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We never throw the intercuneiform screw. When I said gapping I meant at the MC joint in the older system where you only threw one wire for temporary fixation.
Amniotic Fluid Injections - Alert
- Thread starter OblivionDPM
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For majority of my lapidus, I’m still doing it old school way of joint prep and manual reduction - solo and usually can it done in 60 minutes tourniquet time. A single 4.0 lag and a plate and/or staple to augment. I don’t care too much if there’s still a plantar gap or dorsal shift, just backfill with some calc autograft.
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that you bill for because Bofelli says it is a distant site...
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Using calcaneal autograft and billing 20900 is appropriate. As mentioned, the graft has to come from a “distant” site.
This eliminates the providers who remove the medial eminence, chop it up and sprinkle their magic pixie dust in the distal osteotomy site and bill for an autograft. That is local bone and does not cut it.
Bill 20900 for your calc graft, no matter how many passes you make. It’s a 20900.
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I never see the need except in extraordinary circumstances. Large cystic defects, need structural lengthening.
All that smoker, DM hogwash we blame when we dont resect past the subchondral plate.
SUbchondral plate resection and using a 2.0 drill bit to fenestrate the surfaces. Never had an issue. Ever.
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Ha. Now you are guaranteed to have an issue with your next case!! Never say never….
I dont do lapidus. I only do multi joint fusions so im safe.
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Yes I do the same prep as you. I only use calc autograft occasionally but in residency, zero grafts.
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I think it's only necessary for a revision. I have never done the shear-strain dorsal graft materials idea or any filler in 95% of regular primary Lapidus. Maybe you want some bona fide autograft for some bad non-unions, but who knows? Even those will usually heal with proper joint prep and better fixation and better post-op mgmt/counseling.
I've only done BMA with baby graft plug (lateral calc Jamshidi needle) in a few Lapidus revisions of symptomatic shortening, dorsiflex malunion, under-correction, etc... usually with an allograft block if I need length. I have done at least 10 Lapidus revisions by now but never had to revise any of my own (maybe they go elsewhere, lol), and I haven't done the full calc cube graft thing (for Lapidus). Those grafts are too soft and too easy to fracture or crush when plating, and I want a real solid structural allograft to position 1MC and put fixation through (hard allograft with BMA juice on both sides). The MTF Cotton wedge can work ok for the dorsiflexed + short ones. I know the boards answer is autograft for revisions and non-unions, but I don't like creating the second surgical site at calc and using the softer graft unless really necessary.
I do use calc cube autograft for a lot of things like RRA non-unions if I'm in that neighborhood anyways, but I think 1MC and 1MPJ non-unions can be done fine with allo if you need length or just debride fusion site, add DBM/BMA and enhanced fixation. The majority of the non-unions that find me are non-unions simply because the other surgeon decided to do a fusion surgery on medical health turd of a candidate and/or under-fixated or usually didn't protected NWB/WB it.
I consent all Lapidus primary or revis for possible bone graft or bone graft sub, possible BMA... but for most regular ones, I use nothing or just use a bit of medial eminence or DBM if there are any gaps (never really are). Some of my buddies do BMA for basically any fusion, and while it's more of a billing thing, it is possibly helpful and very minimal additional work or pt trauma compared to a real cube graft.
If it's DM, smoker, biggun, etc bad fusion and bad NWB candidate... then I just don't do Lapidus (or definitely the steel lock plate construct if I had to). You can do 1MPJ fusions on those... but only should if it's severe HAV crossover toes, ulcerative, etc.
Honestly I have a lot of sural nerve issues anytime I make an incision over there. Anatomically correct incision to avoid nerve (and peroneals) and it still causes me issues. Small or large they all complain of tingling and numbness.
