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.