Current Concepts With The Lapidus Bunionectomy

By Graham A. Hamilton, DPM, Travis L. Sautter, DPM, and Lawrence A. Ford, DPM

When it comes to treating hallux valgus, the Lapidus arthrodesis can be an effective procedure. These authors discuss the evolution of the technique, offer a guide to key indications and contraindications, and provide essential step-by-step pearls for performing the procedure.

     Hallux valgus is one of the most common deformities we see as foot and ankle surgeons. There are over 100 different types of surgical procedures for this deformity.1,2 With the considerable variety of procedures, it is fairly evident that no one procedure has been able to provide excellent results in all patients and for all deformities.

     Most clinical studies of bunionectomies report a higher percentage of successful results than complications. However, there is no procedure that one can successfully apply to all bunion deformities. 3 Most procedures offered in the literature for the correction of hallux valgus do work if surgeons properly execute and perform the procedures for the right indications. 1,4 Research has shown that head osteotomies, base osteotomies and Lapidus arthrodesis procedures have similar rates of complications and similar needs for revision surgery. 5

     We have come from training environments where podiatric surgeons have utilized the first tarsometatarsal arthrodesis and variations of this procedure with much success. However, we are the first to recognize that this procedure is not the panacea for all feet with hallux valgus nor is the procedure without complications.

     Let us take a closer look at the Lapidus arthrodesis and the modifications of this procedure for correcting hallux valgus and first metatarsus primus varus deformity. While it is beyond the scope of this article to provide a comprehensive or authoritative article on the subject, we hope to provide valuable insight to foot and ankle surgeons who address these deformities in their practices.

A Closer Look At The Evolution Of The Lapidus Procedure

     In 1996, Hansen, a leader in the Lapidus arthrodesis surgical approach, reviewed the history behind the first tarsometatarsal arthrodesis as well as his rationale for using this procedure.

     He delineates how Dudley Morton, MD, an anatomist, recognized the anatomical variants that were often associated with the deformity to include a short first ray, atavistic cuneiform and equinus deformity. Paul Lapidus, MD, attempted to address the deformity where he felt the deformity originated at the first tarsometatarsal joint (TMTJ) area. Hansen explains how a lack of adequate internal fixation led to less than desirable outcomes and for a time, Lapidus abandoned the procedure. 6

     Hansen describes his own coming of age with the procedure and the evolution of the procedure in his hands. He concurs with Lapidus that one should address the deformity at its origin, the first TMTJ. Hansen also believes that to achieve success, surgeons must address significant associated pathology and biomechanical faults that contribute to the deforming force.

     As Hansen eloquently stated, “In my opinion, focusing on the bunion and discussing the advantages and disadvantages of various bunionectomies is an incredibly naïve and shortsighted approach to this problem.” 6 We believe most foot and ankle surgeons would agree with this statement.

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