Lapidus

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ldsrmdude

ldsrmdude

Podiatrist
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I'm off service this month and I've been trying to read a bit to keep my mind at least a little on foot and ankle. I have been readin the bunion chapter in Coughlin and Mann, and thought this was an interesting quote referring to the Lapidus: "With an overall failure rate of 28%, this is not the procedure of choice for the occasional foot surgeon." I also had a bit of a discussion with one of my attendings about fixation and I was surprised at the apparent disdain they had for other fixation techniques. With the good discussion we had about Achilles' tendon ruptures a few weeks ago, I thought throwing this out to the SDN community (attendings, residents, students) would be interesting.

What are your indications and contraindications for a MCJ arthrodesis? What is your preferred form of fixation? Plates (locking or not), screws (how many)? What is your post-op protocol (how long non-weight bearing, cast, protected weight bearing, etc)? I'd love to hear the thoughts of students, residents, or attendings.
 
Whatever provides adequate fixation works........ Grafts I have encountered only in revision cases
 
Do you happen to know what year that 28% failure rate statistic is from? In PodSurg 1 my professor mentioned that in the past, the Lapidus didn't enjoy the popularity it currently does because their fixation technique wasn't as good as it is now. I would imagine with better plates and screws it'd have a lower failure rate recently. Then again, regardless of your fixation technology, the 8 weeks off weight bearing is always hard for patient compliance...

This is a really interesting topic for me since surgery has been my favorite class in school so far.
 
At least 7 articles have now described techniques for the Lapidus without 8 weeks of nonweightbearing. NWB leads to DVT, decrease in first MPJ ROM, atrophy of calf, etc. Plus patients do not want to be NWB for 8 weeks. Thus people have studied weight bearing as early as day 1. Articles to read are Sangeorzan 1989 who had a 92% union with immediate toe touch weight bearing. Saxena 2008 that showed no difference in 6 weeks NWB vs 4 weeks NWB and compared crossing screws to the Darco dorsomedial plate. Sorenson in 2009 had a 100% fusion with a dorsomedial locking plate with a lag screw, with 4 weeks protected weight bearing in a CAM walker. Basile in 2010 had 100% union with two crossing screws and a neutralization K-wire that is put in from the medial first to second metatarsal distally, to neutralize the sagittal plane forces that can destabilize your union. Blitz in 2010 used 2-3 screws, started protected weight bearing after first visit (14 days), with 100% union. DeVries in 2011 had partial weight bearing at 5.3 weeks with 98.5% union. Menke in 2011 with a single lag screw and medial H plate, weight bearing by 4.7 weeks with 90.5% fusion.

Just because a new plate comes out that incorporates a lag screw doesn't mean the plate is better. I've seen surgeons use the plate simply because the rep showed up with it. There is the new stryker CP plate that leaves you with a huge drill hole for the lag screw. Do you really need this if you can get similar results with two crossing screws? Technique for screw insertion varies wildly though, as do indications for each patient be it age/weight/bone density.

With plates, you want your fixation on the compression side of the osteotomy - here, the plantar side. However, that violates the first rule of AO - atraumatic surgical technique, so it is difficult to put on a plantar plate. Technically difficult, but also uses a lot more dissection. Dorsal is the least stabile technically, so a medial plate is the compromise as of now.
 
Nice, thanks for the thorough response. Now that I think about it, I think Dr. Jules mentioned studies that had less than 8wks NWB. Cool to see that there's a lot of recent studies with good data.

Btw, isn't it time to change your status to resident? 👍
 
josebiwasabi said:
Do you happen to know what year that 28% failure rate statistic is from? In PodSurg 1 my professor mentioned that in the past, the Lapidus didn't enjoy the popularity it currently does because their fixation technique wasn't as good as it is now. I would imagine with better plates and screws it'd have a lower failure rate recently. Then again, regardless of your fixation technology, the 8 weeks off weight bearing is always hard for patient compliance...

This is a really interesting topic for me since surgery has been my favorite class in school so far.
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The 28% is from the 1989 Sangeorzan article Sig referred you to. I don't have the article at hand to look it up in more detail, but that's what article is cited by the authors.

The technique that I like best for Lapidus arthrodesis is pretty much how Blitz and DiDomenico do it in one of the other articles Sig mentioned. Essentially 2 crossing screws plus a third from the base of the first into the second met. We typically allow weightbearing in a CAM boot at about 10 days. Sig mentioned the Stryker plate with the hole built into it to allow you to place an interfragmentary screw through the plate. Anyone using this or seeing it used? I've seen it used a few times, and while it worked fine, I ask myself " What's the point?" Also, since Sig brought up some great articles that discuss early weightbearing, how long do you see patients being NWB? I would think that 8 weeks isn't the standard anymore.
 
