Immediate Weight Bearing after Biplanar Plantar Fixation of Lapidus: A Multi-Centered Study Bret Smith, DO, MSc Director, Foot & Ankle Division, Palmetto Health-USC Orthopedic Center Assistant Professor, Orthopedics, University of South Carolina, Columbia, SC Robert Santrock, MD Assistant Professor & Chief of Foot & Ankle Surgery Dept. of Orthopaedics, West Virginia University School of Medicine, Morgantown, WV Daniel Hatch, DPM Surgical Director Northern Colorado PM&S Residency, Greeley, CO Paul Dayton, DPM, MS Assistant Professor, College of Podiatric Medicine and Surgery, Des Moines University, Des Moines Iowa UnityPoint Clinic, Fort Dodge, IA
Disclosures Bret Smith: Treace Medical Concepts (consultant, royalty, stock ownership) Robert Santrock: Treace Medical Concepts (consultant, royalty) Daniel Hatch: Treace Medical Concepts (consultant, royalty, stock ownership) Paul Dayton: Treace Medical Concepts (consultant, royalty) See final AOFAS Program for complete disclosures.
Introduction Current Hallux Valgus Treatment Paradigm Majority of hallux valgus procedures two-dimensional (2D) metatarsal osteotomies Able to weight bear (WB) immediately, but 30-78% long-term radiographic recurrence reported 1,2 Recent CT studies indicate 87% bunions are 3-plane deformities with metatarsal frontal-plane rotation 3 Failure to correct met. rotation increased recurrence 10.0X recurrence if sesamoids not corrected 4 12.7X recurrence if met. rotation not corrected (positive lateral round sign ) 5
Introduction 1 st TMT (Lapidus) Arthrodesis Convenient site for 3-plane anatomic met. correction Corrects at apex of deformity (anatomic CORA) Traditional limitation inability to weight bear (WB) early However, recent studies have challenged WB standards following Lapidus, with limited WB at 2-3 wks 6,7 Recently developed multiplanar plating constructs rely on relative stability & secondary ( biologic ) bone healing 8 may allow for immediate WB
Purpose Early evaluation of novel procedure & fixation construct that allows for 3-plane correction & immediate WB after Lapidus arthrodesis Radiographic Assessment: Union rate & complications 3-plane metatarsal correction
Methods Retrospective, multi-center study (4 centers), consecutive series Surgical Procedure: Instrumented 3-plane, 1 st TMT hallux valgus correction* Multiplanar fixation constructs 2 mini-plates applied with 1 st TMT joint held in compression Two construct options: 1. Dorsal plate + medial plate (57% cases in study) 2. Dorsal plate + medial-to-plantar plate (43% cases in study) Post-op Regimen: Immediate WB as tolerated in post-op boot Exclusion: Revision procedures Additional arthrodesis outside 1 st TMT joint Moderate to severe arthritis of the 1 st MTP joint *Lapiplasty System, Treace Medical Concepts, Inc., Ponte Vedra Beach, FL
Methods 49 patients, age 41.9±17.9 yrs 4.3±1.0 mo follow up (min 3 mo) Radiographic analysis Anatomic measures Intermetatarsal Angle (IMA) Hallux Valgus Angle (HVA) Tibial Sesamoid Position (TSP) Metatarsal rotation (Lateral Round Sign) Non-union/complications Paired t-test for statistical analysis
Results Anatomic Radiographic Measures * 93.6% * * * 2.0 4.1% * p < 0.001
Results Complications Delayed wound healing/swelling 2 (4%) Broken screw in fixation construct 1 (2%) Hardware removal for soft-tissue irritation 1 (2%) Undercorrection (IMA>10 or HVA>20 ) 2 (4%) Non-union 0 (0%)
Discussion Immediate WB possible after 1 st TMT fusion with 2 low-profile, unicortical locking plates at 90 orientation without interfrag screw 3-plane correction maintained with minimal complications Multiplanar, relative stability allows WB to stimulate biological healing process via secondary bone healing 8 Previous biomechanical testing of biplanar plating in cyclic loading demonstrated superiority to anatomic plate & compression screw construct 9 Findings build on studies showing excellent results with early (2-4 wk) WB after 1 st TMT fusion 6,7
Conclusion Early results suggest ability to correct all 3 planes of hallux valgus deformity and allow immediate WB following 1 st TMT fusion with multiplanar plate fixation
References 1. Bock P, Kluger R, Kristen K-H, Mittlböck M, Schuh R, Trnka H-J. The Scarf Osteotomy with Minimally Invasive Lateral Release for Treatment of Hallux Valgus Deformity. J Bone Joint Surg Am. 2015;97(15):1238-1245. 2. Jeuken RM, Schotanus MGM, Kort NP, Deenik A, Jong B, Hendrickx RPM. Long-term Follow-up of a Randomized Controlled Trial Comparing Scarf to Chevron Osteotomy in Hallux Valgus Correction. Foot Ankle Int. 2016;37(7):687-695. 3. Kim Y, Kim JS, Young KW, Naraghi R, Cho HK, Lee SY. A New Measure of Tibial Sesamoid Position in Hallux Valgus in Relation to the Coronal Rotation of the First Metatarsal in CT Scans. Foot Ankle Int. 2015;36(8):944-952. 4. Okuda R, Kinoshita M, Yasuda T, Jotoku T, Kitano N, Shima H. Postoperative incomplete reduction of the sesamoids as a risk factor for recurrence of hallux valgus. J Bone Joint Surg Am. 2009;91(7):1637-1645. 5. Okuda R, Kinoshita M, Yasuda T, Jotoku T, Kitano N, Shima H. The shape of the lateral edge of the first metatarsal head as a risk factor for recurrence of hallux valgus. J Bone Joint Surg Am. 2007;89(10):2163-2172. 6. Sorensen MD, Hyer CF, Berlet GC. Results of Lapidus Arthrodesis and Locked Plating With Early Weight Bearing. Foot Ankle Spec. 2:227 233, 2009. 7. Prissel M, Hyer CF, Grambart ST, Bussewitz BW, Brigido SA, DiDomenico LA, Lee MS, Reeves CL, Shane AM, Tucker DJ, Weinraub GM. A Multicenter, Retrospective Study of Early Weightbearing for Modified Lapidus Arthrodesis. J. Foot Ankle Surg. 55: 226 229, 2016. 8. Perren SM. Evolution of the internal fixation of long bone fractures. J.Bone Joint Surg.(Br) 84B: 1093-1110, 2002. 9. Dayton, P, Ferguson J, Hatch DJ, Santrock R, Scanlan S, Smith B. Comparison of the Mechanical Characteristics of a Universal Small Biplane Plating Technique Without Compression Screw and Single Anatomic Plate With Compression Screw. J. Foot Ankle Surg. 55:567 571, 2016.