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I have a new patient, a 17 y/o who had bunion pain and underwent bilateral lapidus and gastroc recession 2 years ago. she also underwent an Evans procedure bilaterally. She continued to have "2nd metatarsal pain" and underwent bilateral weil osteotomies of the 2nd met. It's been a year since the last of the 3 surgeries (per foot, 6 surgeries total) and she still has "2nd metatarsal pain."

On close examination of the foot the pain is located at the lisfranc complex and Xrays reveal diastasis of the 2nd met/medial cunieform >4 mm and subtle arthritic changes (spurring).

I ordered a CT. RTC in one week. Continue the CMOs and tylenol #3s.

My question is: would you fuse the met cunieform complex or not?

~Hodpod

 

No

Steven

 

Sounds like the domino effect to me.

I feel the indications for the Lapidus are too broad.
Once forefoot to rear foot relationships have been altered and ROM decreased you can bet, especially on a young patient, that secondary problems will arise. These joints are there for a reason. I also think it is VERY difficult to perform a Lapidus with the idea of relocating the first ray in two planes AND perform an Evans at the same time.

Is there a diastasis? So you fuse the second MC and 1-2 cuneiforms; then what? Is there any reason to believe that decreasing the ROM and trying to relocate the second ray (which has already had the Weil) will be successful when trying to establish overall normal biomechanics? Now you have two MC joints that do not function properly and a rear foot that functions how? Was the Evans successful? What's the gait analysis?

Hindsight is always 20 20, but my suggestion is to put the #10 blade away and try to help this patient with orthotics, medication, strengthening and ROM, etc....

My 2 cents
Good luck

Steve