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The lapidus procedure is a first metatarsocuneiform arthrodesis.
Have a look at:
Quote:
Rink-Brune O. 2004 Lapidus arthrodesis for management of hallux valgus--a retrospective review of 106 cases. J Foot Ankle Surg. 43(5):290-5
One hundred six patients who underwent a Lapidus arthrodesis for a symptomatic hallux valgus deformity, mainly with first ray hypermobility, were retrospectively reviewed. Radiograph and chart reviews were performed in addition to a patient survey completed at a mean 17 months postoperatively. Of the 78 patients who completed the survey, 70.5% were satisfied with the procedure; 80.2% would choose the same method again. Seven percent of patients were dissatisfied. Review of preoperative and 3-month postoperative radiographs showed a mean intermetatarsal angle reduction of 12.4 degrees. The average postoperative sesamoid position was 2.5, a 4.0 reduction from the preoperative mean value of 6.5. The complication rate was 5.7%, including 2 nonunions (1.8%) requiring a repeat surgery, 1 deep-vein thrombosis (0.9%), and 3 patients with complex regional-pain syndrome (2.7%). In 16% of patients, resolution of swelling and subjective complaints took longer than 3 months; 4.7% of patients developed sesamoiditis or metatarsalgia that resolved with conservative measures. Radiographic undercorrection was evident in 4.7% of patients. The results showed that the Lapidus procedure provided reliable correction in cases of severe hallux valgus with intermetatarsal angles >15 degrees and in those patients with first ray hypermobility.
This one's got some pictures, but like Admin's said, a good surgery text will probably be better:
Quote:
Patel S, Ford LA, Etcheverry J, Rush SM, Hamilton GA. 2004 Modified lapidus arthrodesis: rate of nonunion in 227 cases. J Foot Ankle Surg. 43(1):37-42.
Several studies of Lapidus arthrodesis have commented on the rate of nonunion (ranging from 3.3% to 12.0%), although these figures are based on relatively small patient populations. This study retrospectively reviewed the medical records and radiographs of 211 consecutive patients (32 men, 179 women; mean age, 46.9 years) who received modified Lapidus arthrodesis for forefoot pathology in 227 feet. In all cases, the procedure was performed using joint curettage with subchondral plate preservation and screw fixation. Patients remained nonweightbearing for 6 to 8 weeks and were monitored for a minimum of 6 months postoperatively. Nonunion was seen in 12 (5.3%) of the 227 feet that underwent modified Lapidus arthrodesis.
Most papers on outcomes of the lapidus or modified lapidus procedure focus on radiographic assessment of the joint along with patient centred outcome measures and I've struggled to find any that assess postoperative dynamic function of the foot objectively. There's a couple on cadaver sections to assess fixation of the joint, and there's this one on an attempt at seeing how it affects open kinetic chain range of motion of the medial column in cadavers:
Quote:
Roling BA, Christensen JC, Johnson CH. 2002 Biomechanics of the first ray. Part IV: the effect of selected medial column arthrodeses. A three-dimensional kinematic analysis in a cadaver model. J Foot Ankle Surg. 41(5):278-85.
This study is the fourth in a series of investigations on the biomechanics of the first ray, this part focusing on open kinetic chain range of motion simulating the clinical examination. Segmental sagittal range of motion of the medial column was measured on intact cadaver specimens and compared to various simulated medial column arthrodesis patterns. These arthrodeses included the first metatarsocuneiform, first metatarsocuneiform-intercuneiform, naviculocuneiform, and talonavicular joints. The specimens were mounted to a test apparatus that was comprised of a modified ankle-foot orthosis which held the ankle and rearfoot in fixed neutral position. Additionally, the lesser metatarsus was affixed to the test apparatus while the first ray was left free to be manipulated via a carbon fiber rod attached to a pneumatic actuator. A 24.5-N (5.5-lb) sagittal plane load was applied to the first ray while the specimen was held rigidly in the apparatus. The first ray was manipulated using a repeated measures design. Data were collected for each osseous segment of the medial column using a radiowave tracking system. Kinematic data were collected and statistically analyzed. Results demonstrated in intact specimens that the naviculocuneiform, first metatarsocuneiform, and talonavicular joints contributed an average of 50%, 41%, and 9% of total first ray sagittal plane range of motion, respectively. Furthermore, first ray range of motion was significantly reduced with all of the simulated arthrodeses of the medial column (p < .05). These findings suggest that first ray range of motion when evaluated clinically is a blend of motions of joints comprising the medial column.