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Yeah, I hate peroneal surgery and avoid it as much as I can. I tell even fibula HWRs and very basic lateral RRA stuff that they will probably have nerve issues from the prior surgery, the original injury, or my surgery... or all of those. For calc fx ORIF and STJ fusions and calc ostetomies and stuff, it is almost 100% chance of at least temporary sural issues. I dissect blunt after skin incision, create thick flaps, put dex in before closing, and only close skin (sometimes also a loose running subcut with knots outside skin), NWB all for at least 2wks in CAM or bivalve cast to minimize edema and scarring, but it is just a very bad area in general. There is no way I want to work lateral heel/fibula unless it's the only way... can't imagine the neuritis outcomes on those peroneal grafts to rebuild the lateral collateral ligaments Chrisman and Evans etc they used to actually do and we just know as trivia for boards
I haven't had any problems with just the BMA needle, but I even do that with a stab incision, probe with stat to make a tunnel to calc, then use trocar needle (to hopefully avoid hitting a stray sural nerve branch). I have also done ok with all my gastrocs (frog leg medial small incision strayer with a mayo scissor) and perc or open TALs or Haglunds... never bad sural problems from those. I guess you are far enough posterior (and anterior enough on ATFL recon). I don't think I've done an Achilles rupture in years, but that would obviously be potential for a lot of scarring and I'd warn them of likely sural problems.
I have seen a lot of peroneal tendon repairs, fib fx, Evans and other flatfoot stuff, some lateral ankle stabs, etc by other surgeons over the years that were probably well done (XR or MRI alignment and fixation and joints look ok to me), but they complain mainly of nerve issues more than anything despite injects and PT and meds and braces. They want a second opinion or a new answer, and it's too bad. I just give them some PT Rx and lidocaine gel or a brace of a new type depending what they've tried and tell them it's a really tough situation but I don't do nerve surgery/releases. I wonder a bit if the medium/larger incisions are almost better in that sural area so that we're not retracting the heck out of them and working somewhat blind like the minimum length incisions or the stab incisions (MIPO, etc), but there's no easy answer.
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Do you get any meaningful bone graft from this? Or is it just BMA? I use a lot of jamshidis for bone biopsies to R/O osteo but never for calc graft harvest because its seems like I would be porcupining for hours to get enough. But maybe im wrong? With my sural problems I would be in to give it a try!
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You don't usually get any meaningful bone from the aspirate... sometimes a few specks of cancellous that looks sorta like 0.25cc red DBM or something if you withdraw the needle and use the trocar to pop out the calc wall plug (then re-insert to get the fluid). It is not very much and nothing structural. I was mainly joking about the 'graft' of BMA since a lot of people bill BMA as graft 20900 not aspirate for non-spinal sx 20999 (may need prior auth... but that's the correct code after 38220 code kinda went away).
What you get is usually just viscous blood rich in active cells that you can put in fusion site or onto an allograft or whatever. You just use the same Jamshidi as for osteo, then a 30 or 50cc syringe and you get maybe 5-10 ml or whatever. You can re-direct the Jamshidi 10-15deg to get more fluid or more cancellous tidbits if you want.
Percutaneous Bone Marrow Aspirate and Bone Graft Harvesting Techniques in the Lower Extremity
Autogenous bone marrow aspirate and cancellous bone graft represent a useful adjuvant to enhance soft tissue and osseous healing in high-risk patients…
There are almost no complications in the lit or my exp... it is one skin suture.
Complications associated with autogenous bone marrow aspirate harvest from the lower extremity: an observational cohort study - PubMed
4 (Case Series; Therapeutic Study).
pubmed.ncbi.nlm.nih.gov
Ive used it for BMA but never for actual structural allograft. I was intrigued by the small incision and possible ability to get some actual substantial allograft.You don't usually get any meaningful bone from the aspirate... sometimes a few specks of cancellous that looks sorta like 0.25cc red DBM or something if you withdraw the needle and use the trocar to pop out the calc wall plug (then re-insert to get the fluid). It is not very much and nothing structural. I was mainly joking about the 'graft' of BMA since a lot of people bill BMA as graft 20900 not aspirate for non-spinal sx 20999 (may need prior auth... but that's the correct code after 38220 code kinda went away).
What you get is usually just viscous blood rich in active cells that you can put in fusion site or onto an allograft or whatever. You just use the same Jamshidi as for osteo, then a 30 or 50cc syringe and you get maybe 5-10 ml or whatever. You can re-direct the Jamshidi 10-15deg to get more fluid or more cancellous tidbits if you want.
Percutaneous Bone Marrow Aspirate and Bone Graft Harvesting Techniques in the Lower Extremity
Autogenous bone marrow aspirate and cancellous bone graft represent a useful adjuvant to enhance soft tissue and osseous healing in high-risk patients…www.sciencedirect.com
There are almost no complications in the lit or my exp... it is one skin suture.
