HAV 3

• Christina Pratt, DPM presents Podiatric Surgery II (PM791) HAV: Part III

Lapidus Procedure

• Is also known as Lapidus arthrodesis
• It is also known as 1st Tarsometatarsal joint (TMTJ) arthrodesis and 1st Metatarsocuneiform joint (MCJ) arthrodesis
• Arthroplasty is the resection/resurfacing of a joint, sometimes with an implant for joint salvage
• Arthrodesis is the fusion of a joint, which is joint destructive
• Is a technique to perform a Lapidus, not a separate procedure
• Includes 1st TMTJ arthrodesis, medial eminence resection, and soft tissue/capsular balancing
• Consider it for patients with hypermobility

Hypermobility Signs

• Excessive motion, significantly higher than the 2nd met head (Root test)
• Pain with motion, exostoses around the joint
• Callus under lesser met heads and elevation of 1st met during weight bearing
• XR shows joint space narrowing at MPJ, proximal sesamoid migration
• Total 1st Ray sagittal plane ROM (Roling, 2002):
  • 1st MC joint = 41%
  • NC joint = 50%
  • TN joint = 9%
• The Lapidus procedure stabilizes unstable foot types and is powerful
• Recurrence (esp in JHAV), metatarsalgia may occur if hypermobility goes unaddressed
• Lesser metatarsal stress fractures or lesser digital contractures may arise if no hypermobility

Lapidus Plane

• Sagittal: results in "plantarflexion attitude", increased medial arch, decreased pronation
• Transverse: leads to correction of IMA and HAA, but hypermobility lessens the efficiency of PL
• Frontal: used for correction of valgus or can rotate the entire first met into position

Lapidus Indications

• Large IMA
• Instability of 1st ray, ligamentous laxity or flexible flatfoot
• Stabilizes the medial column, for metatarsus elevatus
• Can plantarflex

CORA (Center of Rotation of Angulation)

• Osteotomy should happen at the apex of the osseous angulation
• Correction of genu valgum: Osteotomy at/near knee joint – Yes, at the apex. Osteotomy mid-tibia – No
• Correction of HAV: Apex – 1st metatarsal-cuneiform joint

Arthrodesis Procedure

• It is critical to spend operative time on Joint Preparation, Positioning and Fixation

Fixation

• K wires are used for Stabilization, No compression
• Staples are compressive
• Screws use a Traditional AO technique (Sangeorzan and Hansen). Use crossed screws for compression. It is sometimes necessary to add a 3rd screw. Options are:
  • 1st to 2nd met, medial to middle cuneiform, and 1st met to middle cuneiform
• A plate can assist in plantarflexion of 1st met
• Using an osseous wedge may be necessary if needing length (potential for shortening!) or if needing plantarflexion

Lapidus Complications and Considerations

• Shortening of metatarsal, nonunion, malunion (triplanar!), overcorrection, and undercorrection
• The typical post-op plan is 6-8 weeks NWB, or some now immediately WB
• Initially was criticized for non-union rates, up to 15% nonunion rate reported historically, poor surgical technique
• Still makes many surgeons cautious, with a Strict NWB “standard” 6-8 week protocol, with immediate WBAT boot for some

Glissane Principles of Arthrodesis (1949)

• Complete resection
• Close approximation
• Optimal position
• Maintain apposition

1st MPJ Arthrodesis

• An MPJ arthrodesis can correct a bunion
• Indications:
  • Arthritic 1st MPJ
  • HAV with intra-articular pain
  • HAV with Hallux limitus/rigidus
• Consider the deforming forces in HAV:
  • The adductor tendon, through the lateral sesamoid ligament, exacerbates valgus deformity
  • Before arthrodesis, acts on proximal phalanx alone (insertion) then after arthrodesis, it acts on a longer lever arm – proximal phalanx and 1st metatarsal

HAV Pearls

• Address multiplanar deformity when present
• Base your procedure selection on many factors, including patient-specific factors (medical co-morbidities.) clinical evaluation, HAV angles & radiographic evaluation, patient/physician expectations
• The ability to adhere to a post-op course, and indications and complications should be appreciated, and Always potential for recurrence

Future of HAV Surgery?

• MIS = Minimally Invasive Surgery (Minimal Incision Surgery) across all areas of medicine (Arthroscopy, Endoscopy, Laparoscopic, Robotic.) which is on the rise in popularity in F&A surgery.