many thanks, I would be grateful if anyone could point me in the right direction re: post op outcomes and how it may affect normal gait parameters. so as to understand what may be the expected ranges of mobility/return to function.
I have pretty much gone to the Lapidus procedure as a first line therapy for hallux valgus deformity with severely increased intermentatarsal angle. The results are predicatable particularly when there is a hypermobile first ray. I find there are fewer complications than the traditional base wedge procedure. Fixation is your choice, but I have found the compression staples along with extermal fixation augmentation yields the most consistent results.
I have pretty much gone to the Lapidus procedure as a first line therapy for hallux valgus deformity with severely increased intermentatarsal angle. The results are predicatable particularly when there is a hypermobile first ray. I find there are fewer complications than the traditional base wedge procedure. Fixation is your choice, but I have found the compression staples along with extermal fixation augmentation yields the most consistent results.
Summer?
What exactly is a "hypermobile first ray"? Please provide a definition. How do you clnically determine when a patient has a "hypermobile first ray"? Do you measure its motion during gait, assess it via clinical examination, measure it using radiographs, or determine it through pressure mat/insole examination?
The Lapidus procedure (i.e. arthrodesis of 1st metatarsal-1st cuneiform joint) eliminates one of the joints from the first ray and, in doing so, makes the first metatarsal more resistant to dorsiflexion motion for a given first ray dorsiflexion moment. In other words, the Lapidus procedure causes increased first ray dorsiflexion stiffness so that the first ray will dorsiflex less for a given dorsiflexion loading force acting on the plantar first metatarsal head.
The Lapidus procedure also causes increased first ray adduction stiffness since, by eliminating the 1st metatarsal-1st cuneiform joint, any first ray adduction moments that would tend to increase the first intermetatarsal angle (e.g. posteriorly directed compression loading force from base of proximal phalanx of hallux onto first metatarsal head) will produce less first ray adduction motion and less prominence of the medial first metatarsal head during weightbearing activities. Describing the mechanical function of the first ray using the standard biomechanics nomenclature of stiffness, which incorporates both motion and force in its definition, instead of just describing its motion (i.e. hypermobility), is critical toward understanding this and other important segments of the foot skeleton.
Summer, if podiatric medicine wants to progress into a more scientific profession where we can quantify the terms that we use clinically to describe mechanical phenomena of the foot and lower extremity, then we need to do away with the term "first ray hypermobility".
What say you?
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
You are probably right, in that we need to change some of the terminology that we have been using for years. I suspect that I am one of those who still uses the old terminology that we were taught in residency as well as school. There is an interesting post from "Lee" a few threads up which "quantifies" the mobility of the various joints at the medial column.
From simple experience I have found this regarding the Lapidus....It seems to be much more forgiving than the traditional base wedge or Juvara type osteotomy. I have also found that given a patient (particularly females) with rather narrow metatarsals, the base wedge, or Juvara procedure is nearly impossible to fixate correctly. Even if you were able to obtain stable fixation, the resultant narrowing of the metatarsal makes it prone to stress fracture etc. This I have seen firsthand. Consequently, the fusion procedure does provide a more stable platform for fixation, as well as stabilizing the medial column.
Lapidus procedure in patients with rheumatoid arthritis - short-term results.
