Pertinent Insights On Proximal Bunionectomies

Author(s): 
Amber M. Shane, DPM, FACFAS, Christopher L. Reeves, DPM, FACFAS, Paul B. Thurston, DPM, and Garrett M. Wobst, DPM

In nearly a century of existence, the Lapidus bunionectomy has evolved along with advances in fixation hardware and technique. Accordingly, these authors discuss indications, surgical technique and the scientific evidence behind using this procedure for proximal bunionectomies.

Multiple options exist for the correction of severe bunion deformities requiring proximal procedures. Corrective procedures that have well documented success include the closing and opening wedge osteotomies, double metatarsal osteotomies and the Lapidus arthrodesis.

   The opening base wedge osteotomy originally required an interpositional graft with no fixation. While surgeons were able to successfully reduce the large intermetatarsal angle without compromising length, the lack of fixation leads to multiple complications. Specifically, complications include the propensity of the lateral hinge to break, causing the distal fragment to move in any of the three planes of the foot. Due to the advent and improvement in internal fixation, surgeons can successfully execute and consistently reproduce these procedures without the increased concern of correction failure, thus decreasing healing time and allowing patients to bear weight sooner.

   In their study of 66 patients with closing wedge osteotomies, Nedopil and colleagues applied a plate with five screws for fixation and initiated weightbearing to tolerance at two days post-op.1 After an average of 52 months’ follow-up, only one of the 86 feet developed a nonunion.

   Much can be said for these advancements and their benefits regardless of the proximal procedure one chooses. As with all elective surgical procedures, each comes with its own unique challenges, advantages and disadvantages. Selection of the proper procedure is imperative to the overall goal of the correction, pain reduction and the patient’s level of satisfaction. Proper evaluation of the intermetatarsal angle, metatarsal length, hypermobilty, sesamoid position and hallux abductus angle guide the procedural selection process. Additionally, secondary pathology such as lesser metatarsalgia and second metatarsophalangeal joint (MPJ) overload dictate the procedure choice.

What You Should Know About The Evolution Of The Lapidus Procedure

Introduced nearly 100 years ago, the Lapidus arthrodesis continues to be an excellent treatment option for hallux valgus deformities. Its power lies in its ability to simultaneously correct deforming planes such as adduction, plantarflexion, rotation and stability of the medial column as well as long-term maintenance of correction.

   Haas and co-workers performed a study of 57 feet comparing the closing base wedge osteotomy with the Lapidus arthrodesis.2 The authors demonstrated that the closing base wedge osteotomy had a loss of intermetarsal correction of 2.55 degrees from preoperative films to late postoperative films in comparison to the Lapidus, which only lost 1.08 degrees of intermetatarsal correction. When surgeons ensure proper fixation with a stable construct, they may achieve early weightbearing and have decreased concern for nonunion.

   Originally, surgeons performed the procedure much as they do today with the exception of fixation. Early fixation of bone was limited to heavy suture until later developments allowed for internal screw fixation. From the inception of the Lapidus procedure through its evolution to today, much advancement has occurred through research and development of internal fixation and knowledge gained in regard to bone healing.
Traditionally, the Lapidus procedure was reserved for large intermetatarsal angle bunion deformities. Today, surgeons can also use the Lapidus procedure to successfully treat recurrent hallux valgus, a long first metatarsal with mild hallux abducto valgus and hypermobility of the first ray.

Add new comment