One Group’s Postoperative Protocol For Triplane Bunion Correction

Bunion correction surgery has changed considerably in the past century and even more so in the past decade. Early publications outlining procedures most similar to what we may recognize as the McBride and Silver bunionectomies do not address postoperative weight bearing status. In 1986, Robert Weir published a case series of patients who underwent an exostectomy of the dorsomedial eminence of the first metatarsal with technique modifications, including sesamoid excision and extensor hallucis brevis (EHB) tendon bisection with reattachment on the periosteum of the medial aspect of the proximal phalanx. He noted “the patient walking about with fair comfort three weeks later.” He splinted some patients in plaster of Paris, and many remained in the hospital for several weeks.¹

Distal metatarsal osteotomies developed and improved upon throughout the twentieth century with fixation do not require a prolonged non-weight bearing period.^1,5,6 Most patient may bear weight in a stiff postop shoe the day of surgery.² Proximal metatarsal osteotomies generally require non-weight bearing for approximately six to eight weeks, followed by gradual transition to weight bearing.³ In our clinical observation, the long recovery time is partly to blame for the relative lack of popularity of proximal metatarsal osteotomies for bunion correction.

The first tarsometatarsal arthrodesis, commonly known as the Lapidus bunionectomy, historically requires a minimum period of two weeks of non-weight bearing, then four to six weeks of weight bearing as tolerated in a postoperative shoe.⁴ Paul Lapidus originally described his postoperative protocol with immobilization in plaster of Paris for longer than eight weeks.⁵ However, by 1956 he began applying a “steel corset splint,” and on postoperative day two he allowed the patient to bear weight to the heel and lateral foot. Splint removal took place after two to three weeks and patients used crutches for three to four weeks. The patient would transition to wide toe box shoes at six weeks postoperatively and return to work at eight weeks. The patient would also remain in the hospital for one week postoperatively.⁵

More recent investigations explored earlier mobilization protocols and employed them with relative safety. A systematic review by Crowell and colleagues found a non-union rate of 3.61 percent in patients who underwent first tarsometatarsal joint arthrodesis when they began weight bearing before two weeks postop.⁶ King and team initiated weight bearing in a CAM boot within the first two weeks following a modified Lapidus bunionectomy with crossing screw fixation.⁷ They noted maintained correction in 92 percent of patients at 12 months, with eight percent of patients experiencing a delayed union, and 2.2 percent experiencing a nonunion⁷. In a multicenter retrospective study, Ray et al. initiated weight bearing in CAM walker following a triplane bunion correction surgery on the day of surgery or at 2 weeks postoperatively. They evaluated IMA, HAV angles, and TSP radiographically, as well as signs of osseous union, at 6 weeks, 4 months, and 12 months. 1/62 (1.6 percent) of patients experienced a symptomatic nonunion, with RA and PAD comorbidities. Furthermore, 3.2 percent of patients had a recurrence of a bunion deformity at the 12 month follow-up⁸.

The postoperative protocol in our practice after a first tarsometatarsal arthrodesis utilizing triplane bunion correction begins with 10 to 14 days of non-weight bearing with a posterior splint and crutches or knee scooter until the first follow up visit. We find less of a need for narcotic and non-narcotic pain medications utilizing this protocol. Radiographs allow us to confirm that hardware and correction remain intact. Following that, we encourage patients to bear weight as tolerated in a CAM boot for two weeks, after which, patients transition to a stiff-soled postoperative sandal for another two weeks.

During this time, we also encourage patients to start with gentle, passive range of motion exercises at the first MPJ of the operative extremity. At the second postoperative visit, if there are no contraindications on repeat radiographs or the physical exam, patients may transition into supportive shoes and begin physical therapy. Our patients find great success with range of motion of the first MPJ, gait training, swelling, and scar reduction while in physical therapy. We typically employ no activity restrictions and return to running, sports, long distance walking, etc., at 12 weeks postoperatively.

Dr. Miller is the Director of the Pennsylvania Intensive Lower Extremity Fellowship at Premier Orthopaedics in Malvern, Pa.

Dr. Capuzzi is the Fellow of the Pennsylvania Intensive Lower Extremity Fellowship at Premier Orthopaedics in Malvern, Pa.

Dr. Siwy is a second-year podiatric medicine and surgery resident at Tower Health/Phoenixville Hospital in Phoenixville, Pa. 

References

1. Weir RF. The operative treatment of hallux valgus. Ann Surg. 1897;25(4):444-453.
2. Brosky TA, Hall PB. Distal metaphyseal osteotomies in hallux abducto valgus surgery. In: Southerland JT, Boberg JS, Downey MS, Nakra A, Rabjohn LV (eds). McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery (4^th ed) Philadelphia:Wolters Kluwer Health; 2013:279-289.
3. Mothershed RA. Proximal osteotomies of the first metatarsal. In: Southerland JT, Boberg JS, Downey MS, Nakra A, Rabjohn LV (eds) McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery (4^th ed). Philadelphia:Wolters Kluwer Health; 2013:290-301.
4. DiDomenico LA, Wargo-Dorsey M. Lapidus bunionectomy: first metatarsal-cuneiform arthrodesis. In: Southerland JT, Boberg JS, Downey MS, Nakra A, Rabjohn LV (eds) McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery (4^th ed). Philadelphia:Wolters Kluwer Health; 2013:322-330.
5. Lapidus PW. A quarter of a century of experience with the operative correction of the metatarsus varus primus in hallux valgus. Bull Hosp Joint Dis. 1956;17(2):404-421.
6. Crowell A, Van JC, Meyr AJ. Early weightbearing after arthrodesis of the first metatarsal-medial cuneiform joint: a systematic review of the incidence of nonunion. J Foot Ankle Surg. 2021;57(6):1204-1206.
7. King CM, Richey J, Patel S, Collman DR. Modified lapidus arthrodesis with crossed screw fixation: early weightbearing in 136 patients. J Foot Ankle Surg. 2015;54(1):69-75.
8. Ray JJ, Koay J, Dayton P, Hatch DJ, et al. Multicenter early radiographic outcomes of triplanar tarsometatarsal arthrodesis with early weightbearing. Foot Ankle Int. 2019;40(8):955-960.