Why The Lapidus Procedure Is Ideal For Bunions

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Why The Lapidus Procedure Is Ideal For Bunions
Here one can see a preoperative lateral view of hallux valgus showing instability in the dorsal and plantar planes.
This pre-op anterior-posterior view shows hallux valgus with medial instability.
The post-op dorsal-plantar view (left) shows repositioning of the first ray for medial stability and decrease of first ray elevatus. The anterior-posterior view (right) depicts correction of the medial instability.
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Author(s): 
By Babak Baravarian, DPM

Key Considerations In Procedure Selection
In the case of an adolescent patient with hallux valgus deformity, I am very inflexible. One must close the growth plate of the first ray and a Lapidus procedure is the only option I will consider. In order to have a hallux valgus deformity at such a young age, laxity must be present. This is not shoe related and has clearly not occurred from years of walking. I also will consider a potential gastrocnemius recession and rearfoot alignment correction as needed. I feel that the younger the patient, the more the need there is for foot correction as opposed to pursuing hallux valgus correction only.

When treating patients over the age of 75, I will often consider a distal head osteotomy for correction. In an older patient, the result may not be ideal with perfect stability but I feel there will be an early return to ambulation. The limited downtime and risk are substantial and important considerations.
The majority of patients I see — and I believe the majority of patients whom most foot and ankle surgeons see — are between the ages of 25 and 65. This group requires the most care and consideration of a surgical procedure. I will consider a distal head procedure if a patient has a mild to moderate hallux valgus deformity with no gross laxity, if the patient cannot take time off work, has young children and cannot be non-weightbearing. I will also consider the procedure if the patient has health issues preventing a more comprehensive surgery or has little risk tolerance for an extensive surgery, and is willing to consider potential future surgery.
I have found that an offset V procedure with two screws can correct almost all levels of mild to moderate deformity depending on the length of the dorsal arm. I also have found little risk with the surgery and excellent outcomes.

Pre-Op Discussion: What To Discuss With Patients
Before surgery, I warn patients about the potential for recurrence and the fact that the correction may not last a lifetime in those with moderate laxity. I also offer a more comprehensive surgery but discuss the fact that it may not fit with their lives at this time. Finally, I discuss waiting until a better time for a more comprehensive surgery if I feel a Lapidus procedure is the best option. I give the patient the choice and provide a great deal of guidance.
In the group with minimal health or lifestyle issues, no matter what the extent of the hallux valgus deformity is, I explain the fact that the true site of deformity and the cause of the hallux valgus problem is at the first metatarsocuneiform joint (MCJ). The bone does not bend midshaft and that laxity of the first MCJ is the major cause of the problem. It is fairly rare for me to find a hallux valgus deformity that is not lax in nature and has limited dorsal motion. I am a big proponent of the Lapidus procedure in all but the most stable of feet.
If I feel the patient’s foot is amenable to osteotomy correction, I will discuss this option. However, if I feel the Lapidus is the only true option, I will discuss that procedure in detail and only mention the osteotomy in passing for the sake of completeness. I believe surgeons should guide patients in the proper direction and only offer the choices that fit their needs.

Essential Pearls For Performing The Lapidus Procedure
When it comes to the Lapidus, I use a two-incision approach. I start with an incision over the midfoot and place it directly over the first MCJ. I use a distractor to access the joint and prefer the Weinraub retractor with 0.062 K-wires in the metatarsal and cuneiform to allow for a spread of the joint.
With over 300 Lapidus procedures under my belt, I am fairly confident the procedure of choice for joint preparation is to remove all articular cartilage without a bone cut and then fenestrate the subchondral bone with a 0.062 K-wire or 1-mm drill bit under lavage.

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