LAPIDUS What is Old is New

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1 LAPIDUS What is Old is New Alan Jay Block, DPM, MS, FASPS, FACFAS Fellowship trained in Advanced Ankle Techniques Adjunct Professor Dept Of Orthopeadics The Ohio State University Board Member The Ohio College of Podiatric Medical Foundation Board Member Ohio Foot & Ankle medical Foundation

2 28297 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method first metatarsal and medial cuneiform joint arthrodesis

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4 Paul Lapidus was an orthopedic surgeon who work at the Hospital for the crippled and ruptured The deformity has to have a large IM angle (greater than 15 degrees) Increased convalescence Technically Challenging Suture Fixation of the osteotomy 25% non union rate

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8 Hallux Valgus is a 3D Problem Literature consistently demonstrates frontal-plane deformity Mizuno, J Jpn Orthop Assoc 1956: First metatarsal pronated D Amico, J Am Podiatr Med Assoc 1979: First metatarsal pronated Scranton, CORR 1980: 14.5 of eversion of the first metatarsal Eustace, Skel Rad 1993: Valgus rotation of first metatarsal in bunions w/ loading Talbot & Saltzman, FAI 1998: Pronation of metatarsal changed sesamoid appearance Mortier, OTS 2012: Feet with Bunions have everted first metatarsals Okuda, JBJS 2007, 2009: Supination needed to consistently correct sesamoids/round sign Dayton, 2012, 13, 14, 15,16: Direct correlation of TSP & DMAA to rotation of 1 st metatarsal Kim, FAI 2015: CT evaluation showing metatarsal pronation in 87.3% bunions 8

9 Pathology Transverse plane Sagittal plane Frontal plane Instability Hypermobility

10 INDICATIONS 1 st ray hypermobility High Intermetatarsal Angle Arthrosis of the 1 st metatarsal cuneiform Joint Diffuse ligamentous Laxity Recurrent Hallux Abducto valgus Deformity First ray insufficiency (hypermobile) Neylon, T.A. Use of the Lapidus bunionectomy in 1 st ray insufficiency. Clinics PMS & Sx.2001

11 Goals of the Lapidus Congruous 1 st metatarsal phalangeal joint Reduction of the IM angle Realignment of the sesamoids Restore the weight bearing of the 1 st ray Maintain or restore 1 st metatarsal phalangeal Joint ROM Repositioning of the 1 st ray in rectus alignment Correction/Control of the deforming factors Tri-plane correction of the deformity Medial column stability

12 Indications IM angle? Hallux Limitus or Rigidus Rheumatoid Arthritis Dorsal metatarsal-cuneiform exostosis Lesser Metatarsalgia Hypermobility of the 1 st Ray Medial column stabilization

13 Medial Eminence No need to resect the medial Eminence?? No Scar Tissue No change in the ROM (No Limitus or Rigidus) No Staking of the head No Varus??

14 Complications Shorting Hardware Failure Hallux Extensus Delayed Union Mal-union Nonunion Hyperpronation Syndrome Elevatus Overcorrection

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18 new paradigm that considers frontal plane rotation of the first metatarsal as a priority in choosing the most appropriate procedure for bunion correction

19 1. Outcomes of popular hallux valgus procedures are inconsistent High complication/recurrence rates for metatarsal osteotomies of all types 2. Hallux valgus is a 3-plane deformity (metatarsal frontal-plane rotation) Focus has been on the transverse and sagittal planes of the deformity Precision instrumentation enables Correct Before You Cut approach 21

20 3 structural deformities present in a bunion must be corrected: the abducted hallux the adducted metatarsal pronated or valgus metatarsal

21 Normal Moderate Rotation Significant Rotation 23

22 Mortier JP, Bernard JL, Maestro M. Axial rotation of the first metatarsal head in a normal population and hallux valgus patients. Orthop Traumatol Surg Res 98: , 2012 Mortier et al in 2012 used sesamoid axial radiographs to observe the position of the metatarsal in a bunion deformity Measurement showed a mean 12.7 of metatarsal pronation in feet with bunion deformities Conclusion this rotation was due to metatarsal cuneiform instability rather than torsion of the metatarsal shaft Valgus metatarsal rotation in bunion deformities is systematic