[Article in German]
Popelka S, Vavrík P, Hromádka R, Sosna A. Z Orthop Unfall. 2008 Jan-Feb;146(1):80-5.
Quote:
AIM: Hallux valgus combined with flat foot is one of the most common foot deformities affecting patients with rheumatoid arthritis. The Lapidus procedure is indicated when the hallux valgus angle is more than 15 degrees or the first tarsometatarsal joint is hypermobile. We aimed to evaluate the results of the Lapidus procedure in patients with rheumatoid arthritis.
METHOD: We performed the Lapidus procedure in 31 patients between 2002 and 2005. In ten patients we performed a bilateral procedure and in ten patients we performed a single Lapidus procedure. In 27 cases we combined the procedure with a resection of the second-fifth metatarsal heads (Hoffmann procedure), in four cases with a Weil osteotomy of the second-fifth metatarsal necks. We performed an excision of the articular surface of the first metatarsal head (Mayo) in 10 patients, a Keller resection procedure in 9 patients, an arthrodesis of the first metatarsophalangeal joint in 3 patients, and an Akin wedge osteotomy of the proximal phalanx of the thumb in 3 patients. Arthrodesis was fixed by two K-wires in 5 cases, by 2 compression screws in 7 cases, and in thirty-four cases we used memory staples.
RESULTS: We evaluated the outcomes of forty-one procedures in thirty-one patients (24 female, 7 male). The averge age at surgery was 54.3 years. Thirty-two feet were without pain after the procedures, in five cases the patients felt moderate pain in the dorsal part of the foot and in four cases the patients felt pain in the transverse arch of foot. Complications included delayed primary wound closure in five cases, in one case we performed a revision procedure for a deep infection. Delayed hallux valgus developed in 5 cases. The mean first intermetatarsal angle before surgery was 19.5 degrees (range 12 - 27 degrees) and improved to 8 degrees after surgery. In 3 cases we found an unsatisfactory intermetatarsal angle correction with partial renewal of the hallux valgus.
CONCLUSION: A correctly performed Lapidus procedure enables correction of the varus position of 1st metatarsus and hallux valgus.
PURPOSE OF THE STUDY The most frequent deformity of the big toe and forefoot associated with a collapse of the transverse arch of the foot is a valgus deformity. For correction of a hallux valgus, several procedures are described in the literature. A valgus deformity often develops due to a varus deviation of the first metatarsal bone when the intermetatarsal angle between the first and second metatarsals is greater than 10 degrees. When the intermetatarsal angle is larger then 10 degrees or the first ray is hypermobile, a Lapidus procedure is one of the options. The objective of this study was to evaluate the outcomes in patients with halux valgus deformity treated by the Lapidus procedure.
MATERIAL The group comprised 61 patients, 49 women and 12 men, with an average age of 58.3 years at the time of surgery, who were treated at our department in the period from 2002 to 2006. Fifteen patients had bilateral surgery. The results of 76 operations were evaluated. Indications for surgery were hallus valgus in 22 patients, rheumatoid arthritis in 36 and psoriatic arthritis in three patients.
METHODS Access was gained on the mediodorsal side of the foot through an incision medial to the extensor hallucis longus tendon, over the first tarsometatarsal joint up to the first metatarsophalangeal joint. An arthrodesis was fixed with two Kirschner wires in eight feet and with two screws in 15 feet. Recently, the use of shape memory alloy staples (DePuy Mitek) was adopted and applied in 53 feet with good outcome. In the patients with rheumatoid arthritis the Lapidus procedure together with resection of the heads of the second and fifth metatarsals was used from the plantar approach.
