Emerging Concepts With Post-Lapidus Bunionectomy Weightbearing
Given the increasing literature support for early weightbearing after the Lapidus procedure, this author discusses the evolution of plate fixation to facilitate early weightbearing and reviews key factors in appropriate patient selection.
Some surgeons may consider weightbearing Lapidus itself to be a relatively new concept.1-3 In a 2004 article in Podiatry Today, “Early Weightbearing After Lapidus: Is It Possible?,” I highlighted some basic patient guidelines and pearls on surgical technique from proper joint preparation to screw fixation pearls.2
A number of studies have emerged, demonstrating that early weightbearing protocols can achieve fusion rates equivalent to or better than strict non-weightbearing protocols.1,4-12 The Lapidus bunionectomy is now considered a weightbearing procedure and it is time to forget the stigma that weightbearing Lapidus always results in non-union.
What is new, or emerging, are the fixation methods to securely stabilize the fusion to resist the forces of weightbearing during the bone healing phase. Surgeons can achieve successful fusion with a variety of methods but we have yet to determine the best fixation construct for early weightbearing protocols. Specialty plating systems are now commercialized specifically for the Lapidus procedure. Plating has evolved to third-generation systems with specialized design features to match the anatomy and provide a stable construct.
As a surgeon who has long advocated early weightbearing for the Lapidus procedure, I will share my experiences and how my practice has moved away from screw fixation and progressive weightbearing to specialty plate fixation and more immediate weightbearing (with less extrinsic support from a walking boot or post-op shoe).1-3,13 Prior to plating, I often used three screws (two across the first tarsometatarsal joint and one into the lesser tarsus) to increase the stability to allow for early weightbearing at two weeks. This is the technique we published in our multicenter review of 80 cases.1
However, the additional screw in the lesser tarsus often becomes an irritant to the intercuneiform area if one did not perform a concomitant fusion to the base of the second metatarsal or the first intercuneiform joint. This additional screw often required removal at a later date. With specialty plating, in my experience, additional fixation is not necessary to achieve a stable fixation construct. Specialty plating has also allowed me to initiate early weightbearing more immediately postoperatively.
Accordingly, let us take a closer look at third-generation plating for the Lapidus procedure and review the keys to supporting a stable fixation construct.
Should You Plate The Lapidus Bunionectomy?
Successful clinical fusion can occur via isolated screws and/or plates, but the “best” fixation method for early weightbearing has yet to be determined.14,15 Screw fixation was the best option 10 years ago because the plating options simply did not exist.16-25 First, there were “plates” and now there are “plating systems.” Plates have evolved from simple tubular plates to complex engineered plates and screws specifically dedicated for the Lapidus procedure.
Are there theoretical advantages to plating for the Lapidus? Do these advantages translate into clinical benefits for both surgeon and patient? Do plating systems provide surgeons with confidence in their construct to support postoperative weightbearing and achieve successful clinical fusion?