Do you guys typically take out the 3rd screw (1st to 2nd met)? I ask because to me, and I've heard it described this way too, it's essentially acting like a syndesmotic screw. It provides additional stabilization while you are trying to achieve union, but then what is it accomplishing? Then, if the intent if to remove it, does it provide enough additional stability to justify another trip to the OR (at $62/min) when you are asking patient to be NWB for 4-6 weeks anyways?

BTW, that 4-6 week NWB is all I've seen in the last couple months. 8 weeks seems to be reserved for RF fractures/procedures from my observations.
 
dtrack22 said:
Do you guys typically take out the 3rd screw (1st to 2nd met)? I ask because to me, and I've heard it described this way too, it's essentially acting like a syndesmotic screw. It provides additional stabilization while you are trying to achieve union, but then what is it accomplishing? Then, if the intent if to remove it, does it provide enough additional stability to justify another trip to the OR (at $62/min) when you are asking patient to be NWB for 4-6 weeks anyways?

BTW, that 4-6 week NWB is all I've seen in the last couple months. 8 weeks seems to be reserved for RF fractures/procedures from my observations.
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Typically we leave the third screw in unless it needs to come out. In addition to the screw providing stability to the MCJ while it is healing, we try to get some fusion between the base of the 1st met and the 2nd. That screw obviously is important for that. More than one way to skin a cat, but that's the technique I have the most experience with and will likely use in practice.
 
ldsrmdude said:
we try to get some fusion between the base of the 1st met and the 2nd. That screw obviously is important for that.
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Yeah that makes sense.

Saw another Lapidus this morning. One partially threaded interfrag and a dorsomedial locking plate. Like you said, more than one way to skin a cat. Have a feeling I might not see more than a couple of Lapidus procedures all year that are done the same way.
 
dtrack22 said:
Yeah that makes sense.

Saw another Lapidus this morning. One partially threaded interfrag and a dorsomedial locking plate. Like you said, more than one way to skin a cat. Have a feeling I might not see more than a couple of Lapidus procedures all year that are done the same way.
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Yeah, that's a great part about being a student, you get to see a lot of different techniques. The hard part is sifting through the different techniques and seeing what works and what doesn't.

What did you think of the fixation with the screw and the plate? Did they use a saw for joint resection or curette/osteotome?
 
They stressed it intra-op and it seemed to be stable. It looked good. Plate was pretty low profile. I would have to see post op films and clinical exam to really form an opinion on stability and any hardware failure, prominence, etc. The only thing I don't like about the plates (so far) is that every time I've seen one put in, it hasn't fit quite right and needed adjusting. Just seems to be more of a pain than its worth. It's not like there isn't plenty of good research showing screw fixation alone is sufficient for union in a Lapidus. But maybe I've just seen a string of weird cases where things haven't gone as smooth as they normally do.

Saw with saline flush for a majority if the resection. Finished with osteotome and curette.
 
My usual technique is to resect the joint with an osteotome and a curette to bleeding subchondral bone (I'm likely to shorten the 1st ray too much if I use a saw). I then fenestrate the apposing surfaces, use a 0.062 interfrag k-wire as temporary fixation, verify reduction, then fixate with a Synthes locking plate placed dorsomedially.

I like the Synthes plate because:
- It comes in multiple shapes and sizes to fit your application and can be cut easily
- Is easy to bend to shape using the excellent plate bending tool that comes with it
- Has a simple but effective compression clamp method. Compression comes from the clamping rather than from an interfrag screw.
- The locking screw heads can toggle a bit (they can thread into the plate and lock even if not perfectly squared up).

http://www.synthes.com/sites/NA/Pro...riable-Angle-LCP-Forefoot-Midfoot-System.aspx


A very helpful instrument to have is a good spreader so you can see all the way down into the joint as you denude the cartilage. Having an assistant manually hold retractors makes the process kind of challenging whereas an instrument that holds the joint wide open makes a big difference. Check out the compression/distraction device that uses the two wires driven into the adjacent bones. It doesn't interfere with your joint denuding like a lamina spreader does:

http://synthes.vo.llnwd.net/o16/LLN...Technique Guides/SUTGOrthoFootInstrJ9851A.pdf


Likely NWB x 3-4 weeks in camwalker, then protected WB in boot for 3-4 more weeks. I'll write for both a Roll-A-Bout scooter and crutches. I send them home with the boot two weeks pre-op and have them practice using it going up and down the stairs, moving around the house, and doing ADLs before their foot is painful and delicate.
 