Complications associated with autogenous bone marrow aspirate harvest from the lower extremity: an observational cohort study - PubMed
4 (Case Series; Therapeutic Study).
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Anyone use the Avitus BMA/graft harvester?
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I have had many women tell me that they get tingling and numbness when I enter the room. Just sayin’…….
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Was a rep with you? What was their reaction?
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And this is EXACTLY the problem. We all know doctors who never performed a Lapidus in their entire career. Then the system came out and for those who never performed a Lapidus on their own, this was a cookbook procedure. Put this here, put that there, cut here, etc., etc., etc.
For a seasoned surgeon who performed free hand Lapidus procedures, this set can add consistency and reproducibility.
However, for those who are using it as a Lapidus for dummies, the situation airbud was in today could be catastrophic. This subset of doctors would have no clue how to get out of trouble or complete the case the old way, since they never did it the old way.
My greatest concern about his set is that it’s being put in the hands of doctors who have no business using it. They are wannabes who are 100% dependent on the set and it’s jigs and guides.
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I hope you never experience it again but I've had a plural number of cases where the cut guide won't fit/cut to the anatomy.
I used to place the joint seeker (pops out too much), place the cutting guide, and then adjust the cut-guide-fixating- pins under fluoro until it lined up. It kept leading to cases that exceeded an hour and I thought the cuts were still often questionable or incomplete.
My new rule is - no fiddling or wasting time with the guide. Now I place the "speed seeker" (which really can't be adjusted because of the fixed nature of the fulcrum to the joint seeker) and as long as the cuneiform cut is appropriate (which it seems to consistently be) I make the metatarsal cut by hand. I kept having cases where the cuneiform cut would happen but the metatarsal cut would just enter the joint space and do nothing. The the rep would make awkward noises about are you sure and I'd show them that just 1 wafer had been made. Giving up on the original cut guide has now gotten me to where I need to be which is sub-hour. Tourniquet time is patient pain.
Next thing - I meant to write a long post about this, but I'm doing it here - Lapiplasty Fails. AKA - "Springing"
Springing is where you start taking temporary fixation off and then suddenly the correction is lost ie. the toe jumps valgus. I'm personally of the opinion that whatever the toe and metatarsal head look like during the initial fulcrum+positioner phase is what you should be able to make the position look like at the end. That said - however you temporarily position it with the compressor+ maybe fulcrum (after cuts) should definitely be what you get at the end when just plates are in place. Everytime I remove something - I stare at the toe to see if the position changed. I also use this rule when I do a first MPJ and pull the k-wire. If I pull the wire and the toe rotates - that's a fail.
The company explanation for springing is something along the following:
-Malposition created by the plates ie. the plates pull it open due to the order that the screws are placed. The most recent plate + screw guidance I'm being given is - dorsal plate first with the two interior screws filled with gold first, complete the plate, and then medial plate with interior filled with gold first.
The company used to definitely tell you to place the medial plate first. They have supposedly pulled that from the main video and now recommend dorsal first. The medial plate first may have been more prone to pulling the construct apart.
I'm told they are also telling people to not place 2 compressive olive k-wires. Now they are telling people to place one olive compressive (dorso-lateral) and then place simply a non-threaded k-wire.
What I will tell you is that there are other ways to generate springing. So - I don't know about other people but I've been told a lot of different things by reps as far as how to position and set up.
-They used to say place the compressor, then place 2 olive compressor wires, and then place the medial plate. I really wanted to place dorsal first because it made a lot more sense to me, but I constantly had issues with fitting a plate when all that damn temporary hardware was in the way.
-I was told once told that I could leave the positioner (c-clamp) on while plating as a form of positioning when we had a case where we couldn't seem to get the metatarsal to sit right during the temporary fixation after cutting.
***DO NOT leave the c-clamp on while plating. It creates fake forces that will obviously not be present once it is removed and it can overcorrect or temporarily hold a position that is not present after its gone.
I do not in any way claim to be a lapigod but here's my current technique for final positioning.
-I was initially very skeptical of the compressor (remember this is a non-compressive system after all...). The compressor is actually a very nice device for allowing 2 people to conveniently position and stabilize.
