First metatarsophalangeal joint arthrodesis: current fixation options

Republication of "First Metatarsophalangeal Joint Arthrodesis: Functional Outcomes Using 2 Different Fixation Techniques. Is More Expensive Better?"

Background

First metatarsophalangeal (MTP) joint arthrodesis can be fixed using either a dorsal plate or crossed screws. However, there is considerable difference in the cost of these implants, and it is not known if there is sufficient difference in outcome that might justify this cost difference. Our aim was to compare the functional results and patient satisfaction rates after first MTP joint arthrodesis in a group of patients using the same surgical technique except for the fixation devices.

Methods

A prospective cohort of 27 patients who underwent first MTP joint fusion by the same surgeon using 2 crossed screws or a single screw with a dorsal plate was recruited over a 3-year period. Demographic information, patient satisfaction rates, complications, and union rates were evaluated. American Orthopaedic Foot & Ankle Society (AOFAS) and visual analog scale (VAS) scoring systems were used pre- and postoperatively to compare the functional outcomes. Thirty consecutive procedures (screws, n = 15; plate, n = 15) were performed. Age (55.8 ± 11.1 vs 63.3 ± 12.4 years for screws and plate respectively; P = .091) and female gender percentages (80% and 73%, P = .666) were similar between groups.

Results

The overall union rate was 93% with no differences between groups. AOFAS and VAS scores improved significantly postoperatively for each technique, and no differences were found between the two in the improvement in AOFAS (42.4 ± 8.0 vs 44.3 ± 8.2, screws and plate respectively; P = .520) and VAS scores (66.0 ± 5.4 vs 69.0 ± 6.9;P = .195). The implant cost for screws was $40 and for dorsal plate, $328.

Conclusions

First MTP joint fusion using either screws or plate fixation results in an improvement in AOFAS and VAS scores. Functional improvement and patient satisfaction did not differ between the 2 techniques, despite a considerable difference in cost between the two methods of fixation.

Level of Evidence

Level III, prospective comparative study.

Retrospective Comparison of Two Different Fixation Methods for First Metatarsophalangeal Joint Arthrodesis

Background and Purpose: Arthrosis of the first MTP joint is a common condition. Among the available arthrodesis methods, plate/screw and screw methods are the current treatment methods of choice. In this study, we investigate whether there is a difference between these two methods. Methods: Thirty-four toes of 32 patients with advanced arthrosis were included in the study. Eighteen toes were fixed with plates/screws and 16 with cross-screws. In the radiological evaluations, malunion and nonunion were examined. Clinical evaluation was made according to AOFAS-HMI scoring. Results: The mean age of the patients was 57.74 years and the mean follow-up period was 22.21 months. There was no statistically significant difference in clinical scores or union times between the two groups. As complications, superficial skin problems developed in 2 (5.9%) cases, deep infection in 3 (8.8%) cases, and nonunion in 3 (8.8%) cases. There was no statistically significant difference between the two groups in this regard. Conclusion: Plate/screw and cross-screw techniques give similar clinical and radiological results in cases of arthrodesis of the first MTP joint. The cross-screw technique, which can be performed more easily and has lower costs, should be the first choice.

Minimally-invasive hallux arthrodesis with endomedullary and a crossed screw fixation

BACKGROUND

Minimally invasive surgery has several advantages: minor pain, smaller incisions and less tissue damage than traditional open surgery. Hallux arthrodesis with an endomedullary screw fixation provides compression and axial stability. The aim of this study was to describe the procedure and evaluate our first results of the minimally invasive first metatarsophalangeal arthrodesis with an endomedullary screw combined with a crossed screw fixation.

METHODS

We retrospectively studied 15feet, with a minimum 1year follow-up. Patients were evaluated with full-load radiographs and AOFAS score preoperatively and at last follow-up.

RESULTS

Consolidation rate was 93.3%, radiological consolidation time was 18 weeks (14-60). Radiographic alignment was achieved with satisfactory results. The preoperative AOFAS score improved from a mean 49 to 90 (p=0.001). There was one postoperative superficial site infection, which healed and a patient developed a pseudarthrosis but it was asymptomatic.

CONCLUSIONS

The minimally invasive metatarsophalangeal arthrodesis with an intramedullary screw is a secure procedure with comparable results to open techniques.

LEVEL OF CLINICAL EVIDENCE

4.

Revision of Failed First Metatarsophalangeal Joint Implant

Revision surgeries, as well as conversions from implants to arthrodesis, can present unique challenges to the foot and ankle surgeon. Proper perioperative planning assists in optimizing the outcome of the procedure. In general, some amount of bone loss and/or shortening of the first metatarsal takes place, leading to the need for augmenting the site with bone graft or a synthetic substitute. Fixation also plays a key role in obtaining a successful conversion. A solid construct combined with bone graft assists the foot and ankle surgeon in achieving an optimal outcome.

