03/07/2019    Allen Jacobs, DPM

IM Angle Correction Through Austin Bunionectomy (Thomas Graziani, DPM. MD)

Dr. Graziano, with reference to distal
metaphysical osteotomy, suggests that we are
deforming a normal bone to correct a deformity. Do
we not do the same when we perform a calcaneal
osteotomy for correction of a pronation deformity?
Or resect bone in performing a digital
arthroplasty? Or a “cheater Akin “? There are many
theoretical benefits to the Lapidus procedure. But
the theoretical is not always practical.

Recently, I followed a local 3 year residency
trained “foot and ankle” surgeon in the OR. The
pre-op and post-op films were still up on the
screen. Literally, the only difference was the
hardware used for the Lapidus. Not one degree of
IM correction. As a case reviewer for the ABFAS,
and from my other experience, I can tell you that
many Lapidus procedures are poorly executed, with
little correction, excessive elevation,
shortening, non-union, hardware associated
symptomatology not at all uncommon. The incidence
of these problems is reported at a much greater
rate than with distal metaphysical osteotomy.
There may also be considerable increased cost
($6000-$8000) when the Lapidus procedure is
performed utilizing some aiming, plate, and screw
systems.

Here in St. Louis, and from my conversations
elsewhere, the Lapidus is not the standard of
care. It is one of many procedures which may be
appropriately used in some but not all patients.

In bunion surgery, there are usually many correct
answers. Some procedure will fail, even when
properly selected and performed. Procedure failure
is part of surgery.

Dr. James Ganley used to say “correct that which
is deformed” and thusly was not an advocate of
distal metaphysical osteotomy. Conversely, Dr.
Steven Smith summarizes patient expectations
saying “all they want is for it to look good and
feel good“. My friend Dr. Martin Pressman states,
“when the patient looks down, they want to see
straight.“

There is little argument that when healed, a well
performed Lapidus procedure offers durability.
There is also little argument that distal
osteotomy, although associated with some incidence
of recurrent deformity, is associated with a high
patient satisfaction rate.

Patients should be given a reasonable discussion
of reasonable options, risks, sequels, costs. Of
course, as Dr. Graziano suggests, the decision for
procedure selection is one of both patient and
podiatrist. If patient expectations or desires
leave the surgeon uncomfortable, or are perceived
to be contrary to patient best interest, as Dr.
Graziano indicates, you must learn to say no.

Allen Jacobs, DPM, St. Louis, MO

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