Open or Closing Base Wedge...

[347932]

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I was trained to do CBWO in residency and found that in practice there were just too many complications and the procedure just didn't work well in my hands.

The last couple of years or so I've been performing OBWO with plate fixation and have had much better success.

Any opinions out there?

 

[PADPM]

Naturally, the most common complication has always been elevatus of the first ray with a closing wedge. Additionally, there have always been warnings regarding the performance of an opening base wedge due to the possibility of "jamming the joint" secondary to lengthening the column, though I've never actually seen that occur.

With the advent of the newer plating systems, it has certainly made the opening wedge much simpler and more predictable. If given a choice, I would probably prefer the opening wedge vs. the closing wedge unless the joint was already excessively "tight".

However, with a large IM angle, and the biomechanics that are often seen in conjunction with this foot type, a Lapidus is often my procedure of choice.

 

[347932]

Thanks for the reply.

I too have not had any issues with joint tightness since performing the opening wedge.

As far as the Lapidus, I tend to favor that procedure on older patients who have pain and arthritis at the Met Cuneiform Joint with the aforementioned "hypermobility" of the 1st Ray. I tend to stay away from fusions on the younger population due to compliance and activity issues.

When evaluating children with extreme bunion deformities I tend to avoid surgical intervention until epiphysies have closed and then base my procedure selection on severity of deformity.

 

[Feli]

I honestly think base wedges in general (concentric, CBWO, OBWO, etc) are basically extinct procedures. The IM correction isn't maintained as well as a Lapidus, yet the period of NWB, casting, etc is the same. With improved knowledge of the procedures, better flouro in the OR, better knowledge of fixation constructs, orthobiologics and bone healing, etc there's really not a legit reason for the prohibitive fears of elevation, nonunion, etc that you always hear about with Lapidus. I honestly think most of the horror stories you hear about Lapidus are due to many surgeons who weren't trained on the procedure in residency now trying to do it since they heard about it in a conference. The CBWO is certainly much easier in terms of surgical technique, but I just don't believe it addresses the apex of deformity, and besides, most big bunions do have significant 1MC joint arthritis and hypermobility.

Preserving motion in the 1MC joint? Spare me... it is a nonessential flat joint which has less than 3deg of saggital plant motion in any cadaver study you'll find, and the rest of the proximal medial column (namely TN) easily picks up the slack. The Lapidus takes a nonessential and hypermobile/arthritic problem joint (1MC and possibly 1/2 met bases) out of commision but puts a more essential joint (1st MPJ) into better alignment in multiple planes. It just makes the most intuitive sense IMO. I think that basically the only bunionectomies I will end up doing are McBride, Austin, Mau, and Lapidus... with some Riverdins or Akins where indicated. Yes, it's true that you should do "anything when the situation calls for it," but most other bunionectomies just don't have the corrective ability, stability, or versatility of those procedures. I guess it's all just preference, but they're what makes sense to me (Austin needs no explanation, Mau and Scarf are proven as most stable shaft or base osteotomy with least elevation/nonunion - but Mau is less bone cuts + osteonecrosis + periosteal stripping of the 1st met, and Lapidus is proven to hold IM like no other bunionectomy outside MPJ1 desis - which I view as more of a rigidus procedure for obvious reasons).

Since the complications are more devestating, proximal HAV procedures should never be over-utilized when a distal procedure will suffice. However, when the proximal procedures are indicated and the patient is a good candidate (nonsmoker, not obese, compliant, under circa 50yr), then you have to do what they need and what will give the best long term results. A lot of things can work in the hands of a skilled surgeon, but when the recovery time is the same, why not pick the procedure with superior long term outcomes in the literature?

...Base wedges just make very little sense to me unless it's a kid with severe HAV and open 1st met growth plate. The OBWO with the lock plate and DBM or other graft is just a rep toy looking for an indication... you could do a Lapidus with autograft, Mau, or a distraction SCARF just as easily and with much less cost IMO. I agree with PADPM that the OBWO or Lap with bone graft will not lengthen the first ray; at best, the graft or open wedge will just make up for the shortening from the saw cuts and provide a "break even" situation on 1st met/ray length.

