzan and Hansen popularized rigid two screw fixation and began early mobilization postoperatively.7 The potential for a nonunion is the primary concern with early weightbearing after a Lapidus arthrodesis. However, a delayed union or nonunion is an inherent complication with any joint arthrodesis. The incidence of nonunion for the first metatarsocuneiform joint occurs in approximately 3 to 12 percent of cases.7,10,11,13-17 This figure may be somewhat inflated because many researchers reported total radiographic nonunions and did not distinguish among symptomatic cases. Symptomatic nonunions requiring revision likely account for the lower estimated percent of nonunion occurrence. What The Literature Reveals About Early Weightbearing It is important to remember that a radiographic nonunion may be considered a satisfactory result as long as the fusion site is stable and not painful. McInness and Bouche reported a symptomatic revision rate in two of 25 patients (4.8 percent).16 Of 47 Lapidus procedures, Catanzariti and Mendicino, et. al., reported two delayed unions (4.36 percent) and three nonunions requiring revision surgery (6.39 percent).15 In the largest reported series of Lapidus procedures, Patel and Ford, et. al., demonstrated an overall nonunion rate of 5.3 percent (12 of 227 feet).17 Their protocol involved crossed screw fixation and postoperative nonweightbearing. Sangeorzan and Hansen retrospectively reviewed 40 feet after a Lapidus arthrodesis with crossed screw fixation and an early weightbearing program.7 Their protocol involved immediate postoperative toe touch weightbearing in a short leg cast for two weeks followed by “weight of leg ambulation” for an additional two weeks. They also had patients use a short-leg walking cast at four weeks postoperatively until they saw radiographic evidence of union. Radiographic union occurred in 36 of the 40 feet (92 percent). Two patients underwent revision for nonunion with hallux valgus recurrence. Another patient with hallux varus and nonunion also underwent revision. A separate study by Clark, Veith and Hansen evaluated the Lapidus arthrodesis in an adolescent population with an average age of 18. They utilized a technique and postoperative weightbearing protocol that was similar to the aforementioned approach by Sangeorzan and Hansen. All 32 feet in the study achieved a successful union and excellent or good results were reported by 91 percent of patients.8 Bednarz and Manoli consecutively reviewed 31 feet after Lapidus arthrodeses with screw fixation.9 The postoperative weightbearing protocol involved nonweightbearing for two weeks followed by protected weightbearing for two to six weeks. They achieved a 100 percent union rate. Patients returned to conventional shoes at an average of 16 weeks postoperatively (with a range between 10 to 48 weeks). Myerson, et. al., evaluated 67 feet after a first metatarsocuneiform joint fusion.10 Twenty-one feet were placed in a short leg cast and crutches until comfortable weightbearing was tolerated. The remaining 46 feet were ambulating in a postoperative shoe with or without crutches for a duration of six to eight weeks. There were seven radiographic nonunions (9.5 percent) and only one patient underwent a revision fusion. It is clear that early weightbearing after a Lapidus arthrodesis remains a poorly researched subject. To date, there are few studies that have utilized an early weightbearing protocol and there are no studies that compare different postoperative weightbearing protocols. The studies in the podiatric literature involve postoperative protocols of nonweightbearing for six to eight weeks in a short leg cast.13,16,18-21 Interestingly, a few studies in the orthopedic literature demonstrate less “protective” postoperative management protocols and advocate early weightbearing.7-10 Which Patients Are Poor Candidates For Early Weightbearing? When it comes to early weightbearing after a patient has undergone a Lapidus arthrodesis, one should consider it on a case by case basis. Although a specific selection criterion has yet to be established, the surgeon must emphasize proper patient selection in order to maximize results with this protocol. Age and medical comorbidities play an important role in a patient’s ability to obtain a solid union. Patients with peripheral neuropathy, obesity and osteoporosis are poor candidates for early mobilization. Insensate patients are unable to balance their weight appropriately and transfer excessive force across the fusion site. A nonunion may occur but more often the fixation will fail, often requiring revision. Grossly overweight patients also transmit an increased pressure at the fusion site and are at risk. Patients with oversized feet (larger than