RESULTS The evaluation was focused on the patients' satisfaction and their subjective complaints. No pain was reported on 56 (73 %) forefeet, slight pain was experienced on the dorsal side in ten feet (13 %) and pain in the transverse arch also in ten feet (13 %). Complications included slow healing of the wound in seven feet of the patients with rheumatoid arthritis (9.2 %), and infection requiring revision surgery in one patient (1.3 %). Five patients (6.5 %) reported persisting swelling of the foot dorsum for a period longer than 3 months. Reccurence of hallux valgus was recorded in nine feet. The average American Orthopaedic Foot and Ankle Society score, which was 48.1 points pre-operatively, improved to 89.2 points post-operatively. In one patient, bony union was very slow and was achieved at 5 months after surgery.
DISCUSSION An exact evaluation of the results of a Lapidus procedure is not always possible, particularly in patients with rheumatoid arthritis in whom foot disorders are more complex. A much discussed issue is first metatarsal hypermobility. In our group of 61 patients, this was found in 28. Of these, 18 had rheumatoid arthritis and ten had hallux valgus. The rate of pseudoarthrosis following a Lapidus procedure is reported to range from 3.3 % to 9 %. In our group only one patient was affected (1.3 %).
CONCLUSION A correctly performed: Lapidus procedure enables us, by correcting a varus deviation of the first metatarsal, to repair valgus deformity of the big toe resulting in painless walking. Key words: Lapidus procedure, rheumatoid arthritis, hallux valgus, first metatarsal hypermobility.
A review of surgical outcomes of the Lapidus procedure for treatment of hallux abductovalgus and degenerative joint disease of the first MCJ
Natalie G Taylor and Stuart A Metcalfe The Foot Volume 18, Issue 4, December 2008, Pages 206-210
Quote:
Background
The modified Lapidus procedure has been used to treat hallux abducto valgus and degenerative joint disease of the first metatarsocuneiform joint for many years. Historically, the Lapidus has been associated with poor satisfaction due to complications such as non-union. The aim of this study was to review the surgical outcomes of 18 patients using the validated Foot Health Status Questionnaire (FHSQ). The four domains within the FHSQ were all investigated. Pre and post operative angular measurements were also reviewed.
Results
The results of the FHSQ were positive for all four domains, with foot pain having the greatest change. Only two complications were recorded: one poor pain control and one post operative bleed and all 18 patients went to osseous union. Radiographically the mean intermetatarsal angle improved by 7.8° and HAV angle by 22.9. A positive association was also demonstrated between validated ‘Minimal Important Difference’ (MID) scores.
Conclusion
The Lapidus is a valuable procedure that can have few complications and high levels of patient satisfaction.
Arthrodesis of the First Metatarsocuneiform Joint: A Comparative Cadaveric Study of External and Internal Fixation.
Webb B, Nute M, Wilson S, Thomas J, Van Gompel J, Thompson K. J Foot Ankle Surg. 2009 January - February;48(1):15-21
Quote:
Arthrodesis of the first metatarsocuneiform joint for the treatment of severe hallux abductovalgus with or without hypermobility of the first ray has gained popularity in recent years. The purpose of the current study was to compare the strength of external fixation to internal fixation for arthrodesis of the first metatarsocuneiform joint in a cadaveric model. Ten pairs of fresh frozen lower extremity cadaver specimens were used, and randomly assigned to fixation at the first metatarsocuneiform joint with crossed cannulated screws or a monorail uniplanar external fixator. Test specimens were then loaded to failure, which was defined as 3 mm or more of displacement at the arthrodesis site. Because of complications encountered during testing, 4 pairs of specimens were excluded from the final results. In the remaining 12 specimens (6 pairs of cadaver limbs), the mean maximal load to failure was 2300.02 +/- 711.86 N for the external fixator and 1666.38 +/- 1072.75 N for the internal fixation construct, and although this difference was not statistically significant (P = .2557), it was likely to have been clinically significant since approximately 27.55% more force was required to disrupt the external fixation construct in comparison with the internal fixation construct. Given these findings, further research into the mechanical and clinical properties of internal and external fixation for first metatarsocuneiform joint arthrodesis is warranted
Lapidus Bunionectomy: Early Evaluation of Crossed Lag Screws versus Locking Plate with Plantar Lag Screw.
