Performing Revision Surgery Following The Lapidus Bunionectomy

Allen Jacobs DPM FACFAS

As with any bunion procedure, the Lapidus procedure may be associated with a number of potential complications and sequelae. Excessive elevation of the first metatarsal following the Lapidus procedure may result in lesser metatarsalgia or hallux limitus. Excessive shortening following the Lapidus procedure may also result in lesser metatarsalgia, hallux hammertoe deformity and lesser digital deformities. Injury to the peroneus longus or anterior tibial tendons may also occur as one performs the surgery in proximity to the insertion of these tendons. As with any arthrodesis procedure, delayed union or nonunion may occur, and hardware irritation may become problematic.

What are the goals of revision surgery with a Lapidus procedure? With any consideration of revision surgery following failed Lapidus arthrodesis, it is important to remember that every case is unique. One needs to reevaluate the foot globally. It is important not to focus simply on the surgical site itself. Frequently, revision surgery corrects a focal problem following the Lapidus procedure but results in more complications and sequelae following the revision. For example, if a patient has a symptomatic nonunion, one may successfully repair the nonunion by appropriate intervention but the intervention may result in malposition or exacerbation of shortening, thereby causing additional problems.

My old professor of orthopedics at the Pennsylvania College of Podiatry, James Ganley, DPM, used to tell us that if you have the opportunity to perform a revision on your own surgical procedure, make sure you do it correctly as you were not likely to get a third opportunity to correct the problem. Therefore, think long and hard about not only the immediate problem to be revised but the potential consequences of such revisions.

Is the problem just painful hardware? Is the problem a recurrent deformity? Is there painful delayed union or nonunion?

Correcting Shortening Following The Lapidus Procedure

It is interesting that authors have cited shortening of the first metatarsal following proximal closing base wedge osteotomy or Juvara-type procedures as a concern associated with these procedures. However, shortening of the first ray following the Lapidus procedure is reportedly significantly greater than that associated with a closing base wedge osteotomy of the first metatarsal. Sangeorzan and Hansen reported an average shortening of 5.0 mm with the Lapidus procedure, Catanzariti and colleagues reported an average shortening of 4.7 mm and McInnes and Bouché reported an average shortening of 7.5 mm with the Lapidus procedure.1-3

Therefore, before considering a patient for a Lapidus procedure, one must consider preexisting shortening of the first ray as well as the presence of a preoperative lesser metatarsal overload. In such cases, one should consider interpositional graft arthrodesis together with consideration of possible shortening of the lesser metatarsals.

A Closer Look At Sequelae Of The Lapidus Procedure

Sangeorzan and Hansen reviewed the results of the Lapidus procedure and noted a fusion rate of 90 percent, meaning 10 percent failed to achieve union.1 The average intermetatarsal angle reduction was reduced from 14 degrees to 6 degrees and the average hallux valgus deformity reduced from 26 degrees to 11 degrees. Importantly, the authors noted a change in length of 5 mm shortening without grafting and an increase of 4 mm in length with grafting.

Coetzee and Wickum reviewed 105 Lapidus procedures, noting seven nonunions, seven patients with continuing pain requiring revision and five patients with loss of correction.4 The average reduction of hallux valgus angulation was 37 to 16 degrees while the average intermetatarsal angulation reduced from 18 to 8.2 degrees.

Myerson and colleagues reviewed 67 Lapidus procedures.5 The average hallux valgus angle was reduced to 13 degrees and the average intermetatarsal angle reduced to 5.8 degrees from the preoperative 14 degree measurements. The authors reported a not insignificant complication rate, including seven nonunions, three symptomatic dorsal bunion deformities from elevation, 15 percent of patients having only partial relief of pain and 8 percent of patients having no relief of pain following the procedure.

These and other studies illustrated that the Lapidus procedure is not "perfect" and that complications and patient dissatisfaction can occur with a not insignificant incidence following the Lapidus procedure as with any bunion procedure.

Pertinent Insights On Nonunion Following The Lapidus Procedure

The nonunion rate associated with the Lapidus procedure is approximately 10 percent. Myerson and coworkers reported a nonunion rate of 12 percent, Coetzee and Wickum reported 11.5 percent, Catanzariti noted 10.6 percent, Sangeorzan and Hansen related a 10 percent nonunion rate, McInnes and Bouché reported 12 percent, and Saffo and colleagues reported 12 percent.1-6 Therefore, approximately 1 in 10 to 1 in 8 Lapidus procedures fail to achieve union as reflected in studies.

