The Second Opinion

I had to wait a month between my first and second opinion, so I was nervous going to the doctor. I kind of hoped that he would agree with the first doctor, while at the same time was afraid that he would.

This time is was my husband, my son, and me, having driven to Portland the night before, spent the night, and then driven a short distance for the appointment. Rebound Orthopedics is a huge operation, with its own surgical center. We found the right office, though, and finally met with the doctor.

He was a nice guy. He explained that what he recommended I have is a Lapidus Bunionectomy because, if you look at the x-ray, you can see that the bone structure of my foot is all wrong. Rather than muck around with the bunion itself, though the arthritis and callous needs to be cleaned off, he would take care of it at the source–the connection of the long metatarsal to the ankle, which needs to be realigned and then pinned. In short, he saw it as the best procedure because:

(this below is taken from: http://www.podiatrytoday.com/why-lapidus-bunionectomy-best-procedure-severe-bunions)

1. Correction of the deformity at the apex. Realigning the structural deformity of the foot by physically placing the metatarsal into its native position (near parallel) to the second metatarsal restores the foot to a more “normal” anatomic alignment. This also allows for realignment of the big toe joint subluxation. While distal metatarsal osteotomies may improve big toe joint alignment, they are limited in that there is a physical limit of correction with a distal osteotomy. In comparison to a Lapidus procedure, there is no correction limit based on the intermetatarsal angle. Also, a distal osteotomy creates an intrinsic metatarsal deformity to correct a deformity whereas the Lapidus does not. A base wedge osteotomy also creates an intrinsic metatarsal deformity.

2. Preservation of big toe joint function. Sure, the Lapidus procedure involves sacrificing the first tarsometatarsal joint (through fusion) but it allows for big toe joint motion. Preservation of big toe joint motion is important as one considers patients with an active lifestyle and those who wish to wear specific shoe gear such as high heels. Obviously, fusion of a big toe joint eliminates this motion and fixes the toe position. A Keller arthroplasty does allow motion but this is “artificial” motion created by sacrificing a joint.

Implants also provide artificial motion and require resection of a mobile joint. They are probably better indicated for significant arthritis and are not purely for bunion severity.

3. Concomitant treatment of medial column hypermobility syndrome. If hypermobility is present (and deemed pathologic), then the Lapidus procedure offers the advantage of stabilizing the midfoot by decreasing midfoot motion. Some believe that severe bunions are the result of hypermobility and selecting procedures that do not address this may result in recurrence or secondary compensations. Though one may also address hypermobility with osteotomies, there is no current research to indicate the “best” method of surgical management. Nonetheless, the Lapidus procedure is indicated for the treatment of hypermobility.

4. Concomitant treatment of lesser metatarsal overload. In many clinical situations, the severe bunion is associated with lesser metatarsal overload (metatarsalgia) through an inefficient medial column (first ray). Stabilizing and realigning the first ray through a Lapidus procedure provides a stable construct to the medial column and also improves the efficiency of the peroneus longus.16 It is important to inferiorly translate (or plantarflex) the first metatarsal as part of the surgery to restore the weightbearing presence of the first metatarsal head.

The Keller procedure is known to produce and exacerbate lesser metatarsal overload, and may be a poor procedure choice in patients who have metatarsalgia preoperatively. Implant arthroplasty carries a similar yet less infrequent postoperative lesser metatarsal overload risk, but one often must perform other procedures in conjunction to realign the first metatarsal.

5. Avoiding elevatus plastic deformation risk. Postoperative elevatus from early weightbearing is a real risk with base wedge osteotomies. Though this occurrence was more common when wire fixation was in use, the risk still remains with screw fixation. The plastic deformation of an osteotomy site is the result of premature weightbearing causing an intrinsic remodeling of the first metatarsal. With a Lapidus, however, elevation can occur but it may occur concomitantly with fixation failure and nonunion. The elevatus with a Lapidus is extrinsic to the metatarsal and the effect of the failed fusion elevating through the nonunion site.

6. Postoperative weightbearing. The ability for a patient to bear weight after a bunionectomy is often a deciding factor for procedure recommendation regardless of bunion size. Surgeons may make recommendations outside of specific intermetatarsal angle guidelines. Some doctors may even discourage bunion surgery altogether for the severe bunion because of a non-weightbearing protocol. Now that studies have emerged demonstrating that early weightbearing protocol healing rates are similar to that of non-weightbearing protocols, surgeons can consider the Lapidus as part of the potential surgeries when the post-op weightbearing is important.1-13

7. Lapidus failure is often less disruptive than failure from other bunionectomies. A failed bunionectomy is always a challenge for both the surgeon and the patient. With Lapidus, failures are typically in the realm of nonunion. I believe that that nonunion is not a failure but a known potential outcome in a certain percentage of people (but that is beyond the scope of this article). Nonetheless, a painful nonunion of Lapidus is typically focal to the first tarsometatarsal joint and one can rectify this with revision and grafting. Any recurrent angular deformity is through the first tarsometatarsal joint and also undergoes repair at the revision fusion site. A failed metatarsal bunionectomy often results in an intrinsic deformity, which requires metatarsal osteotomy or a revision Lapidus to correct.

Similarly, big toe joint fusions carry the risk of nonunion and malunion. In my experience, a nonunion of the first metatarsophalangeal joint (MPJ) is typically more symptomatic than a nonunion of the first tarsometatarsal joint. This seems to be due to the amount of load passing through the forefoot. Malunions of a first MPJ fusion can cause similar problems with that of a midfoot fusion and may require revision.

A failed Keller or implant procedure involves a revision fusion of the first MPJ with bone block grafting, a procedure that involves a prolonged period of convalescence and non-weightbearing. These reconstructions are challenging for both patient and surgeon.

8. Improving rearfoot alignment. Realigning and stabilizing the first ray has a realigning effect on the rearfoot as well. This is an advantage of the Lapidus. A retrospective radiographic study by Avino and collagues demonstrated radiographic improvement of the talo-first metatarsal angle.

Whew.

Then my husband asked straight out what he thought about what the first doctor proposed (since this doctor had been really circumspect about saying anything bad about the treatment). We could tell that he didn’t want to disparage someone else, but basically said that he preferred to solve the problem at its source, and the other plan was way over-engineered.

Plus, the downtime would be 2 months, not 3.

Yeah, okay. This is what we want to do.

 

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