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

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