In response to some of the rather strong views
supporting a Lapidus in this case, I’m concerned
there may be a tendency for people to be thrown
under the bus every time they get caught doing a
procedure that’s not right out of the textbook.
The textbook would probably say do a Lapidus.
There’s no argument it's the ultimate in
achieving correction that’s going to stay. But
in some cases, textbook and podiatric dogma need
to be abandoned in favor what happens in the
real world.
If 1st MTPJ fusions are not capable of reducing
1st IM angles because only proximal osteotomies
or Lapidus can accomplish that, I say that’s
only true in the textbooks. It is absolutely NOT
true that significant IM angle reduction can’t
be done by fusing the 1st MTPJ (see
illustration). Furthermore when the 1st I-M
angle is increased due to hypermobility, there
should even a better response to an MTP fusion
than if the deformity were rigid. Also, why is
it written stone that fusing the 1st MTPJ
significantly limits activity? I have not seen
that happen…in the real world.
Dr. Mullen focused on “active” as the key word.
How ‘bout “65+”? Active in a 65+ year old isn’t
the same as active in a 30 year old. And the
comment about differences in bone healing
capability shouldn’t apply to this argument,
since the same factors apply equally to fusing
either the MTP or MC joint. But let’s consider
65+ y/o vs. 30 y/o in terms of post-op
morbidity. I think most would agree that Lapidus
is much less forgiving than 1st MTP fusion in
terms of mishaps with weight bearing in the post-
op period. It’s more difficult to have a 65 year
old comply with 6 weeks NWB. Also there's a
huge shopping list of possible complications to
a Lapidus, compared to a distal fusion.
Finally, if as Dr. Mullen states, this case begs
the question “…why fuse a relatively healthy
joint, especially in an active individual?”, I
would ask "What do you think you’re doing to
the Met-cuneiform joint when you do a Lapidus?"
Carl Solomon, DPM, Dallas, TX, cdsol@swbell.net