size 13) also seem to be at risk as they may transmit increased loads to the fusion site through a cantilever effect, which may subsequently promote nonunion. Rarefaction of the bones with osteoporosis reduces the ability of internal fixation to gain adequate osseous purchase and maintain stability with weightbearing. There are several factors associated with nonunion that the patient may control and one should consider these factors before performing a Lapidus arthrodesis. It is well known in the orthopedic literature that smokers are more likely to develop bone healing complications and account for a majority of nonunions.11,22,23 Some surgeons consider smoking a relative contraindication to the Lapidus arthrodesis. Spinal fusion studies suggest that cessation of smoking may return the nonunion rate to that of non-smokers.22,24,25 One should encourage patients to quit smoking prior to surgery and until they obtain a stable fusion.25,26 Also bear in mind that all nicotine-containing products (i.e. patches and gums) possess the same risk for nonunion and should not be substituted for smoking. Given the increased risk of nonunion with smokers, an early weightbearing program may not be practical in this patient population. It’s also important to remember that certain medications are linked to poor bone healing and one should identify these before performing an arthrodesis. These medications include nonsteroidal antiinflammatories (NSAIDs), steroids and chemotherapeutic agents. Researchers have shown that NSAIDs inhibit osteogenic activity and may increase the nonunion rate.27-30 Clinical and animal studies with Cox I NSAIDs (Ketrolac and Indomethacin) and spinal fusions have demonstrated an increased nonunion rate.27-29,31 Therefore, the surgeon should consider avoiding NSAIDs during the postoperative period unless these medications are medically necessary for uncontrollable pain or inflammatory arthritis.27 Key Surgical Pearls For Preventing Nonunions And Facilitating Optimal Results There are several factors within the surgeon’s control that may contribute to a nonunion or help prevent it. For example, incomplete resection of the articular surface may not allow for adequate bone to bone contact, potentially leading to a nonunion. Thermal necrosis of the bone may occur if one uses the oscillating saw for joint preparation. Copious irrigation is encouraged to decrease this occurrence. Additionally, if the surgeon uses curettage to remove the articular surface, then he or she must adequately perforate the subchondral plate in order to allow for osseous ingrowth. Stable fixation of the first metatarsocuneiform joint is mandatory when considering an early mobilization protocol. Improper or poor fixation will increase the likelihood of a nonunion. I utilize the method advocated by Hansen with long cross screw fixation (3.5-mm or 4.0-mm cortical screws).5 One should place the first screw approximately 2 cm distal to the fusion site along the dorsal aspect of the midshaft region of the first metatarsal. Proper placement of this screw will position the screws’ long axis almost perpendicular to the fusion site, which increases its compressive force. The orientation of the screw also resists the cantilever bending moment of the first ray and is often parallel to the weightbearing surface. One should place the second screw from the dorsal lateral aspect of the medial cuneiform into the metatarsal base. I typically place a third screw obliquely from the first metatarsal base into the intermediate cuneiform to further strengthen the fusion site during healing.32 In situations in which the crossed screw fixation is compromised intraoperatively, one may use a medial plate with screws as a salvage technique. To reiterate, one should only consider early mobilization in cases in which solid fixation was achieved during surgery. Assessing The Potential Advantages Of Early Weightbearing In my practice, I typically use a combination of nonweightbearing followed by slow, gradual increases in weightbearing. I emphasize nonweightbearing until the sutures are removed at two weeks postoperatively and the soft tissue envelope has completely healed. I instruct patients to allow for “weight of leg ambulation” in a removable short leg boot. Increases in weightbearing are allowed on a weekly basis and are governed by pain. Patients typically advance to 75 percent weightbearing with support by the six week visit and are allowed full weightbearing in a removable walking boot if the fusion site is not tender. There are several benefits to instituting an early weightbearing program after the Lapidus arthrodesis. Reliable patients can wear a removable short leg boot, which they can remove to shower after the sutures are