Why The Lapidus Procedure Is Ideal For Bunions

By Babak Baravarian, DPM

With over 50 different surgical procedures in the literature relating to bunion surgery, there is a great deal of debate as to the best surgical procedure. Some consider a minimum incision technique to be ideal while others believe an open and more extensive correction is the best. For years, I have pondered the best surgical procedure for hallux valgus correction and have tried many of the procedures. I have come to some conclusions that have dramatically changed my practice and resulted in far better outcomes related to hallux valgus correction. First and foremost, I have to state that these are just my ideas. Hopefully, this article will educate others on my thoughts and my years of dealing with hallux valgus correction. As a resident in Pittsburgh, I had the opportunity to deal with multiple surgeons and experience all different forms of bunion surgery from the most complex reconstructions with several bone cuts to the minimal incision techniques. However, I found on a consistent basis that two or three doctors had excellent results without one hallux valgus procedure as the ideal choice. After I began practice in Los Angeles, I went through a period trying what I thought were the best surgical options and have come to realize that I am really comfortable with only two hallux valgus surgical options. What Advantages Does The Lapidus Procedure Offer? The Lapidus procedure allows for all levels of correction with no need to cut corners. There is minimal difficulty to the procedure and the learning curve was far easier for me than learning a closing base wedge. I am able to correct the intermetatarsal angle, reduce laxity, plantarflex the ray and even correct a small amount of proximal articular set angle by wedging the base slightly. Although there is a small amount of risk of nonunion with the procedure, if one uses the proper technique and the patient is compliant, the risk is very low. Finally, if one considers the entire foot as a whole, the Lapidus procedure is excellent for stabilization of the medial column of the foot, which prevents arch collapse, midfoot arthritis, posterior tibial tendon tear and possibly plantar fasciitis. What You Should Look For In The Physical Exam From a consultation visit, I gather some key information to consider prior to surgery. How old is the patient and how active is the patient? Can this patient take time off for a comprehensive surgery and be off his or her foot for an extended time? Does this patient worry about the possibility of need for further surgery? In the physical exam, I check for tightness of the Achilles complex, the position of the foot while standing and the position of the arch both seated and weightbearing. I will also check for callus formation in two regions. The first is the medial great toe and metatarsal head while the second region is plantar to the second metatarsal head. Then I consider the hallux valgus deformity. The most important factor to me is how loose the first ray is. We discuss the intermetatarsal angle, the proximal articular set angle, the hallux abductus angle and the sesamoid position but I have found that dealing with laxity of the first ray is the single most important factor in my hands for a good outcome. Laxity of the ray is divided into two planes. I believe that the most important plane to consider is not the medial shift of the ray but rather the dorsal shift of the ray. Although I learned that equal dorsal and plantar motion are normal, if there is keratoma formation below the second ray and excess dorsal motion of the first ray, I feel there is laxity. In regard to medial laxity, I feel this is less of an issue as one can shift the ray laterally, increase the medial to lateral stability and decrease the potential for medial re-shift, but the ray can still be lax in a plantar to dorsal motion. Following the exam, I talk to the patient about his or her expectations, lifestyle, age-related recurrence issues and if he or she would consider a second surgery in the future if the hallux valgus deformity returns. 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.

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