Why The Lapidus Bunionectomy Is The Best Procedure For Severe Bunions

Neal Blitz, DPM, FACFAS

The potential for safe early weightbearing has made the Lapidus bunionectomy a viable choice for correction of severe hallux valgus. Accordingly, this author discusses eight key advantages of this procedure over other surgical options for this deformity.

Now that early weightbearing after the Lapidus procedure is a mainstream bunionectomy protocol, surgeons can more comfortably consider a Lapidus for severe bunions since they can mobilize the patient quicker.1-13

   While the Lapidus is ideal for large bunions by correcting the entire alignment of the first ray, surgeons (and patients for that matter) have previously chosen other bunionectomies purely for the ability to mobilize postoperatively. In the past several years, literature has emerged that demonstrates that Lapidus bunionectomy patients can ambulate after their surgery while achieving healing rates equivalent (or superior) to other procedures.1-13

   When it comes to large and severe bunions, the surgical procedure selection is actually the same as it would be for any bunion. The options include: fusion of the big toe joint, distal first metatarsal osteotomy, base wedge osteotomy, Lapidus procedure, Keller arthroplasty and big toe joint replacement. However, some procedures are more appropriate than others. Selecting the proper procedure for your patient is where the challenge lies with the large and severe bunion.

What Are The Advantages Of The Lapidus Procedure?

The Lapidus procedure is a highly versatile bunionectomy and has eight important advantages in comparison to a variety of other potential surgeries.14

   1. Correction of the deformity at the apex. Realigning the structural deformity of the foot by physically placing the metatarsal into its native position (near parallel) to the second metatarsal restores the foot to a more “normal” anatomic alignment. This also allows for realignment of the big toe joint subluxation. While distal metatarsal osteotomies may improve big toe joint alignment, they are limited in that there is a physical limit of correction with a distal osteotomy. In comparison to a Lapidus procedure, there is no correction limit based on the intermetatarsal angle. Also, a distal osteotomy creates an intrinsic metatarsal deformity to correct a deformity whereas the Lapidus does not. A base wedge osteotomy also creates an intrinsic metatarsal deformity.

   2. Preservation of big toe joint function. Sure, the Lapidus procedure involves sacrificing the first tarsometatarsal joint (through fusion) but it allows for big toe joint motion. Preservation of big toe joint motion is important as one considers patients with an active lifestyle and those who wish to wear specific shoe gear such as high heels. Obviously, fusion of a big toe joint eliminates this motion and fixes the toe position. A Keller arthroplasty does allow motion but this is “artificial” motion created by sacrificing a joint.

   Implants also provide artificial motion and require resection of a mobile joint. They are probably better indicated for significant arthritis and are not purely for bunion severity.

   3. Concomitant treatment of medial column hypermobility syndrome. If hypermobility is present (and deemed pathologic), then the Lapidus procedure offers the advantage of stabilizing the midfoot by decreasing midfoot motion. Some believe that severe bunions are the result of hypermobility and selecting procedures that do not address this may result in recurrence or secondary compensations. Though one may also address hypermobility with osteotomies, there is no current research to indicate the “best” method of surgical management. Nonetheless, the Lapidus procedure is indicated for the treatment of hypermobility.15


I have found in over 150 bunions, that the Lapidus is not even comparable to the SCARF. When executed correctly, the SCARF has no comparison. And no joints are destroyed. I just don't get the whole thing with the Lapidus. I get plenty of stabilization with the SCARF, even with hypermobility pre-operatively. I stopped doing the Lapidus because I was getting too much post-op sesamoiditis (even 6 months post-op). The SCARF deserves much more attention and credit, and is very easy to perform through the medial incision. Just a thought. I love the Lapidus in some flatfoot corrections however.

Before justifying Lapidus, it would be prudent to answer one fundamental question: where is the primary pathology, the MPJ or MC joint? In most patients, it is the MPJ and proper MPJ rebalancing by various means will result in IM angle correction. For example, MPJ fusion will eliminate any need for Lapidus.

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