A Lapidus Prodedure for the first MTP and first ray was first used in the early 1900’s, and is an option today for failed treatment of hallux valgus.  In cases where bunion surgery fails to control continued valgus deformity, this surgical procedure is an option.  It involves pinning and fusing the first metatarsal-first cuneiform joint, along with pinning the first metatarsal into the base of the second.  The first metatarsal is placed in a slightly plantarflexed position, and care is used to make sure there is not any rotation.  There may be the need for shortening osteotomies of either the first or the second metatarsal, depending on the lengths or shortness of each.

A recent study found that there was good satisfaction with the procedure, non-unions only occurred in smokers, no patients suffered transfer metatarsalgia (pain from weightshifting over to the lateral 3 metatarsal heads as a compensatory mechanism), and no recurrent hallux valgus increase, or increase in the hypermobility associated with, in an average of 1.8 years.

Post op treatment requires longer (6 weeks) of non-weightbearing, and then cast removal and PT is started if bony union looks good.  Swimming and cycling can start at 8 weeks, and no vigorous activity until 3 months

A Boyd and Pirogoff Hindfoot amputation is similar to a Syme’s, but differs in that it retains part of the calcaneus.  This leaves a longer limb with an average of 3-5cm from bulb to ground (but sometimes only 1cm), versus 6-10 cm seen in the typical Syme’s.  The distal articulation is still fused.  The bulbous nature means that a one-piece socket is impossible, so bivalve systems are used with a SACH heel and flexible forefoot.  The foot has a tendency to roll inwards, especially if the calcaneus is fused in too much varus positioning. 

The Journal of Foot and Ankle Surgery reports that in great toe ulceration, almost all patients exhibit structural hallux limitus, and most have hallux abductus.  After this, the descending order of other factors seen include:  Gastroc/soleus equinus, dorsiflexed first ray, functional hallux limitus, IP join sesamoid, hyperextended IP joint, prominent plantar medial condyle of the distal phalanx, metatarsus primus adductus, and hallux malleus.  A diabetic patient at risk for ulceration with any of these conditions should be treated appropriately.