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Lapidus fusion using the I.O. Fix implant (Extremity Medical)

    Overview

    Learn the Lapidus fusion using the IO Fix implant (Extremity Medical) surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Lapidus fusion using the IO Fix implant (Extremity Medical) surgical procedure.
    Arthrodesis of the first tarso-metatarsal joint (1TMTJ) is indicated for three main pathologies: symptomatic arthritis of the 1TMTJ, hallux valgus deformity and in some Lisfranc injuries involving the medial ray. Although the technique was already well established, in 1934 Paul Lapidus wrote up his experience in arthrodesing the 1TMTJ for hallux valgus and his name has been attributed to this procedure for this indication ever since. Further papers written by Lapidus honed his indications to those patients with hallux valgus in the presence of a fixed metatarsus primus varus and those with an inter-metatarsal angle (IMA) of greater than 15 degrees. Currently, surgeons will also consider the use of the Lapidus procedure in the presence of 1TMTJ instability. In the UK, the technique is not universally popular because most hallux valgus deformity can be corrected by the scarf osteotomy which is versatile in being able to correct a wide spectrum of deformities and has the benefit of behaving as other forefoot osteotomies for hallux valgus, in terms of patient recovery, whereas the Lapidus procedure is very much considered a midfoot arthrodesis. My indications for the procedure are for hallux valgus in the presence of ligamentous laxity and with those patients with a very wide forefoot because of severe hallux valgus.
    Various modifications to the original technique have been suggested. Some authors have passed a screw between the shafts of the first and second metatarsal in order to augment stability at the 1TMTJ fusion mass. This has also been vaunted as a means of allowing the patient to commence early weight bearing, but I think this is a huge demand on a single small fragment-sized screw. Additionally, it can fix the relationship between the two metatarsals leading to metatarsalgia. Other modifications have revolved around attempts to restore length and correct deformity by using bone graft either in the form of tri-cortical blocks or in morcellised form. These modifications tend to have higher non-union rates than in providing simple bony apposition.
    Finally, why I.O. Fix? The I.O. Fix system offers great compression by metalwork that is well buried and lying in the anatomical axis of the first ray. Intuitively to me, this is a good biomechanical solution to stabilising the 1TMTJ. Previously, I have tried using two dorsally placed crossed screws and have always found it a challenge to find enough space for the second screw. As a result I have tried a single lagged dorsal screw with a medially placed locked plate to provide orthogonal neutralisation. However, creating space for the plate can be challenging especially as some mobilisation of the tibialis anterior tendon and its insertion can be difficult. I have concerns about any medial plate causing attritional damage to this tendon. Using a long “X-post”, I feel that the I.O. Fix provides sufficient compression across the depth of a deep joint and has the advantage of being very low profile. Some surgeons use a second orthogonally placed I.O. Fix but, again, I struggle to see where there is sufficient room for this. Lastly, some authors prefer a plantar plate for arthrodesis of the 1TMTJ because it is biomechanically favourable. Although, I agree that this forms a more rigid construct with the plate on the tension surface, I find the dissection difficult and do not feel that the plate seats well on the bony contours.
    There are some issues with using the I.O. Fix system. It may work less well in osteopenia and I would always suggest the first metatarsal is manually reduced onto the medial cuneiform after preparation and the lag screw is gently applied across the joint to hold that degree of compression. In my experience, the implant needs to be used methodically in order to make it work. Because the compressive mechanism is so strong, if the surgeons relies on the lag screw to “draw” the first metatarsal onto the medial cuneiform, there is a danger of the lag screw cutting out.

    Indications

    Indications
    In my hands, I use the Lapidus procedure in patients with significant hallux valgus and instability of the 1TMTJ. This is a somewhat vague statement and I will try to expand what I mean. The hallux valgus deformity needs to be assessed initially by taking a good history. Quite often patients not only complain of the rubbing from the prominent first metatarsal head but, if you listen, also mention symptoms akin to instability of the medial ray (“I feel the foot gives way/arch collapses”) and may complain of impinging pain in the lateral column of the foot. Examination may demonstrate metatarsus primus varus but more often shows a very broad forefoot. It may be possible to elicit hypermobility of the 1TMTJ but this is hard to detect and quantify in my view. Plain lateral weight bearing radiographs may show signs of an increased plantar gap at the 1TMTJ and on the A-P radiograph, there may also be signs of 1TMTJ incongruity. There may be a very significantly raised IMA and the articulating facet of the medial cuneiform may appear to be angled medially and the lateral sesamoid appears to lie completely within the first web space. It is the sum of all of this information that would raise the possibility of performing a Lapidus procedure rather than a scarf osteotomy. The Lapidus procedure certainly has a role to play in revision hallux valgus surgery.

