Modified Lapidus Arthrodesis: Rate of Nonunion in 227 Cases Sandeep Patel, DPM, 1 Lawrence A. Ford, DPM, FACFAS, 2 John Etcheverry, DPM, FACFAS, 3 Shannon M. Rush, DPM, FACFAS, 4 and Graham A. Hamilton, DPM, FACFAS 5 Several studies of Lapidus arthrodesis have commented on the rate of nonunion (ranging from 3.3% to 12.0%), although these figures are based on relatively small patient populations. This study retrospec- tively reviewed the medical records and radiographs of 211 consecutive patients (32 men, 179 women; mean age, 46.9 years) who received modified Lapidus arthrodesis for forefoot pathology in 227 feet. In all cases, the procedure was performed using joint curettage with subchondral plate preservation and screw fixation. Patients remained nonweightbearing for 6 to 8 weeks and were monitored for a minimum of 6 months postoperatively. Nonunion was seen in 12 (5.3%) of the 227 feet that underwent modified Lapidus arthrodesis. ( The Journal of Foot & Ankle Surgery 43(1):37– 42, 2004) Key words: arthrodesis, hallux valgus, metatarsocuneiform joint, Lapidus, nonunion T he role of the hypermobile first ray in forefoot pathology has gained attention recently as the popularity of the Lapi- dus arthrodesis procedure has reemerged. Insufficiency of the first ray has been implicated in the development of hallux valgus, hallux limitus, and lesser metatarsal overload (1–9). Several publications evaluated functional outcomes of Lapidus arthrodesis and reported favorable results and patient satisfaction (1, 4, 10 –12). Nonetheless, the known complications of nonunion, malunion, shortening, transfer metatarsal overload, dorsal drift, intercuneiform diastasis (1, 2, 4 –9, 12–14), and increased postoperative convales- cence may have deterred the use of this procedure for correction of hallux valgus. Reported rates of nonunion range from 3.3% to 12% (1, 5, 10, 12, 14, 15), but these figures are based on relatively small patient populations. These reports may also vary in methods of joint preparation (curettage versus wedge resection) and technique of fixa- tion, including use of screws, pins, and plates (1, 5, 10, 12, 14, 15). The objective of this article is to establish a non- union rate in a large patient population by using the curet- tage technique, a consistent method of fixation, and a stan- dardized postoperative protocol. Materials and Methods Medical charts, electronic databases, and radiographs were retrospectively reviewed for 308 consecutive patients (324 feet) who had modified Lapidus arthrodesis performed from April 1999 through May 2003. The surgical technique, technique of joint preparation, method of fixation, and post- operative management were applied similarly for each pa- tient by 4 different surgeons (L.A.F., J.E., S.M.R., G.A.H.). Only patients who had a minimum of 6 months postopera- tive follow-up were included in this study. Further inclusion criteria were Lapidus arthrodesis with joint curettage and screw fixation as described in the surgical technique. Pa- tients who had simultaneous rearfoot osseous procedures were excluded because they often required longer immobi- lization than 6 to 8 weeks. To accurately assess the non- union rate of the Lapidus arthrodesis procedure, particularly in determining when to initiate weightbearing, the Lapidus had to dictate postoperative management. Indications for the procedure were a hypermobile first ray resulting in symptomatic hallux valgus, hallux limitus, lesser metatarsal overload, or first metatarsocuneiform arthrosis. The retrospective review was implemented to identify those patients who had a delayed union or nonunion from 1 Post Graduate Year 2, San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Permanente Medical Center, San Francisco, Oakland, Walnut Creek, CA; Veteran’s Affairs Medical Center, San Fran- cisco, CA. 2 Staff Podiatric Surgeon, Department of Orthopedics and Podiatric Surgery, Kaiser Permanente Medical Center, Richmond, CA; Attending Staff, San Francisco Bay Area Foot and Ankle Residency Program. 3 Private Practice. 4 Staff Podiatric Surgeon, Department of Orthopedics and Podiatric Surgery, Kaiser Permanente Medical Center Walnut Creek, CA; Attending Staff, San Francisco Bay Area Foot and Ankle Residency Program. 5 Staff Podiatric Surgeon, Department of Orthopedics and Podiatric Surgery, Kaiser Permanente Medical Center, Oakland, CA; Attending Staff, San Francisco Bay Area Residency Program. Address correspondence to: Lawrence A. Ford, DPM, FACFAS, Department of Orthopedics and Podiatric Surgery, Kaiser Permanente Medical Center, 901 Nevin Ave, Richmond, CA 94801. E-mail: Lawrence.Ford@kp.org Copyright © 2004 by the American College of Foot and Ankle Surgeons 1067-2516/04/4301-0007$30.00/0 doi:10.1053/j.jfas.2003.11.009 VOLUME 43, NUMBER 1, JANUARY/FEBRUARY 2004 37