What are the indications for Proximal metatarsal osteotomies?
1. Large intermetatarsal angle
3.Hypermobility of the first ray
What are different procedure for Proximal metatarsal osteotomies?
1. Closing base wedge osteotomy (CBWO)
2. Opening base wedge osteotomy (OBWO)
3. Crescentic osteotomy
4. Proximal Chevron ostetomy
6. Lapidus osteotomy
What's the technique involved in closed base wedged osteotomy?
1. Axis guide placement
3. Internal fixation
4. Lateral release
5. Medial eminence resection
1. what is the distance of entry point from the medical cortex?
2. what is the distance of entry point from the MCJ?
1. 5 mm
2. 1.5 cm
It is best to try to keep the osteotomy 1? to the weightbearing surface when performing CBW osteotomy
But if dorsiflexion of the distal segment is desired, then a 2? is created
If plantarlfexion of the distal segment is desired, then a 3? is created
2. plantar medial corticol hinge
3. dorsal medial corticol hinge
What are some of the complications with CBW osteotomy?
1. Osteotomy Entering 1st MCJ
(a) Osteotomy too oblique
(b) Apex too lateral
2. Osteotomy too Distal (midshaft)
(a) Delayed Healing
(b) Less IMA correction
What fixation would you use for the CBW osteotomy?
Anchor screw placed 3?
Lag screw placed perpendicular to
1. One cortical screw as an anchor
2. One cancellous as a lag screw
3. perpendicular to shaft
•Upper right quadrant from lateral view
•Protects cortical hinge
•Lower left quadrant from lateral view
What do you do for Lateral release/Medial eminence of CBW osteotomy?
1. Perform ?
Less aggressive than with distal osteotomies
Usually parallel to the shaft
1. lateral release first, prior to osteotomy
3. medial eminence last
Some facts about CWBO:
1. IMA angle
NWB postop 2?
Anatomically 3? correction
2. Higher IMA’s and juvenile HAV
2. 6-8 weeks
Main complication: 2?
What kind of osteotomy 3?
1. Crescentic saw
2. Dorsiflexion of the distal fragment
3. Curved osteotomy of the base of the met head
Proximal crescentic osteotomy. Diagram of the osteotomy
site. The surgeon’s hand is pushing the metatarsal shaft in a
lateral direction. The Freer elevator is pushing the metatarsal
base in a medial direction. Note the 2–3 mm overhang on the
lateral aspect of the osteotomy site (From Mann and Mann.8
Used with permission)
What are the Advantages/Disadvantages of Cresentic procedure?
1. Good if first ray relatively short
2. Good IM correction Level 2 studies
3. Dorsiflexion malunions
4. Hallux varus
Apex 2 cm 1?
1. from the TMT
2. stable/ large contact area
3. 2 screws/ plate
What are the advantages of proximal Autsin procedure?
1. Maintain length
2. less chance of dorsiflexion of the distal fragment
3. Faster healing comparing to other procedures at the base
what is the Applications of Lapidus Procedure?
1.Moderate to severe hallux valgus deformity
2.Hypermobile first ray
3.Adjunct to other pes valgus procedures
Some facts about metatarsal cuniform joint:
1. Flat joint
2. Inherently stable
3. Minimal motion (“non-essential joint”)
What is the Lapidus procedure?
Removal of the metatarsal-cuniform joint. as little as possible
Important: the 1st metatarsal should be positioned in 15-20 degrees of plantarflexion otherwise the first metatarsal would be elevated.
What are the indications for Lapidus procedure:
based on lecture notes:
based on the book:
1. Moderate to severe HAV
2. Ligamentous laxity
3. Hypermobile 1st ray
4. Elevated metatarsal
5. Intercuneiform instability
6. Severe hallux valgus
7. intermetatarsal angle>18
8. hypermobility of the 1st metatarsocuniform joint
9. HAA >25 degrees
10. degenerative disease of the metatarsocuniform articulation
What is Lapidus procedure?
Basically Arthrodesis of the first metatarsocuniform joint
What are the contraindications for Lapidus procedure?
1. Short 1st metatarsal
2. Poor bone stock
3. Patient factors
Where do you incise for the Lapidus procedure?
1. Direct medial
2. Dorsal medial
Where do yo position for fusion?
1. Plantarflexion of joint motion
2. Plantar translocation of metatarsal
What are the considerations for Lapidus procedure?
1. Intermetatarsal angle
2. First metatarsal-cuneiform joint architecture
3. 1st metatarsal length
4. Bone quality
5. Pt. factors
What are the post-operative management for Lapidus?
1. Jones dressing 1 week
2. Non-weight bearing SLC x 6-8 weeks
3. Removable cast brace x 4 weeks with progressive increase in weight
4. Return to regular shoes 10-12 weeks
What are the benefits of Lapidus?
1. Correction of large deformities
2. Decreased risk of recurrence
3. Increased medial column stability
4. Decreased risk of complications