    Symptoms & Examination
    The classic patient is a female between the ages of 25 and 65 years. Their symptoms are of pain either from intrinsic aching from within the 1TMTJ, rubbing of the first metatarsal head on footwear or from discomfort due to instability of the medial ray at the 1TMTJ. As I have already mentioned, there may also be an impinging type of pain around the calcaneo-cuboid joint.
    Examination should always involve watching the patient stand from a seated position as it may be clear that they are dynamically collapsing through the midfoot with bearing weight. Clearly, this suggests midfoot instability. It may also be exaggerated when observing the gait. It is important to make sure that the hindfoot is well aligned and that the Achilles tendon is not tight. It is worthwhile being certain that you know whether the patient has systemic signs of laxity. With the patient seated, it may be apparent that the medial ray is unstable at the level of the 1TMTJ. As always with hallux valgus, it is mandatory to see if the deformity is passively correctable and that, in the corrected position, the hallux motion at the first metatarsophalangeal joint (1MTPJ) is pain free and full.
    Investigation
    Plain standing radiographs are the investigation of choice and should show dorsal-plantar, oblique and lateral views of the whole foot. These allow assessment for the presence/absence of arthrosis in the 1TMTJ and 1MTPJ, the presence of metatarsus primus varus and the size of the intermetatarsal angle (IMA). The oblique view is most useful in examining the 2nd and 3rd TMTJs as any arthrosis in these joints may mean a more extensive midfoot fusion procedure. For me the lateral standing radiograph also can indicate 1TMTJ instability if there is plantar gapping of the 1TMTJ. CT may be useful in determining/excluding arthrosis in the TMTJs. In future, standing CT may become the investigation of choice as it offers the benefits of plain standing radiographs and the detail of the joints that the CT confers.
    Operative alternatives
    The Lapidus procedure is less popular in the UK than it is in the US and in certain parts of Europe. In the UK, the scarf osteotomy has become very popular as it very versatile and powerful in correcting a large IMA although purists argue that it doesn’t address the deformity at the CORA (centre of rotation and angulation).
    Many basal osteotomies of the first metatarsal have been described and used but no one single osteotomy technique has gained universal popularity probably as a result of technical difficulties performing them, the limitation to the degree of deformity correction and the limitations of fixation techniques. In addition, they fail to address any pathology arising from the 1TMTJ.
    Some surgeons avoid a Lapidus procedure because of potential complications from the need to immobilise the foot and prevent weight bearing in the post-operative period.
    Contraindications
    As in most aspects of elective foot surgery, I exclude patients from a Lapidus procedure in the absence of good pedal pulses and would not consider surgery in anyone with a neuropathy. I do like my patients not to bear weight post-operatively, so I would also exclude anyone unable to manage crutches or a walking frame. I also prefer my patients not to be taking any corticosteroid therapy in the peri-operative period as I feel this inhibits arthrodesis.
    Non-operative intervention
    As in all elective foot surgery, it is important to try non-operative measures first. For 1TMTJ instability, this would include specific measures to support the medial arch with insoles but would also include the use of wide toe box shoes to reduce the attritional effects of contact with the hallux.

    Setup

    The patient is positioned supine on the operating table and may require a sandbag under the ipsilateral buttock so that the foot points vertically towards the ceiling. Fluoroscopy is mandatory with an image intensifier and a trained radiographer.

    Appropriate antibiotics are administered and a thigh tourniquet and exclusion drape are applied. The limb is prepared with Chlorhexidine from toes to tourniquet.

    Operation – 1

    The patient for this case was chiefly complaining of an aching pain from deep inside the 1MTPJ together with symptoms of rubbing of the prominent first metatarsal head against the uppers of her shoes.
    This standing picture is taken in the clinic. It is clear that the lesser toes are well-aligned and that there is a very broad forefoot, a subluxated appearance at the 1MTPJ and the hallux is pronated.

    The standing A-P radiograph demonstrates the raised IMA, the subluxated 1MTPJ, the medially facing articular surface of the medial cuneiform and the whole of the lateral sesamoid is visible in the first webspace. As a generalisation, the larger the IMA, the more likely there are to be signs of midfoot instability.

