Foot and ankle surgeons – sleep better at night. Complete your Lapidus construct with a Carbon Fiber Spring Plate to insure rigid support with early ambulation
Lapidus bunionectomy (also called Lapiplasty) has become very popular over the past two to three years. The Lapidus procedure has a number of advantages when compared to other bunionectomies. The most significant advantage of the Lapidus procedure is decreased recurrence rate of a bunion over the course of the patient’s life. The recurrence of a bunion post bunionectomy has never been statistically defined in the literature.
What causes a bunion to come back following surgery?
The single biggest factor that contributes to recurrence of a bunion following surgery is age. Although the literature won’t back me up on the following formula, I think we can assume the following;
% chance of recurrence of a bunion post bunionectomy
= 70 – the patient’s current age
For example, if you are currently 50 years of age, according to the formula above, your percentage of chance of recurrence of a bunion post bunionectomy would be 20%. This simple formula does not account for surgical factors and co-morbidities such as the patient’s health history, success of correction at time of surgery and a number of other factors that can influence the outcome of the surgery. But as a general rule, this is an easy formula to discuss how age will affect the recurrence of a bunion post bunionectomy.
What is a Lapidus bunionectomy and how does it compare to other bunionectomy procedures?
The Lapidus procedure originally described by Paul Lapidus, MD in 1960 (1), has been a part of every foot surgeons tool set for years. Until recently, many foot surgeons have used the Lapidus technique sparingly due to post op disability associated with the procedure. The Lapidus procedure is a fusion of the base of the first metatarsal, correcting the alignment of the first metatarsal and great toe. Many of the more commonly used bunionectomies focus on correction of the deformity by a distal first metatarsal osteotomy. The distal metatarsal bunionectomy procedures such as the Austin, McBride, Mitchell and Chevron, realign the bunion with a technique that allows the patient to bear weight, often immediately following surgery. The Lapidus, on the other hand, requires non-weight bearing until the fusion site has healed. The return to weight bearing following Lapidus has been significantly improved fixation with newer, more contemporary fixations techniques.
When can a patient who has had a Lapidus bunionectomy return to weight bearing?
The topic of return to weight bearing following Lapidus bunionectomy varies from surgeon to surgeon. In my practice, I follow this schedule to return patients to weight bearing post Lapidus bunionectomy.
3 weeks post op
50% weight bearing in a cam walker with crutches
4 weeks post op
75% weight bearing in a cam walker with crutches
6 weeks post op
Laced shoe with Carbon Fiber Spring Plate and 90% weight bearing and continued use of crutches
8 weeks post op
Laced shoe with Carbon Fiber Spring Plate, no crutches with full weight bearing
Return to weight bearing following a Lapidus bunionectomy is to a great degree based on the individual patient’s response to weight bearing. Return to weight bearing needs to be incremental, judging the response each day and with each new weight bearing activity. Each increase in activity is monitored for any indication of problems at the Lapidus fusion site. Signs of increased pain, clicking/popping and localized swelling are signs that the fusion site is just not quite ready for weight bearing. In these cases, weight bearing is delayed.
Challenges to early return to weight bearing post Lapidus bunionectomy – what your surgeon is thinking
As we discussed earlier, the Lapidus bunionectomy is a fusion of the base of the 1st metatarsal and the medial cuneiform bone. The success of the fusion is to a great degree dependent upon the proximity of the bones at time of fixation, preparation of the fusion site during surgery and long term stability provided by the fixation used during surgery. Most Lapidus procedures a performed from the top (dorsal) aspect of the foot. The dorsal approach provides good visualization of the fusion site and adequate room for fixation. Dorsal fixation is only reliable until the patient begins weight bearing. In this image, you can see how load bearing of the fusion site that is fixated with dorsal fixation leads to gapping of the bottom or plantar aspect of the fusion. Common sense would say; why don’t you use fixation on the bottom of the fusion site to support the site in weight bearing. Unfortunately, the bottom of the arch is filled with vital structures (tendon, nerves and arteries) that cannot be disrupted during surgery to place plantar fixation.
