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3/1/2016 Lapidus for Hallux Valgus
http://www.aofas.org/footcaremd/treatments/Pages/LapidusforHalluxValgus.aspx?PF=1 1/2
Lapidus for Hallux Valgus
Top and side views of the first metatarsal andmedial cuneiform bones (circled in red) that
make up the first TMT joint.
What is hallux valgus?Hallux valgus is the medical term for a bunion. The first tarsalmetatarsal (TMT) joint is an important joint at the inner part of the middle of the foot.The two bones that meet to form this joint are the first metatarsal and medial cuneiform bones. Whenthis joint has too much looseness or movement, the condition is known as hypermobility or instability.When this joint becomes hypermobile, the first metatarsal moves too much in one direction and thefirst toe compensates by moving too much in the other direction. When this happens, a buniondevelops. What is the Lapidus procedure? The Lapidus procedure is a type of fusion of the first TMT joint that decreases the movement of thatjoint and straightens out the first metatarsal and toe. So the Lapidus procedure treats bunionscaused by first TMT joint hypermobility. What is the goal of the Lapidus procedure?The goal of the Lapidus procedure is to surgically treat hallux valgus that is caused by first TMT jointhypermobility. An orthopaedic foot and ankle surgeon realigns to a normal toe shape by placing thefirst metatarsal straight with the medial cuneiform bone and locking or fusing these two bonestogether. When the first TMT joint is fused, the first metatarsal will not move abnormally. This willallow the first toe to stay straight and prevent the bunion from coming back. What signs indicate surgery might be necessary?Indications for the Lapidus procedure may include:
1. Pain at the bunion. Patients with a painful bunion have a bump on their big toe joint.Typically this bump causes pain when it rubs the inside of a shoe.2. Pain and/or hypermobility at the first TMT joint.3. Difficulties wearing shoes. When patients have a severe enough bunion due to first TMTjoint hypermobility, the foot can be so wide that it is difficult to find shoes that fit.4. Pain that does not improve with nonsurgical treatments such as wearing widetoe shoes.
When should I avoid surgery?Surgery should be avoided for the following reasons:
1. If you have no pain from your bunion and/or your first TMT joint hypermobility. 2. If your bunion is not due to first TMT joint hypermobility. While your bunion could still receive a surgical correction, the procedure would not be a Lapidus If your bunion is not due to first TMT joint hypermobility.3. If you have any signs or symptoms of a bone or skin infection. Performing foot surgery when you have a foot infection can make the infection worse.4. If you have poor circulation in your foot. Performing foot surgery when you have poor foot circulation can lead to problems with surgical wound healing.
General Details of ProcedureTypically, the Lapidus procedure is done on an outpatient basis. This means that the patient arrives one to two hours before the surgery time andgoes home the same day.
The patient is routinely put to sleep with anesthesia to provide enough pain relief, relaxation and comfort during the surgery. In addition to theanesthetic, a nerve block may be offered to the patient to make his/her operative foot and ankle numb and give pain relief for several hours aftersurgery.
Typically, a single incision along the top or medial side of the foot is used to expose the first TMT joint. Once the joint is identified, the cartilage thatlines this joint is removed and the bones are positioned and held straight with screws and/or a plate. Specific TechniquesThe Lapidus procedure starts once the patient is asleep from anesthesia. After an incision is made, the nerves and tendons that lie under the skinare protected from injury. The first TMT joint is identified, exposed and then straightened out. Usually, thetop of the joint is worn down or degenerated while the bottom part of the joint is less affected. It isimportant to remove all of the cartilage from the joint to allow the bones to heal together.
After all of the cartilage is removed, the bones are straightened out. To maximize the success of the bonesfusing together and straight, the surgeon uses screws running across or plates and screws along the sideof the joint for internal support.
After positioning the first metatarsal and medial cuneiform bones straight with proper placement of
3/1/2016 Lapidus for Hallux Valgus
http://www.aofas.org/footcaremd/treatments/Pages/LapidusforHalluxValgus.aspx?PF=1 2/2
Xray showing two screws placed across thefirst TMT joint in opposite directions. Notethat the joint line is not visible, which means
that the joint has fused.
Cavus Foot SurgeryFifth Metatarsal Fracture SurgeryFlatfoot Surgical CorrectionFlexor Digitorum Longus (FDL) Tendon Transfer to Posterior Tibial TendonFoot Drop Treatment (Tendon Transfer)Foot Fracture SurgeryLesser Metatarsal Shortening OsteotomyLisfranc SurgeryMidfoot FusionNaviculocuneiform FusionPosterior Tibial Tendon Transfer to the Dorsum of the FootSecond Metatarsal Shortening OsteotomyTriple Arthrodesis
hardware, some surgeons may add bone graft (from the patient or a cadaver donor) at the first TMT jointfusion site to further help the Lapidus procedure to heal. The incision is closed in layers with stitches orstaples. The patient is then placed into a wellpadded dressing and either a splint or surgical shoe. What happens after surgery?Immediately after surgery, patients need to keep dressings clean, dry and untouched. The first two weeksafter surgery are usually spent with the patient’s foot elevated to help decrease swelling. Within the firstmonth of surgery, the patient’s stitches/staples are removed. With these removed, the patient is thenplaced into a cast, boot or surgical shoe and remains nonweightbearing for another few weeks.
At the next appointment, the patient will receive foot Xrays to check on the healing of the first TMT jointfusion. So long as the bones are healing, patients are allowed to advance their weight bearing. Once thefirst TMT joint is fully healed, patients can wean out of their boot or shoe and return to their previous levelof activity. Physical therapy may be recommended to improve foot and ankle strength and range of motion.
Some residual swelling and discomfort is normal up to a year after surgery. Most patients are able toreturn to normal activities with minimal pain and/or problems by four to six months after the surgery. Potential ComplicationsThere are complications that relate to surgery in general. These include the risks associated with anesthesia, infection, damage to nerves andblood vessels, and bleeding or blood clots.
Complications from the Lapidus procedure can include wound problems and slow healing of the first TMT joint fusion. While these complicationsare rare, they can occur more often in patients with diabetes and in those who smoke. Frequently Asked QuestionsBy making the bones grow together, does that affect my ability to walk or run?A successful Lapidus procedure should allow patients to walk or run with minimal problems or pain once they are fully recovered from the surgery.
Why do I need to be nonweightbearing for so long?Patients are asked to limit their weight bearing for several weeks in order to prevent movement between the first metatarsal and medial cuneiformbones that are trying to fuse together. If there is too much motion between the bones, it can take longer for them to heal. Typically, bones take afew months to heal, so patients must limit weight bearing during that time.
What if my bones do not heal together? When bones do not heal together the condition is called a nonunion. Patients who are diabetic or smoke are at higher risk for having this problem.This can also happen if patients put too much weight on the foot before the bones have a chance to fuse together. The most common symptom ofa nonunion is continued pain after surgery. Xrays can show broken plates or screws that suggest that there is still movement at the fused joint,which is a sign of poor healing. Most nonunions need further surgery to achieve healing. This can involve more orthopaedic hardware (plates andscrews) and/or some form of bone graft to help the bones heal.
The American Orthopaedic Foot & Ankle Society (AOFAS) offers information on this site as an educational service. The content of FootCareMD, including text, images and graphics, is forinformational purposes only. The content is not intended to substitute for professional medical advice, diagnoses or treatments. If you need medical advice, use the "Find an Orthopaedic Foot &Ankle Surgeon" tool at the top of this page or contact your primary doctor.
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