    The standing lateral radiograph does not show any significant widening of the plantar aspect of the 1TMTJ.
    Based upon the history, examination and radiographic findings, I decided upon performing a Lapidus procedure. I also consented her for a concurrent Akin osteotomy of the proximal phalanx, as this is often the final manoeuvre in the correction of the deformity.

    The patient is positioned with a sandbag under the ipsilateral buttock to rotate the foot vertically. An exclusion drape is applied immediately distal to the thigh tourniquet.

    The skin is marked to identify the boundaries of the 1TMTJ and the position of the lateral releaseWith the limb appropriately prepped and the thigh tourniquet inflated, I have marked my proposed skin incisions.
    A is the longitudinal incision traversing the 1TMTJ. It lies exactly midway between the the two dots (B & C) which mark the medial and lateral extent of the 1TMTJ. I have also marked an incision (D) to plan for a lateral release in order to seat the sesamoids back under the first metatarsal head. This dorsal incision is planned to lie immediately lateral to the 1MTPJ.

    Performing the lateral release is the first undertaking.
    The placement of the skin incision should in most cases be close to the lateral aspect of the 1st metatarsal head and at the level of the joint.
    This placement avoids excessive dorsal soft tissue dissection in gaining access to the deeper structures.
    The skin is incised and with a mixture of sharp and blunt dissection, care is taken to diathermy the ever-present veins that lie in the superficial tissues. Deep to them, the capsule of the joint is exposed This is always easier to identify with the greater subluxation of the sesamoids. Not infrequently, when the capsule is opened, there is a small flush of synovial fluid but also the appearance of a significant void with the sesamoid lying at its base.

    Once through the skin, the superficial fat should be swept off the tougher, underlying fascial layer

    The fascia needs to be released distally as far as it extends into the first web space and proximally slightly beyond the level of the MTP joint .
    The purpose of this is to allow an adequate mobilisation of the underlying muscle to reveal the lateral aspect of the joint.

    The lateral release is performed to mobile the sesamoidsThe interosseous muscle is freed from the lateral aspect of the 1st metatarsal by blunt or sharp dissection.
    The Wests retractor can next usefully be placed beneath the medially freed margin of the interosseous to sweep it laterally and expose the lateral and plantar aspect of the 1st MTP joint.

    A horizontal capsulotomy is performed at the level of the MTP joint and placed just above the lateral sesamoid.
    With the capsulotomy correctly located for the lateral release the articular surface of the lateral sesamoid can easily be seen. A McDonalds is useful to probe the joint open and confirm the location of the sesamoid.
    The adductor insertion is dissected off the sesamoid. This sharp dissection should release muscle fibres proximally, extend plantar-wards (but not to the plantar surface of the sesamoid) and exit with a lateral cut distally through the sesamo-phalangeal ligament(a non-discreet condensation of the capsule between the sesamoid and base of proximal phalanx .

    The lateral directed cut through the sesamo-phalangeal ligament is aided by stressing the MTP joint at this stage into varus. The cut is lateral at the level of the joint just and distal to the sesamoid.
    Following this stage of the lateral release the MTP should be stressed into varus. Ten degrees beyond neutral indicates an adequate lateral release has been performed.

    The longitudinal incision over the 1TMTJ is madeThe longitudinal incision overlying the 1TMTJ is opened. Immediately the tendon of extensor hallucis longus (EHL) is revealed. If your incision is placed too far laterally, the tendon of extensor hallucis brevis will be seen.

    The tendon of EHL is reflected medially, exposing the dorsal MTC capsule.The tendon of EHL is reflected medially and this reveals the dorsal joint line of the 1TMTJ (A).

    The dorsal capsule is excised from the 1TMTJThis allows the joint to be mobilised. The deep peroneal nerve and the rest of the neurovascular bundle are retracted by the right hand cat’s paw retractor.

    A 2mm K-wire is drilled into the dorsum of the medial cuneiform.At this stage, the 1TMTJ needs to be distracted in order to prepare the joint surfaces. Ergonomically, I find it is worthwhile placing the wire into the medial cuneiform by locating the centre of the bone in both the medial-lateral and proximal-distal dimensions. It should always lie at least 5mm from the 1TMTJ joint line.
    Once this position is located, a 2mm K-wire is drilled into the dorsum of the medial cuneiform. It should be drilled parallel to the 1TMTJ joint line on the lateral plane. It is worthwhile checking this on the image intensifier. The reason for the ergonomics is that this wire can then be used for positioning the X-post in the application of the I.O. Fix compression device.

