Why The Lapidus Bunionectomy Is The Best Procedure For Severe Bunions

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Author(s): 
Neal Blitz, DPM, FACFAS

Initiating An Early Weightbearing Program With A Lapidus Bunionectomy

In regard to determining which patients you should allow to begin an early weightbearing program, exact guidelines have yet to be established. However, an early weightbearing program does not affect the indications for Lapidus arthrodesis.

   Patients who have an increased risk for complications should avoid early weightbearing or bear weight cautiously. Patients (such as smokers) who have an increased risk for nonunion may not be good candidates for early weightbearing but this is not an absolute contraindication. Obese patients are not great candidates for early weightbearing due to the force that can pass through the fusion site and lead to fixation failure. Do not enroll neuropathic patients in an early weightbearing program for similar reasons. Osteopenic patients with poor bone stock are also poor candidates.

   The fixation construct is extremely important when considering early weightbearing after a Lapidus bunionectomy. A construct that provides compression, resists rotation and counteracts the forces of weightbearing is important when considering the fixation method. When using screw fixation, it is best to use two screws. Surgeons have utilized a variety of techniques for screw fixation and these techniques can be categorized into long screw fixation or short screw fixation. Advocates of long screw fixation believe that longer screws provide resistance to cantilever forces. Plate fixation is also in use with a variety of plating systems. More contemporary options include specialized plating systems that are dedicated and contoured for the first tarsometatarsal joint.

   Surgeons may initiate early weightbearing protocols immediately after surgery, at the two-week visit or at four weeks postoperatively. Of course, the fixation construct plays an important role when it comes to starting early weightbearing. An advantage to waiting until the two-week visit at suture removal is that it allows for surgeons to be confident that the soft tissue envelope is healed. Surgeons should be comfortable with the Lapidus arthrodesis before initiating an early weightbearing program.

Final Thoughts

The Lapidus bunionectomy has several advantages for severe bunions in comparison to other methods in that the surgeon can preserve the big toe joint and realign the first metatarsal at the apex of the deformity.

   Since fixation techniques have improved and early weightbearing protocols have emerged, surgeons can utilize the Lapidus for severe bunions in cases in which they previously had to resort to joint destructive procedures.

   Dr. Blitz is the Chief of Foot Surgery and Associate Chairman of Orthopaedics at Bronx-Lebanon Hospital Center in New York. He is Board Certified by the American Board of Podiatric Surgery and is a Fellow of the American College of Foot and Ankle Surgeons. Dr. Blitz can be reached at nealblitz@yahoo.com, and @DrNealBlitz on Twitter.

   Disclosure: Dr. Blitz is a consultant to Orthofix, Inc., and receives royalties for the Orthofix Contours Lapidus Plating System.

References

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Louis W. Nordeen, DPM, FACFASsays: December 2, 2011 at 10:08 am

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.

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Vladimir Gertsik DPMsays: December 4, 2011 at 11:44 pm

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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