removed. Patients have easier access to the first metatarsophalangeal joint and are able to manually perform range of motion exercises to prevent stiffness. I instruct patients to remove the boot daily to perform range of motion of the ankle, which may theoretically lessen the occurrence of thrombosis associated with cast immobilization. The greatest advantage I have witnessed is less disuse osteoporosis and calf muscle atrophy, a well-known occurrence with strict nonweightbearing protocols. Moreover, some patients may achieve unprotected weightbearing sooner and perhaps return to a stable shoe as early as 10 weeks postoperatively. It is important to understand that the return to conventional shoes is often dictated by swelling and, in some instances, may take several months. Final Notes In conclusion, surgeons may initiate the early weightbearing of a Lapidus arthrodesis in certain clinical situations. One should carefully select patients based on age, weight, medical comorbidities, smoking history and reliability. Only allow an early weightbearing program after achieving solid internal fixation intraoperatively. Also keep in mind that early weightbearing after a Lapidus arthrodesis is typically a guarded or protected process. If you see or suspect complications, proceed to initiate a non-weightbearing protocol. Only those surgeons familiar with the technique, complications and management of a first metatarsocuneiform arthrodesis should consider early mobilization. Further clinical studies are needed to define the role of early weightbearing after a Lapidus arthrodesis. Dr. Blitz is an attending podiatric surgeon within the Department of Orthopedics at the Kaiser Permanente Medical Center in Santa Rosa, Ca. References 1. Albrecht GH. The pathology and treatment of hallux valgus. Russ Vrach. 10:14, 1911. 2. Lapidus PW. Operative correction of the metatarsus varus primus in hallux valgus. Surg, Gynec & Obst. 58:183-191, 1934. 3. Lapidus PW. A quarter century of experience with the operative correction of the metatarsus varus in hallux valgus. Bull Hosp Joint Dis Orthop Inst. 17:404, 1956. 4. Lapidus PW. The author’s bunion operation from 1931 to 1959. Clin Orthop. 16:119, 1960. 5. Hansen, ST. Functional Reconstruction of the Foot and Ankle. 2000, Philadelphia: Lippincott Williams & Wilkins. 6. Ray RG. First metatarsocuneiform arthrodesis: technical considerations and technique modification. J Foot Ankle Surg. 2002 Jul-Aug;41(4):260-72. 7. Sangeorzan BJ, Hansen ST Jr. Modified Lapidus procedure for hallux valgus. Foot Ankle. 1989 Jun;9(6):262-6. 8. Clark HR, Veith RG, Hansen ST Jr. Adolescent bunions treated by the modified Lapidus procedure. Bull Hosp Jt Dis Orthop Inst. 1987 Fall;47(2):109-22. 9. Bednarz PA, Manoli A 2nd. Modified Lapidus procedure for the treatment of hypermobile hallux valgus. Foot Ankle Int. 2000 Oct;21(10):816-21. 10. Myerson M, Allon S, McGarvey W. Metatarsocuneiform arthrodesis for management of hallux valgus and metatarsus primus varus. Foot Ankle. 1992 Mar-Apr;13(3):107-15. 11. Hansen ST Jr. Hallux valgus surgery. Morton and Lapidus were right! Clin Podiatr Med Surg. 1996 Jul;13(3):347-54. 12. Rutherford RL. The Lapidus procedure for primus metatarsus adductus. J Am Podiatry Assoc. 1974 Aug;64(8):581-4. 13. Saffo G, Wooster MF, Stevens M, Desnoyers R, Catanzariti AR. First metatarsocuneiform joint arthrodesis: a five-year retrospective analysis. J Foot Surg. 1989 Sep-Oct;28(5):459-65. 14. Grace D, Delmonte R, Catanzariti AR, Hofbauer M. Modified lapidus arthrodesis for adolescent hallux abducto valgus. J Foot Ankle Surg. 1999 Jan-Feb;38(1):8-13. 15. Catanzariti AR, Mendicino RW, Lee MS, Gallina MR. The modified Lapidus arthrodesis: a retrospective analysis. J Foot Ankle Surg. 1999 Sep-Oct;38(5):322-32. 16. McInnes BD, Bouche RT. Critical evaluation of the modified Lapidus procedure. J Foot Ankle Surg. 2001 Mar-Apr;40(2):71-90. 17. Patel S, Ford LA, Etcheverry J, Rush SM, Hamilton GA. Modified lapidus arthrodesis: rate of nonunion in 227 cases. J Foot Ankle Surg.2004 Jan-Feb;43(1):37-42. 18. Bacardi BE, Boysen TJ. Considerations for the Lapidus operation. J Foot Surg. 1986 Mar-Apr;25(2):133-8. 19. Hofbauer MH, Grossman JP. The Lapidus procedure. Clin Podiatr Med Surg. 1996 Jul;13(3):485-96. 20. Hernandez A, Hernandez PA, Hernandez WA. Lapidus: when and why? Clin Podiatr Med Surg. 1989 Jan;6(1):197-208. 21. Neylon TA, Johnson BA, Laroche RA. Use of the Lapidus bunionectomy in first ray insufficiency. Clin Podiatr Med Surg. 2001 Apr;18(2):365-75. 22. Glassman SD, Anagnost SC, Parker A, Burke D, Johnson JR, Dimar JR. The effect of cigarette smoking and smoking cessation on spinal fusion. Spine. 2000 Oct 15;25(20):2608-15. 