    A second wire is placed parallel to the first into the base of the first metatarsal.It is worthwhile placing this second wire a sufficient distance from the 1TMTJ to allow easy instrumentation of the joint.

    A Hintermann’s distractor is placed across the wires and the joint is distracted.This affords good views and access to prepare the joint surfaces.
    The wires can be bent at point A to “lock” the distractor in place next to the bone and can also be bent at point B to remove the barrels of the distractor from the surgical field.

    With distraction, good views are afforded across the whole joint.

    I like to use a narrow (5mm) flexible chisel blade to remove the articular surfaces.

    The articular surfaces are denuded of cartilage using a flexible chisel.Note the chisel aims to remove sufficient articular surface to expose the vascular subchondral bone surfaces. The joint is much deeper than you would first appreciate. As a rule of thumb, it is comfortably an inch deep and it is too easy to leave the deep joint surfaces unprepared risking the creation of a plantar hinge that compromises compression and positioning of the arthrodesis.

    Note the “kidney shaped” articular surface of the medial cuneiform side of the joint. The depth of the joint from A to B is comfortably an inch deep.

    The reciprocal surface of the first metatarsal base has a slightly different shape.

    The 1TMTJ should be completely denuded of its articular surfaces.

    After removal of the Hintermann’s distractor, a trial reduction of the 1TMTJ is performed.The manoeuvre for this is simply to correct the IMA and apply axial longitudinal compression along the medial ray. In this instance, I felt that further correction of the deformity was necessary.

    Further bone resection from the medial cuneiform may be necessary to improve the deformity correction.Using a fine saw blade, further resection of bone was required to improve the deformity correction. This is best done by removing a small wedge of bone from the lateral aspect of the medial cuneiform rather than the base of the first metatarsal.

    Operation – 2

    Good bony apposition can then be appreciated when the IMA is closed and axial longitudinal compression is applied along the medial ray.
    It can be difficult to achieve this apposition if too much bone is removed given that the 2nd and 3rd metatarsals are being left “out to length”.
    In addition, if a concurrent planus deformity needs correction, then a closing plantar wedge shaped resection of subchondral bone needs to be fashioned. In this instance, care must be taken to gently resect more plantar bone from either side of the joint.

    Temporary K-wires are applied to maintain the 1TMTJ in position once an appropriate position has been obtained.One wire is applied distally by piercing the medial skin near the first metatarsal neck and driving the wire through both cortices of this bone and further into two cortices of the neighbouring second metatarsal. This holds the reduced IMA.
    A second wire is passed medially through the base of the first metatarsal and into the medial cuneiform to stabilise the 1TMTJ.
    Notice that my left hand is clasping the forefoot in a reduced position and my thumb is applying the axial compression across the 1TMTJ counteracted by pressure exerted by gripping the lateral rays. Dorsal translation can easily be avoided by watching what happens at the arthrodesis site. Dorsal angulation can be avoided by watching the two prepared surfaces appose as the forefoot is clasped. My thumb is also applying axial load along the first metatarsal.

    The X-post guide wire position is checked fluoroscopically.The original 2mm K-wire hole is then used to pass the 1.6mm guide wire for the I.O. Fix X-post. This does not require power. The position of this wire and the reduction K-wires are checked fluoroscopically. Note that the X-post guide wire (A) is placed centrally in the medial cuneiform and lies parallel to the 1TMTJ prepared joint surface. In this image, the wire is too long and is withdrawn to the correct depth to determine the length of the X-post.

    The position of the X-post K-wire is also checked in the A-P plane. Using a measure the length of the post can be ascertained.
    The longer the X-post, the better the working length of compression that can be achieved across the 1TMTJ. In this instance, I had selected a 25mm long, blue X-post. The blue X-post has an 8mm diameter thread.

    The 4.5mm cannulated drill is used to drill the required depth of the X-post.The 4.5mm cannulated drill is then threaded over the 1.6mm guide wire and, using the clearly visible 10mm gradations on the drill shaft, the X-post depth is drilled to 25mm.

    This is the 8.0/9.5mm cannulated X-post reamer. It is tapered to cater for the corresponding shape of the blue X-post. It is best used by hand and, in my opinion, never on power.

    The X-post reamer should be advanced to the first etched line when using a blue X-post.

