Pertinent Insights On Proximal Bunionectomies

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

   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.

   For overall successful fusion, pain relief and corrective achievement, stable fixation is imperative. Surgeons have introduced multiple modifications of the Lapidus. Namely, changes in joint preparation and internal fixation constructs have increased the overall success rates and the utilitarian nature of the procedure. Traditional fixation methods include two-screw fixation across the first metatarsocuneiform joint. Some surgeons place an additional screw from the first metatarsal into the second metatarsal or from the first metatarsal to the medial cuneiform.

   With the advent of locking plate technology, surgeons commonly use plate fixation to augment traditional fixation constructs. The addition of the plate with screw fixation can allow for early weightbearing with a low risk of postoperative complications such as nonunion.

   A study by Saxena and colleagues focused on 40 patients who underwent the Lapidus arthodesis.3 Surgeons fixated 19 patients with two cross lag screws and 21 patients with a locking plate and a plantar lag screw. The locking plate with the plantar lag screw group could bear full weight at four weeks. The crossed lag screw group followed the traditional postoperative course of six weeks of non-weightbearing. The results showed no significant difference between the two groups postoperatively.

   We utilize the Lapidus as a standard proximal bunion procedure due to increased stability and correction of hallux abducto valgus and hypermobility with a high degree of predictability.

A Guide To Current Indications For The Lapidus Procedure

The indications for the Lapidus procedure continue to gain popularity secondary to the long-term and reproducible results of the operative treatment. Current indications for the Lapidus procedure include:

• correction of moderate to severe hallux abducto valgus recalcitrant to conservative treatment;

• a symptomatic elevated first ray;

• a hypermobile first ray with clinically identifiable transfer metatarsalgia resulting in second metatarsal overload syndromes;

• adolescent hallux abducto valgus deformity with associated hypermobility or generalized ligamentous laxity;

• deformity of the first metatarsocuneiform joint secondary to degenerative joint disease;

• other forefoot deformities resulting in instability of the medial column, such as splay foot and metatarsus adductus; and

• a salvage procedure for a previously failed bunion correction.

   Definite contraindications for this procedure include patients with open growth plates and active infection. Relative contraindications may include an excessively shortened first ray or when the patient has severe degenerative joint disease of the first MPJ. The literature has not explored the results of combined arthrodesis of the first MPJ and tarsometatarsal joint.4

Pertinent Insights On Surgical Technique

Based on our experience, we would like to offer a few pertinent points to ensure appropriate joint preparation, proper correction and stable fixation with the Lapidus arthrodesis.

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