23. Kwiatkowski TC, Hanley EN Jr, Ramp WK. Cigarette smoking and its orthopedic consequences. Am J Orthop. 1996 Sep;25(9):590-7. Review. 24. Silcox DH 3rd, Daftari T, Boden SD, Schimandle JH, Hutton WC, Whitesides TE Jr. The effect of nicotine on spinal fusion. Spine. 1995 Jul 15;20(14):1549-53. 25. Wing KJ, Fisher CG, O'Connell JX, Wing PC. Stopping nicotine exposure before surgery. The effect on spinal fusion in a rabbit model. Spine. 2000 Jan;25(1):30-4. 26. Daftari TK, Whitesides TE Jr, Heller JG, Goodrich AC, McCarey BE, Hutton WC. Nicotine on the revascularization of bone graft. An experimental study in rabbits. Spine. 1994 Apr 15;19(8):904-11. 27. Glassman SD, Rose SM, Dimar JR, Puno RM, Campbell MJ, Johnson JR. The effect of postoperative nonsteroidal anti-inflammatory drug administration on spinal fusion. Spine. 1998 Apr 1;23(7):834-8. 28. Elves MW, Bayley I, Roylance PJ. The effect of indomethacin upon experimental fractures in the rat. Acta Orthop Scand. 1982 Feb;53(1):35-41. 29. Bo J, Sudmann E, Marton PF. Effect of indomethacin on fracture healing in rats. Acta Orthop Scand. 1976 Dec;47(6):588-99. 30. Tornkvist H, Lindholm TS, Netz P, Stromberg L, Lindholm TC. Effect of ibuprofen and indomethacin on bone metabolism reflected in bone strength. Clin Orthop. 1984 Jul-Aug;(187):255-9. 31. Dimar JR 2nd, Ante WA, Zhang YP, Glassman SD. The effects of nonsteroidal anti-inflammatory drugs on posterior spinal fusions in the rat. Spine. 1996 Aug 15;21(16):1870-6. 32. Ray RG, Ching RP, Christensen JC, Hansen ST Jr. Biomechanical analysis of the first metatarsocuneiform arthrodesis. J Foot Ankle Surg. 1998 Sep-Oct;37(5):376-85. No, Patrick A. Heer, DPM, says it doesn’t make sense. Drawing from his own experience as well as the literature, he says early weightbearing after this procedure can only heighten the risk of non-union and delay healing. Basic concepts in foot and ankle surgery are the basis of what we do surgically to correct a deformity. When we try to alter these basic concepts to “better” a particular procedure or treatment, such as early weightbearing following a Lapidus arthrodesis, the result after careful clinical investigation often returns us to the standard, time-tested practices. Although there are certainly several instances when innovation has improved what we as foot and ankle surgeons do on a daily basis, I have always tried to use common sense based on the literature when evaluating a new product, procedure or trend in our profession. When considering the question of nonweightbearing versus weightbearing postoperatively for a Lapidus arthrodesis, common sense points me to the side of nonweightbearing regardless of the technique or type of fixation. What is the first rule of any arthrodesis procedure? Simply put, it is to fuse the joint in the correct position. The second rule of an arthrodesis procedure is to obtain adequate or complete fusion of the involved joint. Granted, with some procedures, weightbearing does not have a negative effect on the position of the fusion or the healing of the arthrodesis site. When ground reactive forces help to compress the arthrodesis site without having a deleterious effect on the position, then early weightbearing can be beneficial. Ankle arthrodesis comes to mind. We all are aware of the benefits of early weightbearing such as patient convenience, reducing the risk of postoperative cast disease, decreasing the rate of postoperative deep venous thrombosis and the potential for more rapid healing. On the other hand, some procedures are the complete opposite. Just think about the Lapidus arthrodesis for a moment. What you have is a planar arthrodesis site that is more or less perpendicular to the ground reactive forces. Can these ground reactive forces from early weightbearing do anything but jeopardize the intraoperative position you worked so hard to obtain or the overall healing of the arthrodesis site, which has an approximately 10 percent nonunion rate in the literature? I believe that is the case. What I Have Learned In My Experience First of all, let me state that this procedure has never been one of my favorites, even though I firmly believe in its benefit and indications. I find it difficult at times to access the joint, debride thoroughly, ensure anatomical positioning of the arthrodesis site and finally to obtain satisfactory fixation. I have been around a while and have tried various methods with this procedure, but I still find it a consistent challenge to this day. I have tried different combinations of internal fixation, external fixators and combined methods of fixation over the years both with and without bone grafting. In all of these cases, I have never used or even considered initial postoperative weightbearing. It has never made sense to me and several other