    This is the IO Fix X-post (A) with the lag screw (B) seated in the X-post at the 60 degree angle. According to the manufacturers’ technical guidelines, for a Lapidus procedure, the X-post can be placed either in the medial cuneiform or the base of the first metatarsal. My preference is to get good fixation from the X-post in the proximal segment to allow the long limb of the lag screw plenty of bony hold in the metaphysics and diaphysis of the first metatarsal.

    This is the blue X-post. The triangular arrow (A) should line up with the black line (B) on the rim of the X-post. It is important to maintain this relationship between the hex driver and the X-post at all times because once the rim of the post becomes buried in the bone, it is this constant alignment that allows you to know the rotational orientation of the rim of the post.
    Later on in the procedure, the two oblique holes in the hex driver [C] reveal their significance.

    The X-post is introduced over the guide wire following reaming, maintaining the alignment of the black arrow on the hex driver and the black line on the X-post rim.The X-post should be seated to lie just deep to the surface of the bone. If the rim appears slightly proud on inspection, then it certainly will be fluoroscopically and this gives it less working length when applying compression.
    This view demonstrates the X-post in profile and clearly shows the 60 degree angle in its rim.

    Once the X-post is seated, it is imperative to check its alignment.This is where the two oblique holes in the hex driver, and maintaining a constant alignment of hex driver to X-post, become necessary (note that the black etching shows the rim of the X-post is pointing towards the 1TMTJ).
    By passing a 1.6mm K-wire through the oblique hole in the hex driver, the subsequent alignment of the lag screw is seen and further rotational changes can be made. This should be checked fluoroscopically, but as a general rule, if the tip of the K-wire is pointing along the axis of the first metatarsal clinically, then the alignment radiographically will not be too awry.

    The alignment of the lag screw is checked fluoroscopically using a wire in the oblique hole of the hex driver.
    This slightly oblique view shows the handle and shaft of the hex driver together with the guide wire lying in the oblique hole of the hex driver shaft (A).
    It can be clearly seen that the tip of the wire is pointing at the first metatarsal head.

    This is the 8.0mm clearing tool for the blue X-post. Note that it has a blunt ball tipped end and its cutting flutes are visible in the next slide. It has a crucial role in removing any bone or debris that could prevent the lag screw from fully engaging with the X-post. This must be done before commencing any further steps towards insertion of the lag screw.



    The clearing tool is used to remove debris from the the X-post.I like to start with the clearing tool vertically aligned along the axis of the X-post. It can clearly be seen that the tool should be used in a clockwise rotational movement.

    The clearing tool is then angled to 60 degrees with the blunt ball tip pointing through the aperture in the rim of the X-post. This clears a circle of debris away from the X-post rim.

    This is the 8.0mm tapered drill guide. The tips of the taper on either end of this guide are designed to fit snugly into the rim of the X-post at the intended angle of alignment for the lag screw. At one end (A), this allows the 1.6mm guide wired to be passed through the rim of the X-post and at the other (B), it allows the 3.4mm drill to pass over the guide wire.

    The tapered end of the drill guide is inserted into the X-post and should seat with a palpable click and remain securely in place.

    The 1.6mm wire is then inserted on power through the tapered drill guide until the far cortex of the plantar aspect of the base of the first metatarsal is breached.

    The lag screw guide wire position is checked fluoroscopically and the wire measured to determine lag screw length.The guide wire position is checked fluoroscopically. Note the X-post in situ together with the tapered drill guide and the guide wire protruding through the plantar cortex of the base of the first metatarsal by about 5mm.
    The tapered drill guide can be removed and, at this point, a cannulated measure can be used to ascertain the lag screw depth.

    The ends of the tapered drill guide are then switched and the wider end placed so that it locks into the taper.

    The cannulated drill is used to create a path for the lag screwThe path of the lag screw can then be drilled using the 3.4mm cannulated drill.

    This is the lag screw loaded into the hex driver.

    The lag screw is then inserted over the guide wire using finger tightening alone and with firm counter pressure exerted across the arthrodesis from the other hand.The head of the screw should seat snugly into the rim of the X-post. Note the good compression achieved – the joint lies on a line between points A and B .
    It is important that any temporary fixation wires are removed prior to this to prevent them splinting the arthrodesis site apart.
    Note that the implant may work less well in osteopenia where it can easily cut out. I would always suggest the first metatarsal is manually reduced onto the medial cuneiform after preparation and the lag screw is gently applied across the joint to hold that degree of compression. In my experience, the implant needs to be used methodically in order to make it work. Because the compressive mechanism is so strong, if the surgeons relies on the lag screw to “draw” the first metatarsal onto the medial cuneiform, there is a danger of the lag screw cutting out.