Lapidus bunionectomy – what keeps your surgeon awake at night
Herein lies the surgeon’s quandary with the Lapidus bunionectomy and early return to weight bearing;
- I know my fixation technique is adequate but not great
- I know my fixation and construct is stable in non-weight bearing but weak in weight bearing
- I know my patient would like to ambulate as soon as possible
- I know if I get a non-union at this surgery site, I’ll have a long healing period with an upset patient
The solution to each of these post-op challenges specific to the Lapidus bunionectomy procedure, lie in the use of a simple shoe insole called a Carbon Fiber Spring Plate. Carbon Fiber Spring Plates are extremely thin and rigid. Carbon Fiber Spring Plates are thin enough to fit into all shoes with the exception of sandals or flip-flops. In addition to their rigidity, Carbon fiber Spring Plates have toe spring, also referred to as a forefoot rocker. Let’s take a little closer look at how the rigidity and toe spring work to enable earlier return to weight bearing post Lapidus bunionectomy.
Carbon Fiber Spring Plates – rigidity and toe spring enable early post op ambulation
Are you familiar with the term ‘shank’ of the shoe? The shank on a boot or laced shoe extends from the heel to the ball of the foot. The shank of the shoe acts as a brace on the bottom of the foot. During walking, the shank is used to carry the mechanical force generated by the calf and carry that force to the ball of the foot where the mechanical action of walking takes place. When combined with a laced shoe (very important), the shank and laced shoe work in conjunction to brace the midfoot. A Carbon Fiber Spring Plate, when used in conjunction with a laced shoe, acts as a brace for patients who have undergone Lapidus bunionectomy.
- The Carbon Fiber Spring Plate is a rigid brace following Lapidus bunionectomy
The second attribute of the Carbon Fiber Spring Plate is the curvature of the plate at the ball of the foot. This curvature is called a forefoot rocker or a toe spring. Toe spring is used to decrease the amount of load applied to the forefoot and arch during gait. Think of a pair of rigid clogs – stiff but with that rocker sole. A clog is simply an example of a forefoot rocker. The Carbon Fiber Spring Plate capitalizes on the use of toe spring (forefoot rocker) to decrease load to the ball of the foot and arch with weight bearing.
- The Carbon Fiber Spring Plate decreases load to the fusion site following Lapidus bunionectomy
Carbon Fiber Spring Plate – how your surgeon gets a better night’s sleep
Early return to weight bearing following a Lapidus bunionectomy isn’t a perfect science. Walking casts (also called cam walkers) are notoriously flat on the inside and provide no support to the arch. In the first several weeks following a Lapidus bunionectomy, I think there is a place for a walking cast, particularly during the early, limited weight bearing stage. Although an oxymoron, the walking cast is a reminder to the Lapidus patient not to bear weight. But from a functional standpoint, the walking cast provider little support and can actually contribute to stress and distraction (separation) on the bottom (plantar) aspect of the fusion site.
What kind of laced shoe works best with a Carbon Fiber Spring Plate?
In contrast to the walking cast, use of a Carbon Fiber Spring Plate with a laced shoe (very important) provides rigid support to the fusion site while toe spring off-loads the fusion. What kind of laced shoe is best to be used with the Spring Plate? A good quality name brand tennis shoe or casual walking shoe will do. I can’t stress the importance enough that the efficacy of the Carbon Fiber Spring Plate in conjunction with the use of a laced shoe is really what creates the brace needed to support the Lapidus bunion fusion site. To stress this point, I tell my patients that the use of a laced shoe and Carbon Fiber Spring Plate create a Spring Plate Brace.
As a surgeon who performs the Lapidus bunionectomy, I love to sleep well at night. The concept of the Spring Plate Brace is what motivated me to do more Lapidus bunionectomies. Now that I know that I can ambulate my patients earlier, the use of the Lapidus procedure makes even more sense than in years gone by. Early ambulation with confidence post Lapidus bunionectomy – now I can sleep like a baby.
Join me for more discussion regarding Lapidus bunionectomy.