 

[347932]

Feli,

I respectfully disagree with your assessment of the basis of performing a Lapidus in every situation where a large IM angle is evident.

The true indication for the Lapidus procedure is with hypermobility, pain at the Met Cuneiform Joint, a severe IM angle and an atavistic cuneiform. Not all high IM angle bunions fall into this category.

The Lapidus procedure has fallen into much too common grounds imo. There are parts of the country where this is taught as the primary procedure for any patient that comes in with a high IM angle and I believe this practice to be potentially harmful to the thought process of a talented surgeon.

Why are you fusing this joint? To prevent movement. If there is no excessive or painful movement at that joint why fuse it? With current techniques in OBWO I have had no trouble walking these patients within four weeks comfortable in a Cam Boot. What has been your post operative courses on the Lapidus procedure? Most of mine don't fuse within 4 weeks.

 

[Feli]

...The true indication for the Lapidus procedure is with hypermobility, pain at the Met Cuneiform Joint, a severe IM angle and an atavistic cuneiform...

Yes... or maybe just a bunion where you want long term correction?

http://www.ncbi.nlm.nih.gov/pubmed/17761320

If you read Reeves' chapter in Chang about Lapidus, he provides a nice summary of how Lapidus indications are viewed much differently by many modern surgeons.

...post operative courses on the Lapidus procedure? Most of mine don't fuse within 4 weeks.

Who said a joint/fracture/etc needs to be 100% radiographically fused to weightbear on it? What is really the point of advances in internal (and external) fixation, orthobiologics, and protective weightbearing devices if we are just going to follow the same old NWB timelines and wait for solid union on our XRs anyways?

http://www.ncbi.nlm.nih.gov/pubmed/20610203

 

[347932]

Feli,

You quoted an article that clearly indicates that no studies are available that prove that earlier weightbearing is indicated in Lapidus fusions. One study showing suspect results does not change much imo. Especially with an 80 patient study group and no control group. Give me a study with a 1000 study group and my ears will perk up a bit.

Also, in that same article in mentions that there was a 100% fusion rate in the patients studied. For this statement alone, the article is very suspect in my mind. Nothing we do is 100%, especially in a study environment.

I consider myself a "modern" surgeon as I finished my three years of residency in 2002 and was trained to consider all possibilities, the patient and deformity presented when making surgical decisions. I've done my share of every type of bunion procedure and find that in my hands, the OBWO works exceptionally well (and the fixation I use is hardly rep toys looking for an indication), as does the Ladidus procedure when procedure selection is made with clear thought. Also, I think that the Lapidus procedure is quite a good bit easier technically than a well done and thought out OBWO with appropriate fixation.

As an aside, how do you fixate your Lapidus procedures?

 

[Feli]

... in my hands, the OBWO works exceptionally well (and the fixation I use is hardly rep toys looking for an indication), as does the Ladidus procedure when procedure selection is made with clear thought. Also, I think that the Lapidus procedure is quite a good bit easier technically than a well done and thought out OBWO with appropriate fixation.

As an aside, how do you fixate your Lapidus procedures?

This is really the bottom line: surgery is both an art and a science. The John Ruch McGlamry text chapter is exactly right when it states something to the effect of "there are hundreds of bunionectomy procedures that have all worked for someone at some time, yet anatomy is the common denominator." It's based on how you're trained, what you feel comfortable with, and what makes sense to you. Surgeons will frequently have to agree to disagree, and both continue to get good results doing what works and makes sense for them... that's nothing new 😉

...As an aside, how do you fixate your Lapidus procedures?

I'm still a resident, so I see it all: screw and k wire, 2 screws, 3 screws, 4 screws, screw + lock plate (dorsal, dorsal-med, or plantar-med), claw plates dorsal and medial, ext fix minirail, etc.
...What would (/will) I do? Probably 3 solid Synthes 3.5/4.0 set screws in most cases due to solid, proven, cost effective construct and occasionally single lag screw + graft + PRP + low profile (Darco or similar) lock plate if the bone quality was poorer than anticipated once I got in there. Again, JMO and what makes sense to me.

 

[347932]

I tend to favor compression staples these days. Good solid compression and very quick, but I'm trying a new intramedullary fixation technique that has promise in high risk patients.