    Check the position of the I.O.Fix construct fluoroscopicallyThe position of the I.O.Fix construct is checked fluoroscopically in both planes.

    The lateral view shows the amount of thread length needed to pass through the plantar cortex of the first metatarsal base.

    Operation – 3

    Simulated weight bearing to assess any further need for correctionAt this point, I assess the foot with simulated weight bearing to see if there is any further need for corrective surgery. From this photograph, I was keen for a further marginal change to the appearance of the hallux alignment. I therefore decided to perform an Akin osteotomy.

    A mid-medial approach to the proximal phalanx.I approach my Akin osteotomies through a mid-medial approach to the proximal phalanx.

    The medial surface of the proximal phalanx is exposedHaving divided the fat and exposed the medial surface of the proximal phalanx, I place a Hohmann retractor dorsally and plantarwards hooked around the phalanx. These act as a guide so that the cutting edge of the saw blade is always oscillating in a plane between the two retractors.

    Perform a medially-based, closing wedge osteotomy aiming to preserve a hinge of cortex on the lateral wall of the proximal phalanx.I quite like to minimise the chance of a limb of the staple breaching the 1MTPJ, therefore I tend to perform my osteotomy immediately distal to the flare of the metaphysis as the bone becomes diaphyseal. I make a saw cut proximally and use the depth markers on the saw blade to judge the depth of the cut. In the metaphysis, this is about 16mm. The saw gives the surgeon palpable feedback as to where the lateral cortex of the proximal phalanx lies. Once that has been felt, withdraw the saw blade. A second saw cut is then made about 2-3mm distal to the original saw cut, aiming for the same area of lateral cortex. Relying on that feel from the saw blade, the wedge of bone can be removed. The flexor and extensor tendons are protected from being injured by the saw blade by the Hohmann retractors .

    Prepare the staple fixation by drilling pilot holes with a 1.1 K-wireHaving removed the wedge of bone and closed the osteotomy on its hinge, I use a 1.1mm K-wire to drill a pilot hole to accommodate an 8mm straight (90 degree) staple.

    Having inked the staple, I can then mark the point for a second pilot hole, drill it and pass the staple to secure the osteotomy.
    The deep layers and skin are closed before applying dressings and a below-the-knee temporary cast

    Final fluoroscopic images are taken to assess the reconstruction before closure in anatomic layers with 2/0 vicryl and 3/0 monocryl to the skin.
    Jelonet dressings are then applied followed by orthopaedic wool and two plaster of Paris slabs held in place with a crepe bandage.

    Post Operative

    The patient is placed in a below the knee back slab for the first two weeks after surgery. At two weeks, the wounds are inspected and re-dressed and a complete, lightweight below-the-knee cast is applied for a further four weeks. Weight bearing is not permitted for the first six weeks after surgery and in my practice, rivaroxaban is prescribed for this duration to prevent thrombo-embolic events.
    At six weeks, the patient can commence weight bearing in a walker boot which can be removed for sleeping. Basic ankle range of motion exercises are encouraged.
    At twelve weeks, the foot is assessed radiographically with standing views in three planes before abandoning further immobilisation. At this stage, physiotherapy can be helpful in mobilising the ankle and hind foot joints.

    Recommended Reading

    Thompson IM, Bohay DR, Anderson JG. Fusion rate of first tarsometatarsal arthrodesis in the modified Lapidus procedure and flatfoot reconstruction. Foot Ankle Int 26: 698-703, 2005.
    In over 200 cases, this series documents a non-union rate of 4% with a fewer than this number being symptomatic from the non-union.
    Coetzee JC, Resig SC, Kuskowski M, Saleh KJ. The Lapidus procedure as salvage after failed treatment of hallux valgus. A prospective cohort study. J Bone Joint Surg. 85A: 30-36, 2003.
    In this prospective study dealing with failed hallux valgus surgery, the authors noticed negligible increase in the IMA in the 4 years after the revision procedure.
    Barp EA, Erickson JG, Smith HL, Almeida K, Millonig K. Evaluation of fixation techniques for metatarsocuneiform arthrodesis. J Foot Ankle Surgery 56(3): 468-473, 2017.
    This single surgeon retrospective review was designed to see which fixation method appeared superior for a Lapidus procedure. The overall non-union rate was less than 7% with fewer being symptomatic but the crossed screw technique had a higher non-union rate compared to a plate and screw construct.

    Reference

    • orthoracle.com

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