When evaluating pain or persistent symptoms following the Lapidus procedure, the presence of a nonunion on clinical or radiographic examination may not represent the actual source of pain. A recent review of the Lapidus procedure, demonstrating the most common complication to be nonunion, noted that only 25 percent of nonunions following the Lapidus procedure are actually symptomatic.7 Therefore, given a patient with persistent pain at the operative site, one must consider additional sources of pain even in the presence of a demonstrable nonunion. Again, in preoperative planning to revise a symptomatic nonunion, do not forget to consider the potential effects of the revision (such as excessive elevation or shortening), and determine a methodology to interdict such problems.

Fixation Considerations With The Lapidus Procedure

Authors have endorsed a variety of recommendations for the fixation of the Lapidus procedure. More recently, there have been variations in procedure such as the use of longer screws, specialized plates adapted for the Lapidus procedure or locking plates in an effort to allow earlier ambulation, and possibly decrease the incidence of delayed or nonunion.8-11 However, given the paucity of soft tissue on the dorsal aspect of the foot, hardware irritation or symptomatic compression of the branches of the superficial peroneal nerve may occur with the bulk of such fixation devices, necessitating eventual removal.

In general, studies have demonstrated superior load to failure and bending moment characteristics utilizing plates versus cross screws for the stabilization of a Lapidus arthrodesis.8 Studies have described the use of locking plates with single lag screw fixation as well as locking plates with plantar lag screw fixation allowing earlier weightbearing following the Lapidus procedure.9,10

In addition, in a study of 102 patients, authors demonstrated the use of small external fixation for the stabilization of the Lapidus procedure to allow weightbearing after 13.1 days on average.11 This fixation was reportedly associated with no nonunions and an average of 5.3 weeks to consolidation and fusion. 

What To Consider In Revision Surgery

Given the known complications and sequelae that can occur following the Lapidus procedure, revision surgery should consider the specific cause of pain, as well as the potential complications and sequelae associated with revision surgery. The presence of a nonunion may not be responsible for pain, which could be due to hardware but not the nonunion itself. One should consider scarring or tenodesis of the peroneus longus or tibialis anterior insertion. In these cases, appropriate soft tissue revision surgery may be indicated with failed physical therapy. Injury to the medial proper branch of the medial dorsal cutaneous nerve, less commonly the medial terminal branch of the deep peroneal nerve, may be associated with scar formation and fibrosis following surgery. In considering revision surgery, one must determine whether the patient must obtain plantarflexion, whether shortening must have correction, and consider efforts to avoid an additional elevation or shortening of the first ray.

Although a very accepted and utilized procedure for the correction of hallux valgus, the Lapidus procedure is associated with a not insignificant risk of complications for which the surgeon must carefully consider and appropriately employ revision surgery.
 
References
 
1. Sangeorzan BJ, Hansen ST. Modified Lapidus procedure for hallux valgus. Foot Ankle. 1989; 9(6):262-6.

2. Catanzariti AR, Mendicino RW, Lee MS, Gallina MR. The modified Lapidus arthrodesis: a retrospective analysis. J Foot Ankle Surg. 1999; 38(5):322-32.

3. McInnis BD, Bouché RT. Critical evaluation of the modified Lapidus procedure. J Foot Ankle Surg. 2001; 40(2):71-90.

4. Coetzee JC, Wickum D. The Lapidus procedure: a prospective cohort outcome study. Foot Ankle Int. 2004; 25(8):526-31.

5. Myerson M, Allon S, McGarvey W. Metatarsocuneiform arthrodesis for management of hallux valgus and metatarsus primus varus. Foot Ankle. 1992; 13(3):107-15.

6. Saffo G, Wooster MF, Stevens M, Desnouers R, Catanzariti AR. First metatarsocuneiform joint arthrodesis – a five-year retrospective analysis. J Foot Ankle Surg. 1989. 28(5):459-65.

7. Choi JH, Zide JR, Coleman SC, Brodsky JW. Prospective study of the treatment of adult primary hallux valgus with scarf osteotomy and soft tissue realignment. Foot Ankle Int. 2013; 34(5):684-90.

8. Scranton PE, Coetzee JC, Carreira D. Arthrodesis of the first metatarsocuneiform joint: a comparative study of fixation methods. Foot Ankle Int. 2009; 30(4):341-5.

9. Menke CR, McGlamry MC, Camasta CA. Lapidus arthrodesis with a single lag screw and a locking H plate. J Foot Ankle Surg. 2011; 50(4):377-82.

10. Saxena A, Nguyen A, Nelsen E. Lapidus bunionectomy: evaluation of crossed lag screws versus locking plate with plantar lag screw. J Foot Ankle Surg. 2009; 48(2):170-79.

11. Wang J, Riley BM. A new fixation technique for the Lapidus bunionectomy. J Am Podiatr Med Assoc. 2005; 95(4):405-9.

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