Saxena A, Nguyen A, Nelsen E. J Foot Ankle Surg. 2009 Mar-Apr;48(2):170-9.
Quote:
We compared outcomes of the Lapidus bunionectomy fixated with crossed lag screws versus a locking plate with a plantar lag screw. Forty patients who underwent Lapidus bunionectomy between August 2001 and May 2006 were evaluated in a combined retrospective and prospective fashion. Crossed lag screws were used in 19 of the patients, and a locking plate with a plantar lag screw was used in 21 of the patients. Other than fixation, the only interventional difference pertained to postoperative weight bearing, where those receiving the plate initiated full weight bearing on the operated foot at 4 weeks postoperative, as compared to 6 weeks for those receiving crossed screws. Overall, the mean preoperative AOFAS hallux score was 41.75 +/- 2.52, and the postoperative score was 90.48 +/- 8.41 (P < .0001). The overall mean preoperative first intermetatarsal angle was 15.3 degrees +/- 2.32 degrees , and long term the angle was 5.03 degrees +/- 2.86 degrees (P < .0001). When comparisons were made based on the method of fixation, use of an adjunct Akin osteotomy and surgery performed before 2003 were statistically significantly associated with crossed screw fixation, and the preoperative AOFAS score was statistically significantly higher in the locking plate fixation group. There were no statistically significant differences related to postoperative complications between the 2 fixation groups. In conclusion, the Lapidus bunionectomy fixated with a locking plate and a plantar lag screw allows earlier weight bearing in comparison with crossed lag screws, without a difference in complications
We reviewed the medical records and radiographs of 35 patients (3 males, 32 females; mean age 40.8 years) who underwent isolated, modified Lapidus arthrodesis for forefoot pathology in 39 feet. The purpose of the review was to evaluate the structural radiographic changes of the medial longitudinal arch (MLA) following isolated arthrodesis of the first tarsometatarsal joint. Pre- and postoperative standardized measurements of sagittal plane views of the foot were assessed to examine change in the MLA construct. The talo-first metatarsal angle and medial cuneiform height both had statistically significant changes, 2.97 degrees (range, 0-11.5 degrees) and 3.44 mm (range, 0-13 mm) (P < .0001) respectively. Our findings suggest that the Lapidus arthrodesis may influence the medial longitudinal arch
Loved them while in training because we got to fuse something, but in private practice there are so many other procedures that can correct an IM angle that are less invasive, take less time to heal, leave less or no hardware and have less complications.
AND: Why perform an arthrodesis on an asymptomatic joint? Is this done anywhere else in the body?
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
The lapidus procedure is a fusion of the 1st MCJ. It used either for O/A of the joint or significant HAV especially with hypermobility. Some surgeons have a lower threshold for use but personally I would want to see rediographic evidence of IM angle of 20 deg or more.
It can be fixed by a number of means including screws, plate (dorsal medial and plantar) or staples. Sometimes bone grafting is needed but this largely depends on the correction needed and length preservation.
The main post op problem is non-union (up to 15% in the lit, my own rate is around 6%) stiffness and protracted swelling local to the MCJ.
It is a big commitment to the patient regarding recovery as it requires casting for up to 10 weeks with 6 weeks being non-weightbearing.
Post -op function is good at the joint in isolation is sacrifisable. Remember the patient has significant pathology to start with and would not have normal funtion anyway. What I always tell patients is that surgery always has compromise as I can not give them a normal foot just a foot which looks more normal and hopefully functions better than pre-op, and is pain free or as near to that as possible. From my own PASCOM audit most people say they are better or much better but a high % have occasional twinges or pain on standing for long periods.
Hi Tony,
Could you please explain the relevance of the need for grafting as far as the level of correction is concerned?
I haven't seen (in my limited experience) a case where grafting has been necessary to correct hallux valgus where an MC fusion has been performed, other than in the case of revision surgery, where the 1st met has been excessively short due to previous surgery and the patient has had recurrence of their hallux valgus.
