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Lapidus procedure

Discussion in 'Foot Surgery' started by guykusabbi, May 18, 2006.

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  1. guykusabbi

    guykusabbi Welcome New Poster


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    can anyone help regards to what this procedure entails and how this affects post op foot function ?
     
  2. admin

    admin Administrator Staff Member

    Any good foot surgical text has plenty of information on that! What specifically are you wanting to know?
     
  3. Lee

    Lee Active Member

    Lapidus

    The lapidus procedure is a first metatarsocuneiform arthrodesis.
    Have a look at:

    This one's got some pictures, but like Admin's said, a good surgery text will probably be better:

    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:

    Have a good one. ;)
     
  4. guykusabbi

    guykusabbi Welcome New Poster

    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.
     
  5. summer

    summer Active Member

    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.
     
  6. 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?

    You may want to read this thread to see where I am coming from. http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=797

    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?
     
  7. summer

    summer Active Member

    Kevin

    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.
     
  8. NewsBot

    NewsBot The Admin that posts the news.

    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.
     
  9. NewsBot

    NewsBot The Admin that posts the news.

    Our Results of the Lapidus Procedure in Patients with Hallux Valgus Deformity.
    Popelka S, Vavřík P, Hromádka R, Sosna A.
    Acta Chir Orthop Traumatol Cech. 2008;75(4):271-276.
     
  10. NewsBot

    NewsBot The Admin that posts the news.

    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
     
  11. NewsBot

    NewsBot The Admin that posts the news.

    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
     
  12. NewsBot

    NewsBot The Admin that posts the news.

    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.
     
  13. NewsBot

    NewsBot The Admin that posts the news.

    The effect of the lapidus arthrodesis on the medial longitudinal arch: a radiographic review.
    Avino A, Patel S, Hamilton GA, Ford LA.
    J Foot Ankle Surg. 2008 Nov-Dec;47(6):510-4.
     
  14. drsarbes

    drsarbes Well-Known Member

    Lapidus!

    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
     
  15. tonyw

    tonyw Member

    Hi

    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.

    Hope this is helpful

    Tony Wilkinson
    Vice-Dean Faculty of Surgery
     
  16. Ryan McCallum

    Ryan McCallum Active Member

    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.

    Look forward to meeting you at Part C next Sat.
     
  17. tonyw

    tonyw Member

    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
     
  18. Lee

    Lee Active Member

    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 ;)
     
  19. Ryan McCallum

    Ryan McCallum Active Member

    Thanks a lot mate. You have made me laugh out loud for the 1st time in an otherwise boring day stuck in the books!!!
    Cheers,
    Ryan
     
  20. Lee

    Lee Active Member

    Just remember the link when you're sat in your viva in the afternoon getting a grilling. Probably good for de-stressing. Good luck!
     
  21. 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.
     
  22. NewsBot

    NewsBot The Admin that posts the news.

    The modified lapidus procedure.
    Gérard R, Stern R, Assal M.
    Orthopedics. 2008 Mar;31(3).
     
  23. NewsBot

    NewsBot The Admin that posts the news.

    Results of lapidus arthrodesis and locked plating with early weight bearing.
    Sorensen MD, Hyer CF, Berlet GC.
    Foot Ankle Spec. 2009 Oct;2(5):227-33.
     
  24. NewsBot

    NewsBot The Admin that posts the news.

    Early Weight Bearing After Modified Lapidus Arthodesis: A Multicenter Review of 80 Cases.
    Blitz NM, Lee T, Williams K, Barkan H, Didimenico LA.
    J Foot Ankle Surg. 2010 July - August;49(4):357-362.
     
  25. NewsBot

    NewsBot The Admin that posts the news.

    Immediate Weight Bearing Following Modified Lapidus Arthrodesis.
    Basile P, Cook EA, Cook JJ.
    J Foot Ankle Surg. 2010 Jul 15. [Epub ahead of print]
     
  26. NewsBot

    NewsBot The Admin that posts the news.

    The use of the Lapidus procedure for recurrent hallux valgus.
    Ellington JK, Myerson MS, Coetzee JC, Stone RM.
    Foot Ankle Int. 2011 Jul;32(7):674-80.
     
  27. NewsBot

    NewsBot The Admin that posts the news.

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