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NatCh said:
My usual technique is to resect the joint with an osteotome and a curette to bleeding subchondral bone (I'm likely to shorten the 1st ray too much if I use a saw). I then fenestrate the apposing surfaces, use a 0.062 interfrag k-wire as temporary fixation, verify reduction, then fixate with a Synthes locking plate placed dorsomedially.
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I like using an osteotome for the exact reason you mentioned. I've seen first rays get really shortened with the saw.
I like the Synthes plate because:
- It comes in multiple shapes and sizes to fit your application and can be cut easily
- Is easy to bend to shape using the excellent plate bending tool that comes with it
- Has a simple but effective compression clamp method. Compression comes from the clamping rather than from an interfrag screw.
- The locking screw heads can toggle a bit (they can thread into the plate and lock even if not perfectly squared up).

http://www.synthes.com/sites/NA/Pro...riable-Angle-LCP-Forefoot-Midfoot-System.aspx


A very helpful instrument to have is a good spreader so you can see all the way down into the joint as you denude the cartilage. Having an assistant manually hold retractors makes the process kind of challenging whereas an instrument that holds the joint wide open makes a big difference. Check out the compression/distraction device that uses the two wires driven into the adjacent bones. It doesn't interfere with your joint denuding like a lamina spreader does:

http://synthes.vo.llnwd.net/o16/LLN...Technique Guides/SUTGOrthoFootInstrJ9851A.pdf
Click to expand...
We use a similar device, and it's great. Works better than a lamina spreader like you said.
Likely NWB x 3-4 weeks in camwalker, then protected WB in boot for 3-4 more weeks. I'll write for both a Roll-A-Bout scooter and crutches. I send them home with the boot two weeks pre-op and have them practice using it going up and down the stairs, moving around the house, and doing ADLs before their foot is painful and delicate.
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Giving them the boot before hand and having them wear it and get used to it sounds like a great idea.
 
Great topic - we do a lot of First TMTJ arthrodesis in my training and here's my take so far:

1) I have not done a distal osteotomy on a metatarsal for almost a year -- and there's a reason for that. If you execute the Lapidus appropriately, with proper fixation, your patients should be weight-bearing from day 1 and the correction you achieve from the Lapidus is much more predictable. This is becoming more and more common with a lot of foot and ankle surgeons in the DPM community.
2) You can achieve correction in all three planes with appropriate manipulation.
3) You do not need to do any dissection at the first MTPJ
4) My fixation of choice: Interfrag screw and a medial 1/3 tubular locking plate with locking screws --> You don't need a special plate in my opinion if your fixation is solid.
5) Use cancellous bone graft to fill the void after you plantarflex the metatarsal on the cuneiform but make sure you have some bone-on-bone contact - you can use cancellous bone chips as allograft or even calcaneal autograft.
6) Nonunion is attributed to poor technique and inadequate fixation. We operate on smokers, diabetic patients, etc. and still get them to heal.
 
PMSIII said:
I have not done a distal osteotomy on a metatarsal for almost a year -- and there's a reason for that. If you execute the Lapidus appropriately, with proper fixation, your patients should be weight-bearing from day 1 and the correction you achieve from the Lapidus is much more predictable. This is becoming more and more common with a lot of foot and ankle surgeons in the DPM community.
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I think that's very interesting that you haven't done any distal metatarsal osteotomies in almost a year. It's definitely a change from what I would say the majority of surgeons I have seen do, ie an Austin bunionectomy. I understand what you're saying though about not needing to do a distal met osteotomy if you execute a Lapidus correctly. Do you think there is ever an indication for a distal met osteotomy?
 
dtrack22 said:
PMSIII

What's the orientation of your interfrag screw?
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3.5 mm cortical screw - not cannulated. I insert in a true lag fashion dorsally from the distal 1/2 of the metatarsal to the base of the cuneiform at the most inferior-proximal part of the first cuneiform bone. I typically drill this under C-arm and the screw is countersunk prior to even drilling to relieve the stress off of the first metatarsal bone. This is done by using a bur to break through the cortex at the insertion point and thereby allows you to throw the screw in such an acute angle without stressing the cortex. The advantage in doing so is that you can capture a longer distance and both cortices across the joint - very strong screw. Also, I never have to worry about irritation from the screw head.
 
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ldsrmdude said:
I think that's very interesting that you haven't done any distal metatarsal osteotomies in almost a year. It's definitely a change from what I would say the majority of surgeons I have seen do, ie an Austin bunionectomy. I understand what you're saying though about not needing to do a distal met osteotomy if you execute a Lapidus correctly. Do you think there is ever an indication for a distal met osteotomy?
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Sure. Distal metatarsals will have their place. I just don't see myself doing more of them because I feel comfortable enough getting a more predictable correction with a first TMT joint arthrodesis and in general I prefer not to violate the first MTPJ unless I'm doing an arthrodesis of that joint (or in some cases, chilectomy).

In my mind, I'm not convinced that you can get a predictable correction with a chevron/austin considering that the frontal and sagittal planes are always left behind. I think we often times get carried away focusing too much on the forefoot and leaving the global picture that contributes to the deformity including the equinus, hindfoot, midtarsal joint, and the midfoot "sag" or instability. That's whay I truly believe that understanding forefoot pathology and executing sound forefoot surgery is no easy task by any means.

Furthermore, I think it is also critical to understand the overall function of the extremity by watching the patients walk because often times than none they have a compensation in their proximal/superior joints/limb. So the goal is always to accomplish the best result for the patient's individual needs.
 
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