Percutaneous Modified Lapidus Procedure with Early Weightbearing: Technique and Early Outcomes of the First 30 Cases

CATEGORY: Bunion; Midfoot/Forefoot INTRODUCTION/PURPOSE: Minimally invasive techniques (MIS) have focused on first metatarsal osteotomies in hallux valgus correction. Concurrently, new fixation methods allow early weightbearing protocols with the open Lapidus procedure, with nonunion rates comparable to those of more traditional protocols requiring nonweightbearing. We aimed to assess clinical and radiographic results of an MIS-modified Lapidus technique with axial nail fixation (Phantom Lapidus Intramedullary Nail: Paragon28, Englewood, CO USA) and early weightbearing. METHODS: After institutional review board approval, the first 30 consecutive percutaneous MIS-modified Lapidus procedures by a single surgeon were retrospectively reviewed. Indications for surgery included moderate to severe hallux valgus deformity with or without first tarsometatarsal joint (TMT) instability, first TMT arthritis, adolescent bunion, and failed prior surgery. All patients initiated weightbearing within 12 days and returned to regular footwear by 6 weeks postoperatively. Patients had a minimum follow-up period of 3 months (average 8.3 months). The pre- and postoperative visual analog scale (VAS) pain scores, intra- and postoperative complications, and need for revision surgery were recorded. Pre- and postoperative radiographs were used to evaluate the hallux valgus angle (HVA), 1-2 intermetatarsal angle (IMA), and sesamoid station. Postoperative radiographs were evaluated for signs of hardware loosening and union of the first TMT arthrodesis site. A postoperative CT scan was obtained if nonunion was suspected. RESULTS: Thirty consecutive percutaneous modified Lapidus procedures were performed in 28 patients. VAS scores improved from 4.1 preoperatively to 1.8 at final follow-up. The IMA decreased 8.3 degrees to an average of 5.9 degrees. The HVA decreased 19.2 degrees to 11.7 degrees. The medial column was shortened by 0.6%. There were no intraoperative complications. There were two reoperations, including one nonunion requiring revision first TMT fusion with autograft and one hallux valgus recurrence requiring a distal chevron osteotomy. There were no wound complications, surgical site infections, hardware complications, postoperative transfer metatarsalgia, or nerve-related problems. CONCLUSION: The current study provides clinical evidence that the intramedullary nail is a biomechanically stable construct evidenced by the high union rate, lack of hardware failure, and tolerance for early weightbearing. This percutaneous modified Lapidus technique may allow for a low rate of wound complications, accelerated rehabilitaion, and improved cosmesis.