What is a Lapidus procedure?

This is an operation to fuse/stiffen the 1st tarsometatarsal joint (a small joint in the midfoot area).

Why would it be performed?

Lapidus is performed for 2 main reasons:

• Arthritis in the joint. Here the surgery is to eliminate the pain due to arthritis. Prior to surgery, a steroid injection may have been tried. If this doesn’t give good relief, then surgery is the next option.
• As part of bunion surgery when there is hypermobility (excessive movement) of the joint. In this case the aim is to aid in the realignment of the big toe and prevent recurrence of the bunion.

What does it involve?

A small cut is made between the ankle and the big toe. The joint is opened up and fused with screws, plates or staples. Sometimes if there is deformity at the joint it will be reshaped. Extra bone is used (either a small piece of bone from the shin) or an Allograft (sterile bone chips), to help with this.

How long will I be in hospital?

Most people who are reasonably fit will have the procedure done as a day case, having had their preoperative assessment 2-6 weeks previously. Sometimes it may be necessary to stay overnight. Your surgeon will discuss this with you.

Will I need a general anaesthetic (go to sleep)?

The operation is usually done under general anaesthetic but in some circumstances, you will have an injection in your back, leg or ankle to make the area numb whilst staying awake. Your anaesthetist will advise you on the best approach. 
Even if you go to sleep for the operation, a local anaesthetic may be injected around your ankle to help with pain relief after the operation. 

Will I have a plaster on after the operation?

You will need to wear a plaster from your toes to your knee until the joint has fused. This is usually between 8-12 weeks. You may be suitable to wear a removeable boot rather than a plaster 8 weeks after your operation.

What will happen afterwards?

You must rest with your foot elevated for 2 weeks after your operation. This is to help with the swelling and enable the wounds to heal. There will be a lot of swelling after the operation. By the time you leave the hospital, you will be able to use crutches. You should keep your weight off the foot. You must keep the foot dry.

Your plaster will be changed and your wounds checked approximately 2-3 weeks after the operation. Another appointment will be made for a few weeks later when the plaster will be changed, x-rays undertaken and you may be able to transfer into a removable surgical boot and start to put some of your weight through the foot when wearing the boot. Your surgical team will advise you regarding your weight-bearing status. You will see the physiotherapist to teach you how to walk with the boot.

Further x-rays will be arranged a few weeks later to check on the joint fusion. When good fusion is seen, you can start to wear a normal supportive shoe.
There will be some degree of swelling for many months, so it is important to elevate your foot at regular intervals and to pace your activities sensibly as you recover from the operation in order to optimise the outcome.

How soon can I...

Go back to work?

This will vary according to your occupation. If you have a job which involves you being on your feet in an industrial setting you may need to take up to 6 months off work.

Drive?

You cannot drive until the plaster is off, you are back to wearing normal shoes, you can fully weight bear and you are able to safely perform an emergency stop. If you have an automatic car and only your left foot is operated on, then you may be able to drive sooner but check with a member of your foot and ankle team first.

Play sport?

After your plaster/boot is no longer needed, you can start to take gradual exercise, starting slowly and building up sensibly, pacing your activities. Your midfoot will be stiffer and vigorous exercise is not usually possibly after a midfoot fusion.

Risks

• COVID-19 infection increases the risk of complications and we recommend you read the separate leaflet regarding this. If you are in one of the vulnerable groups, you should think carefully about proceeding with surgery unless it is absolutely necessary.
• Chronic Regional Pain Syndrome (CRPS)
• The main problem is swelling of the foot which may take several months to recede and some people’s feet remain slightly puffy. You may find that only trainers are comfortable for several months. Keeping your foot up, applying ice or wearing elastic stockings may help to keep the swelling down. Swelling is part of the body’s response to surgery rather than something ‘going wrong’ but if you are worried about the swelling, ask one of the foot and ankle team if the amount of swelling you have is reasonable for your stage of recovery.
• If you need to have a bone graft taken from a bone in your leg, this is sometimes painful for a couple of weeks and some people may have a small numb area beneath the scar. This is normal but can be irritating.
• The most serious thing that can go wrong is infection in the bones of the foot. This only happens in 1% of people but if it does, it is serious, as further surgery to drain and remove the infected bone and any infected screws or pins will be necessary. You may then need more surgery to get the foot to fuse in a satisfactory position. The result is not usually as good after such a major problem as if the foot had healed normally.
• In about 10-15% of cases fusions do not heal properly and need a further operation to get the bones to fuse, basically another 1st TMT joint fusion.
• Minor infections in the wounds are slightly more common and normally settle after a short course of antibiotics.
• Sometimes the cuts are rather slow to heal. This usually just requires extra dressing changes and careful watching to make sure the wounds do not become infected.
• 5% of 1st TMT joint fusions do not heal in exactly the position intended, either because the position achieved at surgery was not exactly right or because the bones have shifted slightly in the plaster. Usually this does not cause a problem, although the foot may not look ‘quite right’. Occasionally, the position is a problem and further surgery is required to correct it.
• Sometimes, screws or pins become loose as the bone heals and cause pain or rub on your shoe. If this happens, they can be removed usually with a simple operation which can often be done under local anaesthetic. We find that approximately 1% of our patients need a screw taken out.
• Deep vein thrombosis and pulmonary embolism (clot in leg and lung).

There are general risks with any operation that include blood clots, anaesthetic and tourniquet complications. Generalised pain, swelling and stiffness can occur (Chronic Regional Pain Syndrome - CRPS).

What can I do to help?

Most patients find that simple measures can make a big difference to the outcome of surgery. The evidence from our studies and our own experience supports this:

• Take simple vitamin C and vitamin D or multivitamins needed for healing
• Stop smoking. Smoking slows down healing and is linked to increased complications.
• Keep fit and maintain a healthy weight. Many foot problems are improved by losing weight.

Further information

The British Orthopaedic Foot and Ankle Society - www.bofas.org.uk