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Jay Lieberman
DPM, FACFAS,
Director of
Podiatric Medical Education,
Northwest Medical Center |
Guest Case Study: (Following Dr. Lieberman's case study, you'll find the results from last week's survey on the podiatry profession.)
Orthner-Lapidus Fixation System
ntil recently, I dreaded the sight of a deformity this large. Invariably, it meant a proximal osteotomy; a procedure in which I never had much confidence. The average patient simply cannot be relied upon to be non-weightbearing for 8-10 weeks. The Juvara or the Louisan-Balacescu procedures produce a long lever arm which can easily be displaced—even with "eggshell weightbearing". The majority of the osteotomy is positioned in the proximal diaphysis which is not an optimal area for bone healing. On occasion, one encounters a patient with a narrow metatarsal—which means the surgeon may not be able to obtain two points of fixation.
In my opinion, the Lapidus is the procedure of choice here because it not only addresses the hypermobility, but corrects the deformity at the site of incongruity. For more insight, view Sam Mendocino's Lecture on the Lapidus Procedure for Hallux Valgus Surgery.
The Lapidus has its drawbacks. The fixation is tricky. The surgeon runs the risk of fracturing the cortex. A non union or an elevatus of the first ray is a real possibility.
nter the ....... Orthner-Lapidus Fixation System. A bone plate that is specifically designed to enhance the success of the Lapidus Procedure. The plate is low profile and anatomically designed to seat well along the first metatarsal cuneiform joint. There is a standard design but the step down plates comes in various sizes. The choice of size depends on the amount of sagittal plane correction the surgeon desires and the anatomic requirements of the patient. A threaded drill guide temporarily attaches to the plate to insure precise positioning of the four plate locking and self tapping titanium screws.
Nothing about the Lapidus Procedure is difficult, but I recommend reading the following articles which offer some pearls of wisdom.
- McInnes, B., Bouche, R. Critical Evaluation of the Modified Lapidus Procedure J. Foot Ankle Surg. 40(2): 71-88, 2001
- Ray, R., First Metatarsaocuneiform Arthrodesis: Technical Considerations and Technique Modification J. Foot Ankle Surg. 41(4): 260-272, 2002
- Faber, F.W., Mulder, P., Verhaar, J. Role of First Ray Hypermobility in the Outcome of the Hohmann and the Lapidus Procedure J. Bone and Joint Surgery 86(3): 486-495, 2004
I like the idea of obtaining temporary fixation of the newly positioned first metatarsal to the second ray by using two K wires; one proximal and one distal. I have fluoroscopy on hand and use guide wires to assist in adhering to the principles of the hinge axis concept.
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| The case demonstrated here is a 46 year old male. You will note that the fibular sesamoid was removed intra operatively. Re-orienting the articular cartilage and correcting the high proximal articular set angle was considered, but the benefits were outweighed by the potential shortening of the first ray. |
The Orthner-Lapidus Fixation System offers a high degree of post op stability that simply cannot be obtained with one or two screw fixation. Its low profile design with the plate locking screw heads is well tolerated by patients even in lace up shoes. |
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Results from last issue's Survey
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We were interested to see if the results varied by how many years of training the podiatrist had. First, as far as how happy they were to be a podiatrist, the results show IDENTICAL responses regardless of years of residency training.
44%
30%
16%
10%
1% |
Extremely Happy
Very happy
Happy
Not Very Happy
Unhappy |
90% are happy to be a podiatrist
Podiatrists that did 2 or 3 years of residency training were more likely to feel there is a significant difference in being a DPM versus being an MD/DO, in their respect and standing in the community of healthcare. 2 and 3 year residency trained podiatrists would also be more likely than those that did 1 year residency programs, to trade professions with an MD/DO colleague in orthopedics if given the opportunity.
The more years podiatrist train, the more likely they are to feel that most DPMs chose this career because they could not qualify/enter an allopathic or osteopathic school.
Regardless of their years of residency training, 9 out of 10 podiatrists feel that most practicing DPM's are financially successful in their professional careers, and 5 out of 10 or half would advise their sons or daughter to follow in their foot steps and become a podiatrist. Here are the full results of the survey: |
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