-After looking down a clean joint, ensuring no cartilage, trying to see if the cuneiform has been straightened - I put the fulcrum back in.
-I like the fulcrum a lot. Remember the fulcrum was in there when you established that initial toe position you liked so much. Part of the correction that everyone likes so much I believe is based on that slight medial kick-out from the fulcrum.
-So I put the fulcrum back in, I compress down to almost closed and then I position the first ray and toe and have my assistant tighten the compressor. This is one of my favorite things about the compressor - a brand new tech can theoretically do this as opposed to any sort of hand positioning wire throwing etc. Repeat until you clinically see a toe position that matches the correction you visualized earlier. If you can't position by hand and you want to try using the fulcrum+positioner+compressor you MUST take the positioner off once you've compressed because otherwise its just giving you fake information. If you pull the positioner with the device compressed and the toe position is lost - it was fake. Don't keep going. Question your cuts or question how you've positioned the metatarsal on the cuneiform. There is some play with the compressor and sometimes slightly more medial push can be unexpectedly appropriate looking.
My big thing is - take a mental photo of the moments during the case where you saw the good positioning. ie. memorize what it looked like during your temporary positioning. If you love your post-cuts positioning - memorize that toe position so you know if you lose it. And remember that a successful lapidus does not look like a successful Austin.
-If you are compressed and you like it. I throw my wires and then remove the compressor. I want everything out of the way. When you throw the wires and pull the compressor - there should be no loss of toe position. The wires are simply maintaining the appropriate bone on bone position and they shouldn't be able to open or change it because you've already brought together compressed-fitted-surfaces with the compressor.
-Then I plate using the technique above - dorsal first, internal first. Pull the medial wire and plate medial again, internal first. At no point as temporary fixation is pulled should the position of the toe and metatarsal jump or change. You are simple transitioning from one fixation to another.
-Last thing. When I'm doing these - my rep, love him or hate him, it always obsessed on the fusion site position and alignment. Its important - but that's not what the patient is looking at. They are looking at the toe and the metatarsal. Take images along the way. Take a pre-op intra fluoro shot at the beginning because it will look different even loaded than the pre-ops you have in the room. Take a shot of your temporary fixation with just the compressor or just the wires. They should look like your final plated shots in positioning and toe alignment.
I know this is long and redundant but I've had to play with my techique a lot. This is a very interesting system but if you are capable of doing it by hand - maybe you should just keep doing it. My perfect world would probably be to just use the fulcrum and positioner and then do the cuts by hand everytime. I recently did a CMT midfoot dorsiflexory fusion and it killed me how low my tourniquet time was for it compared to using the full lapiplasty set.
Last final thing. I believe in the fulcrum. I kind of think that's the most important but overlooked part of the set. If you aren't using Treace I still think you should consider putting something into the 1st space to try and achieve some push-out of the 1st ray.
Long post. May be typoes. Short story. Toe position should not change as fixation is removed and switched. Jig may lengthen case and require hand cutting.
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As someone who does it freehand, none of that made sense to me lol. but I'm assuming there are a bunch of valuable pearls in there.
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If you can do it freehand you should. That said. Not to quote some sort of company line. I feel like I've seen a lot of awful lapidus during my travels. The company's products, images, etc do at times show what we should be aiming for - that powerful correction can be produced (regardless of the system). You don't have to buy all of it, but a lot of historic lapidus is wildly under corrected and I think a lot of people may not have even realized what it should look like when they are done.
My 2nd month out of 4th year a resident proudly showed me their first lapidus. It was fused essentially wide open in situ at not kidding like ..40 degrees. The attending casually explained to the patient that it was their mistake to not explain to the patient before hand that she was always going to need two procedures and now it was time for her 1st MPJ. It was absurd. There was no initial correction. The 1st MPJ would theoretically resolve the great toe malposition but the patient wasn't going to benefit from the usual IM decrease caused by decompression because the 1st TMTJ position was fixed. I don't know what they were really thinking, but the resident was very clearly -proud- when he showed me the x-ray.
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Thanks for the Friday evening entertainment. That was a good laugh. Please keep these stories coming.
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Entertainment or cringe? This patient is just a lapidus to me. They will continue to have a gentle reasonable 1st metatarsal head prominence that will be well tolerated. When I think metatarsus adductus correction I think - much more severe or inability to achieve any correction of the 1st ray because of the 2nd ray position.
