Emerging Concepts With Post-Lapidus Bunionectomy Weightbearing
The amount of pressure that a patient passes through the foot postoperatively is a gray area. Some advise graduated increases in weightbearing pressure over the course of six weeks. Others allow immediate weightbearing after the patient leaves the operating room. It is reasonable to provide a cane or crutches for assistance, and this is what I do in my practice. Another variation is to have the patients use a cane/crutch assist until the early postoperative discomfort has resolved. In general, most patients seem to avoid much walking for the first two weeks due to the acute nature of the surgery and early post-inflammatory response of healing.
What The Literature Reveals About Early Weightbearing For The Lapidus Procedure
Early weightbearing is not a new concept. Paul Lapidus, MD, allowed weightbearing in a postoperative shoe with a medial plate.25-28 Since fixation options in the 1930s consisted of suturing, the results led to nonunion/malunion. This was mainly because the fusion site did not remain stable. Since the introduction of rigid internal fixation in the late 1980s for Lapidus arthrodesis, there have been numerous studies demonstrating that early weightbearing is an appropriate postoperative protocol.1,4-12 In the four years between 1987 and 1992, there were only four studies regarding early weightbearing.
It was not until 17 years later when the early weightbearing publications emerged that surgeons became comfortable with the procedure and postoperative protocol, and improved their techniques. Since 1992, seven publications demonstrate a variety of postoperative early weightbearing protocols after the Lapidus procedure with satisfactory results.1,2,6,8,13 While there is literature support for the early weightbearing protocol, proper patient selection is essential.
Emphasizing Proper Patient Selection
There are no exact guidelines that tell you which patients you should allow to bear weight early but there are some well known patient factors that can lead to fixation failure and nonunion. Surgeons should evaluate each patient on a case-by-case basis with regard to the following: age/activity level; overall health status; medical comorbidities; medications; body mass index (BMI); and smoking use.
Age. This is not a contraindication for early weightbearing. However, you should consider that older or elderly patients may have osteoporosis, which could lead to problems obtaining a strong fixation construct.
Activity level. Patients should be mindful that the Lapidus procedure is a reconstructive procedure to realign the bones and fusion is required. While solid fixation will keep the bone steady during healing and postoperative weightbearing, it is not a pass to trample or abuse the foot.
Smoking and non-steroidal anti-inflammatory drugs (NSAIDs). Nicotine is a well known deterrent to fusion. Researchers have also linked anti-inflammatories to delayed bone healing. In these patients, early weightbearing may not increase the risk of failure but it is another variable to contend with and you should be cautious in this subset of patients. Be sure to counsel patients and have them quit nicotine and/or stop NSAIDs.
Obesity. The heavier the patient, the more weight on the foot and fusion site. Morbid obesity is an absolute contraindication. In heavier patients, it is important to have a strong fixation construct.