authors agree. I typically use the 4-4-4 plan when performing arthrodesis procedures without bone grafting. This consists of four weeks nonweightbearing, four weeks partial weightbearing (which I think is an overlooked and undervalued aspect of bone healing for all of those early weightbearing advocates), and four weeks of assisted weightbearing during the postoperative healing course. Of course, this is just one point of view. Now let us look at the multitude of supporting evidence. What Does The Literature Reveal? The third edition of McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery recommends “nonweightbearing for six to 10 weeks or until radiographic evidence of an osseous union is noted.”1 In discussing the results of the procedure, the text mentions Myerson’s study of 67 cases in which patients were allowed to bear weight fully during the recovery period in a cast or surgical shoe. The results from Myerson’s study showed seven non-unions and five dorsal bunions, which the author from the McGlamry chapter felt could be directly related to the postoperative weightbearing.1 The section concludes by stating “Patients are best maintained nonweightbearing until healing of the osteotomy is achieved.” In addition to Myerson’s recommendations, take a look at what Hansen notes in his text Functional Reconstruction of the Foot and Ankle. His postoperative routine essentially consists of nonweightbearing for about two and a half weeks followed by partial weightbearing for five to six weeks.2 In Coughlin and Mann’s Surgery of the Foot and Ankle, they recommend nonweightbearing for four weeks followed by cast-assisted weightbearing for four weeks or until the fusion is complete.3 As far as the current journal literature is concerned, several articles have been written about the Lapidus procedure and I will try to highlight a couple of the more well-known references. In their seven-year follow-up study of the Lapidus procedure, McInnes and Bouche recommend nonweightbearing for at least six weeks.4 They also note that two factors for exercising caution in choosing this procedure are cigarette smoking and the inability of the patient to remain nonweightbearing for six to eight weeks.4 Patel, et. al., also recommended six weeks of nonweightbearing.5 In discussing the 12 nonunion cases in their study, they noted that four were noncompliant in regard to postoperative nonweightbearing. In their conclusion, they state “Patients must be thoroughly educated about the necessity of strict NWB and the length of time they must remain immobilized … In reviewing the literature, we noted that postoperative regimens consisting of weightbearing earlier in the postoperative course led to higher rates of nonunion.”5 In Conclusion There are several other references one can investigate on this subject. You will find the literature weighs heavily on the side of non-weightbearing after a Lapidus procedure. Whether or not you are new to the procedure or it is a staple of your surgical armamentarium, hopefully you can see the importance of nonweightbearing to maintain postoperative positioning and promote healing in this procedure based on a review of the literature, the concepts presented here and your own common sense. Dr. DeHeer is a Fellow of the American College of Foot and Ankle Surgeons and is a Diplomate of the American Board of Podiatric Surgery. He is also the team podiatrist for the Indiana Pacers and the Indiana Fever. References 1. Banks AS, Downey MS, Martin DE, Miller SJ, editors. McGlamry’s comprehensive textbook of foot and ankle surgery. 3rd edition. Philadelphia (PA): Williams and Wilkins: 2001. p. 544–552. 2. Hansen ST. Functional reconstruction of the foot and ankle. Philadelphia (PA): Williams and Wilkins: 2000. p. 335–338. 3. Coughlin MJ, Mann RA, editors. Surgery of the foot and ankle. 7th edition. St. Louis (MO): Mosby: 1999. p. 222–225. 4. McInnes BD, Bouche RT. Critical evaluation of the modified Lapidus procedure. J Foot Ankle Surg 40: 71 – 89, 2001. 5. Patel S, Ford LA, Etcheverry J, Rush SM, Hamilton GA. Modified Lapidus arthrodesis: rate of nonunion in 227 cases. J Foot Ankle Surg 43: 37–42, 2004. Additional Reading 6. Saffo G, Wooster MF, Stevens M, Desnoyers R, Catanzariti AR. First metatarsocuneiform joint arthrodesis: a five-year retrospective analysis. J Foot Ankle Surg 28: 459 -465, 1989. 7. Lombardi CM, Silhanek AD, Connolly FG, Suh D, Violand M. First metatarsocuneiform arthrodesis and Reverdin-Laird osteotomy for treatment of hallux valgus: an intermediate-term retrospective outcomes study. J Foot Ankle Surg 42: 77 -85, 2003. 8. Baravarian B, Briskin GB, Burns P. Lapidus Bunionectomy: arthrodesis of the first metatarsocuneiform joint. Clin Podiatr Med Surg 21: 97–111, 2004.