Lapidus for Hallux Valgus

What is hallux valgus?

Hallux valgus is the medical term for a bunion. The first tarsal-metatarsal (TMT) joint is an important joint at the inner part of the
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Top and side views of the first metatarsal and medial cuneiform bones (circled in red) that make up the first TMT joint.




middle of the foot. The two bones that meet to form this joint are the first metatarsal and medial cuneiform bones. When this joint has too much looseness or movement, the condition is known as hypermobility or instability. When this joint becomes hypermobile, the first metatarsal moves too much in one direction and the first toe compensates by moving too much in the other direction. When this happens, a bunion develops.
 

What is the Lapidus procedure? 

The Lapidus procedure is a type of fusion of the first TMT joint that decreases the movement of that joint and straightens out the first metatarsal and toe. So the Lapidus procedure treats bunions caused by first TMT joint hypermobility.  
 

What is the goal of the Lapidus procedure?

The goal of the Lapidus procedure is to surgically treat hallux valgus that is caused by first TMT joint hypermobility. An orthopaedic foot and ankle surgeon realigns to a normal toe shape by placing the first metatarsal straight with the medial cuneiform bone and locking or fusing these two bones together. When the first TMT joint is fused, the first metatarsal will not move abnormally. This will allow the first toe to stay straight and prevent the bunion from coming back.
 

What signs indicate surgery might be necessary?

Indications for the Lapidus procedure may include:
1. Pain at the bunion. Patients with a painful bunion have a bump on their big toe joint. Typically this bump causes pain when it rubs the inside of a shoe.
2. Pain and/or hypermobility at the first TMT joint.
3. Difficulties wearing shoes. When patients have a severe enough bunion due to first TMT joint hypermobility, the foot can be so wide that it is difficult to find shoes that fit.
4. Pain that does not improve with nonsurgical treatments such as wearing wide-toe shoes. 
 

When should I avoid surgery?

Surgery should be avoided for the following reasons:
1. If you have no pain from your bunion and/or your first TMT joint hypermobility. 
2. If your bunion is not due to first TMT joint hypermobility. While your bunion could still receive a surgical 
    correction, the procedure would not be a Lapidus If your bunion is not due to first TMT joint hypermobility.
3. If you have any signs or symptoms of a bone or skin infection. Performing foot surgery when you have a foot
    infection can make the infection worse.
4. If you have poor circulation in your foot. Performing foot surgery when you have poor foot circulation can lead to
    problems with surgical wound healing.
 

General Details of Procedure

Typically, the Lapidus procedure is done on an outpatient basis. This means that the patient arrives one to two hours before the surgery time and goes home the same day.

The patient is routinely put to sleep with anesthesia to provide enough pain relief, relaxation and comfort during the surgery. In addition to the anesthetic, a nerve block may be offered to the patient to make his/her operative foot and ankle numb and give pain relief for several hours after surgery.

Typically, a single incision along the top or medial side of the foot is used to expose the first TMT joint. Once the joint is identified, the cartilage that lines this joint is removed and the bones are positioned and held straight with screws and/or a plate.
 

Specific Techniques

The Lapidus procedure starts once the patient is asleep from anesthesia. After an incision is made, the nerves and tendons
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X-ray showing two screws placed across the first TMT joint in opposite directions.  Note that the joint line is not visible​, which means that the joint has fused.​
  that lie under the skin are protected from injury. The first TMT joint is identified, exposed and then straightened out.  Usually, the top of the joint is worn down or degenerated while the bottom part of the joint is less affected. It is important to remove all of the cartilage from the joint to allow the bones to heal together.

After all of the cartilage is removed, the bones are straightened out. To maximize the success of the bones fusing together and straight, the surgeon uses screws running across or plates and screws along the side of the joint for internal support.

After positioning the first metatarsal and medial cuneiform bones straight with proper placement of hardware, some surgeons may add bone graft (from the patient or a cadaver donor) at the first TMT joint fusion site to further help the Lapidus procedure to heal. The incision is closed in layers with stitches or staples.  The patient is then placed into a well-padded dressing and either a splint or surgical shoe.
 

What happens after surgery?

Immediately after surgery, patients need to keep dressings clean, dry and untouched. The first two weeks after surgery are usually spent with the patient’s foot elevated to help decrease swelling. Within the first month of surgery, the patient’s stitches/staples are removed. With these removed, the patient is then placed into a cast, boot or surgical shoe and remains non-weight-bearing for another few weeks.

At the next appointment, the patient will receive foot X-rays to check on the healing of the first TMT joint fusion. So long as the bones are healing, patients are allowed to advance their weight bearing. Once the first TMT joint is fully healed, patients can wean out of their boot or shoe and return to their previous level of activity. Physical therapy may be recommended to improve foot and ankle strength and range of motion.

Some residual swelling and discomfort is normal up to a year after surgery.  Most patients are able to return to normal activities with minimal pain and/or problems by four to six months after the surgery.      
 

Potential Complications

There are complications that relate to surgery in general. These include the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.

Complications from the Lapidus procedure can include wound problems and slow healing of the first TMT joint fusion. While these complications are rare, they can occur more often in patients with diabetes and in those who smoke.
 

Frequently Asked Questions

By making the bones grow together, does that affect my ability to walk or run?
A successful Lapidus procedure should allow patients to walk or run with minimal problems or pain once they are fully recovered from the surgery.

Why do I need to be non-weight-bearing for so long?
Patients are asked to limit their weight bearing for several weeks in order to prevent movement between the first metatarsal and medial cuneiform bones that are trying to fuse together. If there is too much motion between the bones, it can take longer for them to heal. Typically, bones take a few months to heal, so patients must limit weight bearing during that time.

What if my bones do not heal together?
When bones do not heal together the condition is called a nonunion. Patients who are diabetic or smoke are at higher risk for having this problem. This can also happen if patients put too much weight on the foot before the bones have a chance to fuse together. The most common symptom of a nonunion is continued pain after surgery. X-rays can show broken plates or screws that suggest that there is still movement at the fused joint, which is a sign of poor healing. Most nonunions need further surgery to achieve healing. This can involve more orthopaedic hardware (plates and screws) and/or some form of bone graft to help the bones heal.

The American Orthopaedic Foot & Ankle Society (AOFAS) offers information on this site as an educational service. The content of FootCareMD, including text, images and graphics, is for informational purposes only. The content is not intended to substitute for professional medical advice, diagnoses or treatments. If you need medical advice, use the "Find an Orthopaedic Foot & Ankle Surgeon" tool at the top of this page or contact your primary doctor.​​​