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Haven’t done a lapidus for a couple of years now. But when I do it will never be any product made/developed by Treace. I don’t get how anyone can stand their marketing, reps, knowingly false claims, etc. Not to mention, if you absolutely want a jig system, there are better options on the market. You used to be able to say “options with much lower non union rates” but Treace quietly fixed that major problem with their initial system.
I directed my Treace rep to some of the other older pods in the area so that my clinic could continue to grow and take patients from them 😁
I directed my Treace rep to some of the other older pods in the area so that my clinic could continue to grow and take patients from them 😁
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Fraudulent surgery. Such a shame. The IG posts my classmates share of their post op XR frighten me too.
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Totally agree 💯. Until this was brought up in my thread, never crossed my mind. Then BOOM it happens. You are welcome.
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Do you even metadductus bro?
I don't know, that jig seems like a lifesaver. 3D CORRECTION!😂😂
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How else would you fixate the neurovascular bundle in the first interspace?
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How bout this:
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This is a rep’s wet dream. IM looks like it might be good.
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It’s malpractice as far as I’m concerned
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Yeah, like I said, I was considering taking the 'course' and jokingly asked the rep (after their spiel about how the invite-only course teaches ppl to do Lapidus right and you get expert instruction from the best Lapidus surgeons and bla bla). I replied, "ya, so it's hard to take time off since the office is busy... what if I don't have time to go to the weekend class but just want to use it for my Lapidus next week?" What followed was a quick backpedal about how they could just bring a cadaver to my office and fast track things so if I'd use it for my upcoming case. I do Lapidus every month, sometimes every week and have for years (not that they know that). I think they were going to try to still have me attend the full 'course' later on, but I don't doubt they would have made the same expedite offer to someone who had only seen a couple Lapidus in residency and done few/none No joke.
As stated, I was going to get 'certified' on their system just to have it available and piggyback their good marketing, but when you look up their 'find a doc,' most are note even BQ/BC. It is not really a list I'm sure I want to be on, at least that's how it is in my area. It is basically just like the HyProCure 'master surgeon' hocus pocus. It is not a good setup for success with something as complicated as Lapidus to 'certify' any random foot surgeon, even if it's a good system (I don't really care since it's too expensive and probably adds time for something that works well as-is). At least when TARs and stuff come out, they limit it to ppl who are BC and have done 5 or 10 ankle fusions and stuff. As has been said, Lapidus is not easy and has enough that can go wrong even before adding a dozen more parts and more steps.
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Hey now. My expert rep, trained in the latest 3D bunion correction technology, told me "looks good" as he looked up from his phone for the 1st time in 3 hours.
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Does anyone use LapiFuse rather than Lapiplasty? Any complaints on it? We basically solely use LF at my current program and any time I see a post-Lapiplasty XR I can't get over the shortening done to the first met. LF seems to avoid shortening for the most part.
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Ya I’ve dabbled with it. It’s pretty much doing a traditional manual lapidus but the jig helps you reduce the IM versus me using a Weber clamp to reduce my IM after I manually de-rotate my 2.0/2.4mm distractor pins. The kit comes with fresh sharp curette and osteotome which makes the joint prep much quicker.
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He was too busy telling his wife he made enough money today on commission to go on vacation.
D
deleted1097413
lmao
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They're all just crazy expensive, too much dissection, and unnecessary, man. You can get the procedure done with a basic podiatry instruments set and any reasonable screws or plate.
The anatomy, IM, flexibility, etc is never quite the same from HAV pt to pt, so you need to know how to do it manually. Technology is fun, but technique is what always wins the day. I have no problem with good surgeons playing with these systems if they want to feel like a champ by making the procedure more complex or to try to scam some attention or food off a rep, but they all know it's not really needed to get the end result.
The part with LapiFuse where you supposedly compress the fusion site again (with eccentric screw into plate) after you already did a lag screw doesn't even make sense... either your lag screw was no good, or compressing on that again destabilizes its bite. They also show the first lag screw done with no temp fix of the 1MC joint (just a clamp distal) which is a great way to screw up your reduction/alignment. Any time you're fixating a fracture, fusion, osteotomy, etc... you want at least 2 points of fixation whenever possible (cann screw guide pin doesn't count... 2 k-wires, clamp and k-wire, k-wire and prior screw, etc) to achieve positional and rotational stability.