23 Grode and McCarthy using cryomicrotomy rather than radiographs. They sectioned cadaveric feet in multiple planes and at multiple levels in varying degrees of bunion severity Their observations included that, in a bunion, the position of the medial eminence or bump actually represents the dorsomedial surface of the head of the first metatarsal that is brought into prominence by rotation through Eversion Grode SE, McCarthy DJ. The anatomic implications of hallux abducto valgus: a cryomicrotomic study. J Am Podiatry Med Assoc 70: , 1980

24 In 2013, Dayton et al reported a case series of 25 procedures in which rotational correction was incorporated as part of a modified Lapidus procedure ( Rotational Lapidus) The addition of rotational correction to the Lapidus procedure resulted in a decrease of the IMA but also significant decreases in the HAA, PASA, and sesamoid position achieved without capsular balancing Dayton P, Feilmeier M, Kauwe M, Hirschi J. Relationship of frontal plane rotation of first metatarsal to proximal articular set angle and hallux alignment in patients undergoing tarsal metatarsal arthrodesis for hallux abducto valgus: a case series and critical review of the literature. J Foot Ankle Surg 52: , 2013

25 Under fluoroscopy, the MTPJ can be visualized. When the sesamoids are aligned and the lateral round sign has decreased, one can be confident the MTPJ is in anatomic alignment

26 In 2014, DiDomenico et al described their procedural approach to multiplanar bunion correction using the hallux to drive derotation of the valgus metatarsal by way of ligamentotaxis the hallux was moved in a supinated or varus direction, the metatarsal followed This, in turn, aligned the metatarsal phalangeal joint, reducing the HAA, PASA, and sesamoid position DiDomenico LA, Fahim R, Rollandini J, Thomas ZM. Correction of frontal plane rotation of sesamoid apparatus during Lapidus procedure: a novel approach. J Foot Ankle Surg 53: , 2014

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35 Risk Factors for Recurrence Recurrence risk factors implicate frontal-plane rotation Shibuya, J Foot Ankle Surg 2018: Incomplete sesamoid reduction Sravisht, FAI 2015: Pre-op severity & increased DMAA Pentikainen, FAI 2014: Pre-op congruence, DMAA, TSP, HVA & IMA Okuda, JBJS 2009: Incomplete sesamoid reduction 10X risk of recurrence Okuda, JBJS 2007: Metatarsal lateral round sign (metatarsal pronation) 12X risk of recurrence

36 All Bunions Have Same Level of Deformity No matter severity, 1 st metatarsal is deviated, not deformed The anatomic CORA is the first TMT joint [Tanaka Y, et al JBJS 1995] The Center of Rotation of Angulation 49

37 Traditional 2D Assessment Fundamental Deficiency: Procedure selection based on 2D radiographic representation Transverse plane focus (IMA, HVA, DMAA, TSP) Sagittal plane considered (elevation, hypermobility) What about the frontal plane? Note: None of the 2D measures provide indication for metatarsal osteotomy they do not identify a metatarsal deformity 50

38 Metatarsal Pronation Radiograph Signs Hallux Valgus Lateral Rounding of Metatarsal Head (profile of plantar condyle) Okuda, JBJS 2007 Apparent Lateral Displacement of Sesamoids Dayton, JFAS 2013 Normal Lateral Bowing of Metatarsal Shaft D Amico, JAPMA

39 7 yrs Same Patient 3D vs 2D Correction 8 yrs 55

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52 Predictable and reproducible long term outcomes Correct the anatomical alignment 77

53 1 st Metatarsal Osteomyelitis 16 y/o Black Female Osteomyelitis Right 1 st Metatarsal s/p bunion surgery 8 months Non-compliant patient No Meds Complains of draining wound x 7 months Denies F/C/SOB Wound is open in tennis shoe

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55 Surgical Steps Removal of osteomyelitic 1 st metatarsal Spanning of gap with mini external fixator Addition of antibiotic beads w/ Xyvox

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73 LAPIDUS What is Old is New Alan Jay Block, DPM, MS, FASPS, FACFAS Fellowship trained in Advanced Ankle Techniques Adjunct Professor Dept Of Orthopeadics The Ohio State University Board Member The Ohio College of Podiatric Medical Foundation Board Member Ohio Foot & Ankle medical Foundation