01/14/2020    Keith L. Gurnick, DPM

Unrecognized - Unaddressed Complications of the Lapidus Bunionectomy

Over the past few years, the re-emergence of the
Lapidus procedure and/or modifications of the
Lapidus procedure for bunion correction has been
widely promoted and discussed as a procedure of
choice for better long-term results for hallux-
abducto-valgus or bunion conditions that require
surgery correction. The historic rationale for
choosing to do a Lapidus included those patients
with flexible or "hypermobile" first ray, foot
collapse with medial displacement at the 1st
metatarsal-cuneiform joint, or arthritic first
metatarsal-cuneiform joint, in conjunction with
increased 1st-2nd metatarsal angles (high IM
angle).

More recently, it appears to be the procedure of
choice for many foot surgeons who have expanded
the criterion to include those patients, who in
the past would have received a more distal
procedure such as an Austin, or a Scarf (or
variations on an Austin or Scarf). Obviously a
concurrent procedure is done at the bunion site,
such as a McBride or sometimes even an Aiken at
the hallux as well. I am referencing not only
podiatric surgeons, but also orthopedic foot
surgeons.

Here is what I am finding on these patients who
have come to see me, (meaning I did not do their
bunion surgery, but they quit seeing the surgeon)
who have had what appears to me to be more
complications with the Lapidus than has been
discussed or referenced in the literature and I
am wondering if others are seeing the same
issues.

First: the need for follow up or additional
surgery to remove prominent hardware. The use of
orthopedic plates (with screws) to fixate or fuse
a Lapidus, vs. 2 crossed screws by themselves,
leaves prominent dorsal hardware in an already
potentially sensitive area of the foot, where
shoe pressure can cause irritation and pain, thus
requiring hardware removal down the road. I had
not seen this frequency of need to remove
hardware from distal osteotomy/bunionectomies
where fixation had been accomplished with buried
internal K-wires or screws.

Second: Post-operative metatarsus primus
elevatus, due to poorly bone cuts at the 1st M-C
joint that can lead to jamming of the 1st
metatarsal phalangeal joint, hallux rigid and
symptomatic arthritis of that joint. Third: Sub
2nd metatarsalgia, due to either excessive
shortening of the 1st metatarsal and or
iatrogenic elevates of the first metatarsal. This
symptom often is delayed 6 months to a year post-
op until the patient has returned to normal shoe
gear and normal activities.

Usually when we discuss bunion surgery potential
complications pre-operatively with our patients
we include infection, delayed or non-union, pain
that does not resolve, recurrence, hallux varus,
etc. For a Lapidus, this list should be expanded
to include future need for hardware removal
(likely), metatarsus primus elevatus and/or
shortened 1st metatarsal with subsequent sub-2nd
metatarsalgia that could require orthotics or
shoe selection changes that limit the use of
heels in women and possibly some activities as
well.

I have nothing against the Lapidus procedure.
Like any surgical procedure, it should be
reserved and done on the correct patients with
the right indications. Currently I believe it is
being oversold and overused, mostly by surgeons
who have not yet learned or experienced the
sequela.

Keith L. Gurnick, DPM, Los Angeles, CA

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01/16/2020    Dennis Shavelson, DPM

Unrecognized - Unaddressed Complications of the Lapidus Bunionectomy (Keith L. Gurnick, DPM) From:

Dr. Gurnick raises valid points regarding
iatrogenic complications and the overuse of the
Lapidus procedure. I respectfully suggest that
the underpinning etiology of these complications
and overuse is a lack of modern closed chain
biomechanics in the decision-making process.
Biomechanically, correcting a high forefoot
SERM-PERM Interval when existing should be a
fundamental biomechanical goal of any
bunionectomy. The surgical procedure is often
not capable of making this crucial change on its
own.

Diagnostically, the surgeon must define the
amount of “hypermobility” that needs to be
corrected. This is because until that is
established as a goal of care, met primus
elevatus, transfer metatarsalgia and poor 1st
MPJ function (closed chain sequellae post
bunionectomy) are left to chance. The contact
open chain x-ray view should be taken and
incorporated in the decision making. A
functional foot typing® that determines the
rearfoot influence on the forefoot SERM-PERM
Interval as well as the amount the Forefoot
SERM-PERM Interval needs to be reduced can be
considered as the starting platform for
procedures and pre- and pos-top care for those
needing a launching site.

Non-invasive biomechanical props in the form of
strappings, pads and custom foot orthotics that
reduce the FF SERM-PERM Interval and make the
muscle engines trainable should be a part of the
biomechanics of the initial visit as a test
drive for the patient’s ability to have his/her
Forefoot SERM-PERM Interval corrected without
the need for 1st met-cuneiform surgery.

Diagnosis of weak, atrophic or poorly functional
primary muscle engines (pedal amnesia) such as
peroneus longus, abductor hallucis and flexor
hallucis longus should be determined and
corrected as much as possible pre-op and
continued post-op.

Biomechanical external fixation in the form of
corrective strappings, pads and PostopThotics®
should be built into the surgical treatment plan
as well as compensatory threshold training® of
inhibited muscle engines to help stabilize,
support, strengthen and balance the patient’s
feet for improved function and reduced
complications.

Until a surgeon has 1 st met lesions,
sesamoiditis and plantar 1st met head wounds as
a complication (the procedure lowered the FF
SERM-PERM Interval too much) he/she should learn
to make Lapidus cuts that plantarflex the 1st
met when grounded better and better and err in
the direction of plantarflexing when planning
and executing osteotomy cuts.

In my opinion, the biomechanical skills of
surgeons pre- and post-op should be honed to the
point where “hypermobility” can be controlled
without invading the 1 st met-cuneiform joint
for more than half of the patients that are
receiving a Lapidus procedure.

Dennis Shavelson, DPM (retired), NY, NY