Alicia Williams, DPM
June 9,2010
Dr.Anain Jr-Director
Dr.DiDomenico-Mentor
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Tendons inserting on the first ray:
◦ Tibialis Anterior-inserts on the medial cuneiform
and base of the first metatarsal
◦ Peroneus Longus-inserts on the first metatarsal
◦ Flexor Hallucis Brevis-divides into 2 muscle bellies
-encase the sesamoids
-inserts on the base of
proximal phalanx
◦ Abductor Hallucis-inserts medially on base of
proximal phalanx
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No muscles originate on the first met
The first metatarsal is held in alignment, by
splinting action of the abductor hallucis
medially and pull of the peroneus muscle
laterally acting on base of the metatarsal
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The hallux deviates inward toward the lesser
toes(valgus)
A bump starts to develop on the medial
aspect of the metatarsal
The prominence is known as the bunion
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“bunion” a structual deformity of the bones
and joint of the first metatarsal
May often present with a bursa (sac of fluid)
between tendons and bone or even skin and
bone and often painful with palpation
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In the gait cycle stance phase begins with
heel contact lateral to the ankle joint and
ends in the support phase in which our body
weight is centered near the first metatarsal
Shock absorption
Distributing plantar pressure to the heel and
heads of the metatarsals
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Mobile first ray will dorsiflex on weight
acceptance to prevent trauma to the head of
the first metatarsal
Limited dorsal mobility will cause an increase
of plantar pressure resulting callus build up
and eventually ulceration
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(HA)-created by the bissection of the
longitudinal axis of the hallux and
longitudinal axis of the first met
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Normal is less the 15°
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Greater than 15 degrees considered abnormal
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Determined by the bisection of the
longitudinal axes of the first and second
metatarsal
Less than 9° is considered normal
Often used to determine surgical correction
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Comparison of the 1st and 2nd relative
metatarsal length
Determined by the measurement between the
two arcs that represent the 1st and 2nd
lengths
Normal is + 2
+ if 1st metatarsal is longer than the second
- if 2nd metatarsal is longer than the first
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Conservative: changing footwear(wide
toebox, good arch support), antiinflammatory meds, padding
Surgical: various techniques which include
osteotomies in the head of metatarsal, base
ostetomy, fusion of met-cuneiform joint
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Austin
bunionectomy
◦ Head osteotomy
◦ Creating a “V” shaped
osteotomy in the
head of the
metatarsal
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Closing Base Wedge
Osteotomy
◦ Osteotomy created in
base of metatarsal
◦ Wedge of bone is
removed
◦ Achieve reduction of
intermetatarsal angle
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Open Wedge
Osteotomy
◦ Short metatarsal
◦ Osteotomy is created
in the proximal shaft
of the first metatarsa
◦ Bone graft inserted to
increase the length of
the metatarsal
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Lapidus Bunionectomy
◦ Hypermobility of the
first ray
◦ Intermetatarsal angle
greater than 18°
◦ Fusion of the first
metatarso-cuneiform
joint
Modified Lapidus Procedure
(Retrospective Chart Review)
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To determine if the absence of the lateral
release(step #2) obtain correction in
comparison with the true lapidus procedure
All results were based on the following:
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Intermetatarsal angle
Hallux abductus angle
Metatasal protrusion distance
Sesamoid position
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A retrospective Chart review of 100 patients
that underwent modified Lapidus
bunionectomy procedure from 2002 to 2007
Inclusion criteria-healthy patients, no
previous surgical intervention
Exclusion criteris-previous surgical
intervention, previous infections, decrease in
bone density
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Age varied between all the patients
Pre op xrays were taken which assessed the
1st intermetatarsal angle, met protrusion
angle and the relationship of the hallux to the
remaining metatarsals
F/u visits consisted of imaging to assess
progression, alignment and sesamoid
position
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Patients were seen 3, 6, and 12months
Measurements of angles were also used to
determine the amount of correction
Also we assessed the level of shortening that
occurred with surgical correction
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Patient in supine position
Thigh tourniquet was used
Foot was prepped
Tourniquet set at
250mmHg
Dorsomedial 7cm incision
over 1st met &
metcuneiform joint
Dissection down to the level
of bone avoiding
neurovascular structures
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Resect medial eminence
Cartilage removed from
base of 1st met
A wedge of bone was
resected from medial
cuneiform
Used a dril to create holes
in bone to allow bleeding
Reduced w/ kwire
PF the metatarsal
Fixate with internal fixation
Remove kwire
Skin closure
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Was used to assessment the level of pain if
any or any complications
Complications included, infection, transfer
lesions, or reoccurence, wound dehisence
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Both IM and met protrusion angle were affected in
all patients
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Reduction in HAA in compared to pre op imaging
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Some patients acquired more shortening than other
patients
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Reduction of the IM angle compared to pre op
values
Two patients complained of severe pain following
surgical procedure
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No evidence of bone infection, transfer lesions or
OA on radiographs
Little change in sesamoid positioning in
comparison with pre op radiographs
Two pts were not seen for the 3month and 12
month f/u
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Two patients were not seen for any f/u
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16 pts did not f/u for 12month visit
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Pre op IM angle was 17.45°
Post op IM angles was 11.97°
Pre op HAA was 16.1°
Post op HAA was 13.9°
Met protrusion pre & post op had shortening
of the first met. Significant shortening post
op
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The purpose of this study was to evaluate the
whether a good amount of correction was
achieved once eliminating step #2(release of
the ligament)in the Lapidus procedure
Results did show there was a reduction in the
intermetarsal angle, with little change in the
sesamoid position
Shortening did occur in some of the patients,
however asymptomatic and patients returned
to daily activities
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Patients that did not f/u for visits were eventually
removed from the study
In conclusion the modified Lapidus bunionectomy
achieve similar results in correction of bunion
deformity compared with the true Lapidus.
Has been reported that when fusing the metatarsalcuneiform joint, the soft tissue in is no longer the
deforming force.
Fusing the joint in its correct anatomical position
A great procedure for bunion correction