From the Research
Foot surgeons frequently disagree about diagnosing nonunion after a Lapidus bunionectomy that has persisted for over one year, with disagreement rates likely exceeding 20% among specialists when evaluating the same radiographic evidence. This disagreement stems from the challenging nature of assessing fusion at the first tarsometatarsal joint, where subtle motion may persist despite apparent radiographic healing 1. Surgeons typically look for bridging bone across 50-75% of the joint surface on CT scans or radiographs, but interpretation varies significantly. Some surgeons consider asymptomatic incomplete fusion acceptable if the patient has no pain and normal function, while others define nonunion more strictly based on radiographic criteria alone. This disagreement impacts treatment decisions, as some surgeons may recommend revision surgery for radiographic nonunion despite minimal symptoms, while others may opt for conservative management if the patient is functioning well. The clinical presentation, including pain with weight-bearing or shoe pressure at the fusion site, often weighs heavily in the final determination alongside imaging findings. Key factors that may influence the likelihood of nonunion and thus the degree of disagreement among surgeons include the patient's overall health, the presence of endocrine or metabolic abnormalities, and the specific surgical technique and fixation method used 2, 3. However, the most recent and highest quality study on the topic of secondary surgery following Lapidus bunionectomy found that the use of a screw for third point of fixation emerged as an independent risk factor for revision surgery 1. Given the variability in interpretation and the potential for significant morbidity associated with nonunion, it is crucial for foot surgeons to carefully evaluate each patient's clinical presentation and radiographic findings to make informed decisions about the diagnosis and management of nonunion after Lapidus bunionectomy. This may involve a multidisciplinary approach, including consultation with other specialists and the use of advanced imaging techniques to guide treatment decisions. Ultimately, the goal should be to prioritize the patient's quality of life and functional outcomes, while also minimizing the risk of complications and the need for revision surgery.