Lapidus and Proximal metatarsal osteotomies (Surgery)

Question 1

What are the indications for Proximal metatarsal osteotomies?

Answer 1

1. Large intermetatarsal angle
2. Juvenile HAV
3. Hypermobility of the first ray

Question 2

What are different procedure for Proximal metatarsal osteotomies?

Answer 2

1. Closing base wedge osteotomy (CBWO)
2. Opening base wedge osteotomy (OBWO)
3. Crescentic osteotomy
4. Proximal Chevron ostetomy
5. Lapidus osteotomy

Question 3

What’s the technique involved in closed base wedged osteotomy?

Answer 3

1. Axis guide placement
2. Osteotomy
3. Internal fixation
4. Lateral release
5. Medial eminence resection

Question 4

Entry point:

1. what is the distance of entry point from the medical cortex?
2. what is the distance of entry point from the MCJ?

Answer 4

1. 5 mm
2. 1.5 cm

Question 5

It is best to try to keep the osteotomy 1? to the weightbearing surface when performing CBW osteotomy

But if dorsiflexion of the distal segment is desired, then a 2? is created

If plantarlfexion of the distal segment is desired, then a 3? is created

Answer 5

1. perpendicular
2. plantar medial corticol hinge
3. dorsal medial corticol hinge

Question 6

What are some of the complications with CBW osteotomy?

1?

a

b

2?

a

b

Answer 6

1. Osteotomy Entering 1st MCJ
   (a) Osteotomy too oblique
   (b) Apex too lateral
2. Osteotomy too Distal (midshaft)
   (a) Delayed Healing
   (b) Less IMA correction

Question 7

What fixation would you use for the CBW osteotomy?

Two screws

1?

2?

Anchor screw placed 3?

Lag screw placed perpendicular to

Answer 7

1. One cortical screw as an anchor
2. One cancellous as a lag screw
3. perpendicular to shaft

• Upper right quadrant from lateral view
• Protects cortical hinge

4. osteotomy

• Lower left quadrant from lateral view
• Provides compression

Question 8

What do you do for Lateral release/Medial eminence of CBW osteotomy?

1. Perform ?
2. Perform?
3. Resect?

Less aggressive than with distal osteotomies

Usually parallel to the shaft

Answer 8

1. lateral release first, prior to osteotomy
2. osteotomy
3. medial eminence last

Question 9

Some facts about CWBO:

1. IMA angle

Learning Curve

NWB postop 2?

Anatomically 3? correction

Answer 9

2. Higher IMA’s and juvenile HAV
3. 6-8 weeks
4. better

Question 10

Crescentic osteotomy:

using: 1?

Main complication: 2?

What kind of osteotomy 3?

Answer 10

1. Crescentic saw
2. Dorsiflexion of the distal fragment
3. Curved osteotomy of the base of the met head

Question 11

Crescentic Osteotomy

Proximal crescentic osteotomy. Diagram of the osteotomy

site. The surgeon’s hand is pushing the metatarsal shaft in a

lateral direction. The Freer elevator is pushing the metatarsal

base in a medial direction. Note the 2–3 mm overhang on the

lateral aspect of the osteotomy site (From Mann and Mann.8

Used with permission)

Answer 11

Question 12

What are the Advantages/Disadvantages of Cresentic procedure?

1?

2?

3?

4?

Answer 12

1. Good if first ray relatively short
2. Good IM correction Level 2 studies
3. Dorsiflexion malunions
4. Hallux varus

Question 13

Proximal Austin

Apex 2 cm 1?

Relatively 2?

Fixated with

Answer 13

1. from the TMT
2. stable/ large contact area
3. 2 screws/ plate

Question 14

What are the advantages of proximal Autsin procedure?

1?

2?

3?

Answer 14

1. Maintain length
2. less chance of dorsiflexion of the distal fragment
3. Faster healing comparing to other procedures at the base

Question 15

what is the Applications of Lapidus Procedure?

1?

2?

3?

Answer 15

1. Moderate to severe hallux valgus deformity
2. Hypermobile first ray
3. Adjunct to other pes valgus procedures

Question 16

Some facts about metatarsal cuniform joint:

1?

2?

3?

Answer 16

1. Flat joint
2. Inherently stable
3. Minimal motion (“non-essential joint”)

Question 17

What is the Lapidus procedure?

Answer 17

Removal of the metatarsal-cuniform joint. as little as possible

Important: the 1st metatarsal should be positioned in 15-20 degrees of plantarflexion otherwise the first metatarsal would be elevated.

Question 18

What are the indications for Lapidus procedure:

based on lecture notes:

1?

2?

3?

4?

5?

based on the book:

6?

7?

8?

9?

10?

Answer 18

1. Moderate to severe HAV
2. Ligamentous laxity
3. Hypermobile 1st ray
4. Elevated metatarsal
5. Intercuneiform instability
6. Severe hallux valgus
7. intermetatarsal angle>18
8. hypermobility of the 1st metatarsocuniform joint
9. HAA >25 degrees
10. degenerative disease of the metatarsocuniform articulation

Question 19

What is Lapidus procedure?

Answer 19

Basically Arthrodesis of the first metatarsocuniform joint

Question 20

What are the contraindications for Lapidus procedure?

1?

2?

3?

Answer 20

1. Short 1st metatarsal
2. Poor bone stock
3. Patient factors

Question 21

Where do you incise for the Lapidus procedure?

1?

2?

Answer 21

1. Direct medial
2. Dorsal medial

Question 22

Where do yo position for fusion?

1?

2?

Answer 22

1. Plantarflexion of joint motion
2. Plantar translocation of metatarsal

Question 23

What are the considerations for Lapidus procedure?

1?

2?

3?

4?

5?

Answer 23

1. Intermetatarsal angle
2. First metatarsal-cuneiform joint architecture
3. 1st metatarsal length
4. Bone quality
5. Pt. factors

Question 24

What are the post-operative management for Lapidus?

1?

2?

3?

4?

Answer 24

1. Jones dressing 1 week
2. Non-weight bearing SLC x 6-8 weeks
3. Removable cast brace x 4 weeks with progressive increase in weight
4. Return to regular shoes 10-12 weeks

Question 25

What are the benefits of Lapidus?

1?

2?

3?

4?

Answer 25

1. Correction of large deformities
2. Decreased risk of recurrence
3. Increased medial column stability
4. Decreased risk of complications