Many thanks and kind regards,
Ryan.
Its not needed in 99% cases. The times I have used it ar for
1. revision failed hav osteotomy, in a case wher there was severe elevation in and reurrent im angle. the graft was shaped to plantar flex and correct im without loss of length
2. failed primary lapidus.
Good luck in part C, REMEMBER: say what you see, we are not looking for anything but eveyday problems
Tony
Its not needed in 99% cases. The times I have used it ar for
1. revision failed hav osteotomy, in a case wher there was severe elevation in and reurrent im angle. the graft was shaped to plantar flex and correct im without loss of length
2. failed primary lapidus.
Good luck in part C, REMEMBER: say what you see, we are not looking for anything but eveyday problems
Tony
Yes,
Good luck Ryan. Following on from Tony's advice you might want to check out the following link before your exam: http://www.youtube.com/watch?v=Izet8zN1vmE
Say what you see
Interesting discussion. We just had our first ever "Biomechanical Implications of Foot Surgery" seminar yesterday in Oakland which was sponsored by the California School of Podiatric Medicine, was chaired by Dr. Paul Scherer and had Tom Sgarlato, Jeff Christensen, Doug Richie, Howard Hillstrom, Adam Landsman, Cherri Choate, Mike Colburn, Shannon Rush and myself lecturing at it.
The Lapidus bunionectomy came up quite a bit during the seminar and Jeff Christensen and I talked during the seminar about the need to improve the terminology for the first ray, moving away from "hypermobility" to a quantifiable measure of the load-deformation characteristics of the first ray, such as "stiffnes" or "compliance".
The Lapidus bunionectomy works so well for the simple mechanical reason that it takes an overly compliant first ray segment and makes it into a more stiff first ray segment, by eliminating one of the joints of the first ray. The Lapidus bunionectomy increases first ray dorsiflexion stiffness, and also increases first ray adduction stiffness so that during weightbearing loads, the first metatarsal will dorsiflex less and adduct less for a given loading force on the plantar forefoot (Kirby KA: Foot and Lower Extremity Biomechanics III: Precision Intricast Newsletters, 2002-2008. Precision Intricast, Inc., Payson, AZ, 2009, pp. 83-84).
Once we get rid of the ridiculously ambiguous and unquantifiable clinical term of "first ray hypermobility" and start to approach the first ray with quantifiable mechanical terminology that actually means something definite, we will finally start to make progress in understanding this complex but very important part of the human foot, the first ray.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Lapidus believed that the best way of realigning the painful foot with hallux valgus was with a procedure performed at the apex of the deformity, simultaneously stabilizing the articulation and preventing recurrent deformity. Metatarsocuneiform arthrodesis represents one of several approaches in hallux valgus surgery, and while the Lapidus procedure is not appropriate for all bunion deformities it has been shown to be useful in treating selected cases of hallux valgus associated with metatarsus primus varus and first ray hypermobility. A successful outcome depends on proper patient selection, accurate surgical technique, and a carefully monitored postoperative program. There is a learning curve in performing this operation; however attention to the important technical points we have outlined is crucial to obtain a powerful and durable correction of metatarsus primus varus and hallux valgus. Patient compliance with the postoperative weight bearing restriction is of utmost importance.
In the endeavor toward Lapidus fusion, the authors have studied a new application of locked plating for the first tarsometatarsal joint. The goal was to assess the time to fusion, time to ambulation, rate of delayed union/nonunion, rate of revision, and need for hardware removal following the use of locked-plate technology in the fusion of the first tarsometatarsal joint. The findings denoted an average of 6.95 weeks to radiographic fusion, an average of 2 weeks to ambulation, a 9.52% rate of asymptomatic mal-union, a 0% rate of delayed union or nonunion, and a 0% rate of revision. The rate of need for hardware removal was 4.76%.
Lapidus procedure
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