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They are all stupid expensive, no doubt about it. The main thing I like about their system though is their joint prep set that lets you shave the bare minimum off the joint. I do feel like it prevents shortening as much as possible. Though I guess technically you could use Wright's joint prep set for the procedure and just throw a few screws to skip the whole LapiFuse system.
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Regarding amniotic injection clawback, what are everyone's thoughts on if Medicare will do this for amniotic graft sheets for ulcers?
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The shortening is not really a problem (unless 1st met was way short to begin with, in which case bone graft should be planned). You can just plantar translate the met at the 1MC fusion site, temp fix, make sure to load the foot to see if all rays purchase well, and that plantar translate will compensate for any shortening. You can do Weils if needed for long 2,3 or contracted lesser MPJs. The systems largely negate your ability to plantar translate or load the foot while it's temp fixated since there is so much junk in your way.
Shaving off the bare minimum of the joint surfaces is actually seldom a good thing... your non-union risk goes up, you can't close down the IM (without leaving big gaps, cutting off lateral base of first met and medial 2nd... which kills perf artery). The proper way to do it, in my hands, is to use a saw and resect the joint quickly and well with a long bunion blade saw (the way in Chang textbook or the article below). Lapidus, like any fusion, causes shortening no matter how it's done... the key for fusions is getting good position in the end result. Even Myerson, who has done more Lapidus than all of us combined and advocates attempting hand resection and minimal resection, clearly says in his book and articles that that won't work in the majority of cases, that you won't be able to just translate the joint to correct deformity, and you then need to resect more off the lateral side of the cunieform. I don't even bother with hand resect anymore in any but the very smallest of IM cases (maybe for bunion IMA of 12-15deg crazy hypermobile). You need to take that wedge off the cunieform to re-shape it almost every time, so I just do that from the start... that cunieform being a faulty rhomboid "atavistic" is the whole problem in the first place, as described in original Lapidus article.
THIS was the article that basically popularized modern Lapidus in podiatry (and Myerson, who the West Penn guys tend to cue off, was the one who did popularize Lapidus for ortho F&A). The West Penn article was written by two ACFAS past presidents plus a main author who easily could've been if he wanted to... widely considered as one of the best all-time educators in podiatry. It's JFAS, so you can login through ACFAS or your library... very good 10min read.
The question becomes: if these West Penn guys who pioneered modern podiatry Lapidus (and me... and tons of other DPM and ortho surgeons) can do this procedure well with $100-300 in screws (cannulated or solid), then how in the heck does anyone need a $3000-$6000+ "system" to do the same job? They don't. It's technique over technology. If you told a physician-owned surgery center you were going to use any Lapidus system, they'd tell you to go kick rocks and probably revoke your shares if you went through with the case using a system, which would lose them money on the surgery. As I said, I use a ~$1000 steel lock plate construct in about 2/3 of my Lapidus cases just to protect the patient a bit more from a fall on their boot or to let them WB a couple weeks earlier, but I also tell them that plate might need to come out later if it irritates EHL or a nerve when wearing shoes. I saw dozens and dozens of long term Lapidus in my month at West Penn that had 2 screws or even 1 screw + 1 Steinmann pin and did just fine. There are many simple ways to get the job done.
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It remains to be seen if they will even got after the amnio inject money aggressively - or at all. It may just be a power move to get people to stop doing them and stop the cash hemorrhage.
The grafts are definitely not on solid footing (nor is anything super overpriced with no EBM), but there's no way to know right now. I would say it is likely they will get the same fate as amnio injects, reimbursements cut significantly (PRP, sclerosing, etc), or at least indications severely narrowed (bone stims, other grafts, HBO, etc). We shall see...
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Tenaculum, pin distractor, 4.0 screw, simple 4 hole locking plate. I use a burr on the lateral side of the met and cuneiform. 60 minutes... 75 if I add in an Akin... Toe is straight when they leave the OR, without any magical bandage holding it straight either... I let them protected WB immediately.
All of these Lapidus systems are a joke...
All of these Lapidus systems are a joke...
