Journal Article Presentation:

Early Weight Bearing After Modified Lapidus Arthrodesis

Dan Preece DPM PGY-2

Authors: Blitz N, Lee T, Williams K, Barkan H, DiDimenico L.

Journal of Foot and Ankle Surgery, Jul/Aug 2010.

Early Weight Bearing After Modified Lapidus Arthrodesis: A Multicenter Review of 80 Cases.

Study Type: Retrospective, multicenter review of 80 patients. (80 feet in 76 pts)

Study Question: Effects of early weightbearing on fusion rates following arthrodesis of 1st met-cuneiform joint.

Early Weight Bearing After Modified Lapidus Arthrodesis

Intro: Early studies used fixation of cat gut or a single screw which showed high levels of nonunions. 6 weeks of NWB became standard of care. However non of these studies were based on today’s fixation techniques.

Limited data has shown that early weight bearing yields very low percentages of non unions with current screw fixation techniques.

◦ 76 patients, 80 feet from 2002-2007.

◦ Surgeries performed by two surgeons (Blitz, DiDemenico).

◦ Only surgeries that involved only the first ray were included (muscle-tendon balancing, austin, akin…).

◦ Pre and Post-Op radiographic angles taken (IM, Hallux Valgus angle, lateral metatarsal angle)

◦ Outcomes measured were: trabeculation across osteotomy, pain at surgical site on clinical exam.

Methods:

◦ Fixation: Majority solid screws x 3, 11 pts only received 2

screws, 1 pt received 4.

Two screws in sagital plane perpendicular to osteotomy and lagged.

Third screw medial to lateral across 1-2nd met bases or into intermediate phalanx and not lagged.

◦

Methods continued:

◦ NWB in Jones dressing/splint or Cam walker x 2-3 weeks.

◦ After 1st post-op visit all placed in CAM walker, progression to full WB as tolerated.

◦ All pts were fully WB by 6 week visit.

Post-Op Protocol:

Pre-Op HVA: 21 Post-Op HVA: 9

Pre-Op IMA: 13 Post-Op IMA: 6.6

Pre-Op LMA: 21.45 Post-Op LMA: 25.8

Days to partial WB: 15 Days to radiographic union: 44.5 Union Percentage: 100%

** all P values were .001 or smaller

Measures:

Joint preparation approach made no difference. Curretage vs planar resection with sagittal saw. Presence or absence of subchondral plate.

2 vs 3 screw fixation had same outcomes.

Autogenous bone graft was used in all cases, either trephine or from exostectomy. No difference.

Obesity and smoking made no difference.

Discussion:

Data gathering stopped at time of clinical/radiographic fusion. This does not rule out the possibility of a non-union during the course of healing/rehab.

Unclear when weightbearing truly began between the 2nd and 6th week marks. Was advanced as tolerated. Possible that WB only began at week 5 and 6.

Criticisms: