In this episode, I discuss the historical development of the Lapidus procedure, patient selection, surgical technique, contemporary fixation strategies, union rates, complications, hardware-related problems, recovery, and realistic patient expectations. Because reported outcomes vary with patient selection, operative technique, fixation construct, and definitions of union, we must distinguish general evidence-based ranges from outcomes that should not be interpreted as universal guarantees.
The Lapidus procedure is more common now than ever. Advancement in techniques and methods, instrumentation and fixation have brought more surgeons into accepting this technically demanding operation into their repertoire for larger bunion deformities. This is not an operation for everyone, nor should be performed by every surgeon.
There are numerous pitfalls that must be avoided, and begin with careful patient selection. Comorbidities such as diabetes, peripheral vascular disease, certain metabolic deficiencies, or psychological or psychosocial issues which may prevent complete compliance are all potential contraindications to this procedure. There are other methods for correcting hallux valgus and should be considered in this group before attempting a small joint fusion in the mid foot that requires meticulous joint preparation and protection post operatively.
Because of the higher potential for complications, for me the Lapidus procedure becomes one of exclusion, where no other procedure will adequately address the inter-metatarsal angle, first ray instability, or first metatarsal position in the three cardinal planes. Distal osteotomies are extremely effective at reducing most mild to moderate and often even severe deformities. Careful joint take down, restoring the metatarsal head alignment over the sesamoids, and reduction of adductor pull very often serve to eliminate the retrograde perceived rotation of the first metatarsal.
A successful outcome for this procedure cannot be guaranteed. But hedging towards a successful outcome begins with careful patient and radiographic evaluation preoperatively; meticulous joint take down; precision cutting jigs to reduce the deformity without introducing new planes of deformity or excessively shortening the ray; proper compressive fixation; and appropriate protection post-operatively.
I institute strict non-weight bearing after these procedures. The potential for plastic deformation (what's known as Wolf's law) that will likely cause elevation of the metatarsal downstream from premature load bearing is too great. Additionally, the torque exerted from the body mass over this small area regardless of security of fixation plays too great a role and cannot be underestimated.
A final note, 'branded' systems or implants do not overcome or eliminate the inherent technical nature of this procedure. While plenty of material exists marketed towards both surgeons and patients touting the advantages of a particular system, no system can prevent the complications that are inherent to reconstructive surgery or claim superiority over another given that each surgery and outcome is patient specific.