First Metatarsophalangeal Joint Arthrodesis: Does the Addition of a Lag Screw to a Dorsal Locking Plate Influence Union Rate and/or Final Alignment after Fusion

First metatarsophalangeal (MTP-1) joint fusion is a reliable method for the correction of various deformities, including hallux valgus and hallux rigidus. Ideal constructs provide high rates of fusion in the desired alignment. The present study examined the union rates and the change in dorsiflexion angle during the follow-up period in patients who had undergone MTP-1 fusion with a dorsal locking plate and a lag screw compared with patients who had undergone fusion with a dorsal locking plate alone. We performed a retrospective review of 99 feet undergoing MTP-1 fusion. The joints were fused using either a dorsal locking plate alone or a lag screw plus a dorsal locking plate. Union was determined radiographically during the follow-up period. Suspected nonunions were confirmed by computed tomography. The dorsiflexion angles were radiographically measured at the first postoperative visit and at the final follow-up visit. Of the 99 feet, 36 (36.4%) were in the lag screw plus dorsal plate group and 63 (63.6%) in the dorsal plate group. The mean follow-up period was 12.9 (range 12 to 33.5) months. The dorsal plate plus lag screw group had a significantly lower change in the mean dorsiflexion angle (0.57° ± 5.01°) during the postoperative period compared with the dorsal plate group (6.73° ± 7.07°). The addition of a lag screw to a dorsal locking plate for MTP-1 arthrodesis might offer improved stability of the joint in the sagittal plane over time compared with a dorsal plate alone.

First Metatarsophalangeal Joint Arthrodesis

Background:

First metatarsophalangeal (MTP) joint arthrodesis can be fixed using either a dorsal plate or crossed screws. However, there is considerable difference in the cost of these implants, and it is not known if there is sufficient difference in outcome that might justify this cost difference. Our aim was to compare the functional results and patient satisfaction rates after first MTP joint arthrodesis in a group of patients using the same surgical technique except for the fixation devices.

Methods:

A prospective cohort of 27 patients who underwent first MTP joint fusion by the same surgeon using 2 crossed screws or a single screw with a dorsal plate was recruited over a 3-year period. Demographic information, patient satisfaction rates, complications, and union rates were evaluated. American Orthopaedic Foot & Ankle Society (AOFAS) and visual analog scale (VAS) scoring systems were used pre- and postoperatively to compare the functional outcomes. Thirty consecutive procedures (screws, n = 15; plate, n = 15) were performed. Age (55.8 ± 11.1 vs 63.3 ± 12.4 years for screws and plate respectively; P = .091) and female gender percentages (80% and 73%, P = .666) were similar between groups.

Results:

The overall union rate was 93% with no differences between groups. AOFAS and VAS scores improved significantly postoperatively for each technique, and no differences were found between the two in the improvement in AOFAS (42.4 ± 8.0 vs 44.3 ± 8.2, screws and plate respectively; P = .520) and VAS scores (66.0 ± 5.4 vs 69.0 ± 6.9; P = .195). The implant cost for screws was $40 and for dorsal plate, $328.

Conclusions:

First MTP joint fusion using either screws or plate fixation results in an improvement in AOFAS and VAS scores. Functional improvement and patient satisfaction did not differ between the 2 techniques, despite a considerable difference in cost between the two methods of fixation.

Level of Evidence:

Level III, prospective comparative study.

Radiographic evaluation of first MTP joint arthrodesis for severe hallux valgus: Does the introduction of a lag screw improve union rates and correction of the intermetatarsal angle?

BACKGROUND

First metatarsophalangeal (MTP-1) joint fusion is a reliable method for the correction of various deformities including hallux valgus and hallux rigidus. Ideal constructs provide high rates of fusion in desired alignment. The present study examines the union rates, as well as the change in dorsiflexion angle during the follow up period in patients who underwent MTP-1 fusion with a dorsal locking plate and a lag screw, versus patients fused with a dorsal locking plate alone.

METHODS

This is a retrospective review of 99 feet undergoing MTP-1 fusion. Joints were fused using either a dorsal locking plate alone or a lag screw plus a dorsal locking plate. Union was determined radiographically during the follow up period. Suspected nonunions were confirmed with CT. Dorsiflexion angles were radiographically measured at first post-operative visit and at final follow up.

RESULTS

There were 36 patients in the lag screw plus dorsal plate group, and 63 in the dorsal plate group. Mean follow up was 12.9 months (Range: 12-33.5 months). The dorsal plate plus lag screw group had a significantly lower change in mean dorsiflexion angle (0.57°±5.01°) during the post-operative period compared to the dorsal plate group at final follow up versus the dorsal plate group (6.73°±7.07°).

CONCLUSION

The addition of a lag screw to a dorsal locking plate for MTP-1 arthrodesis may offer improved stability of the joint in the sagittal plane over time compared to a dorsal plate alone.

LEVEL OF EVIDENCE

Retrospective level III evidence.

Accuracy and Reliability of Postoperative Radiographic Evaluation of First Metatarsal-Phalangeal Joint Arthrodesis

The clinical value of routine postoperative radiographic evaluation after orthopedic procedures has recently been called into question. The objective of the present investigation was to evaluate the ability of foot and ankle surgeons to accurately and reliably assess postoperative radiographs after first metatarsal-phalangeal joint arthrodesis. Thirty sets of digital radiographs from 11 patients who had undergone first metatarsal-phalangeal joint arthrodesis were retrospectively evaluated by 5 podiatric physicians board-certified in foot surgery. The surgeons were asked to answer several questions, including whether the radiograph appeared to be >4 or <4 postoperative weeks; whether the radiograph appeared to be >8 or <8 postoperative weeks; their estimation of the postoperative week; and whether they would allow the patient to begin weightbearing based on the radiographic findings. With respect to whether the radiographs were >4 or <4 postoperative weeks, surgeons made accurate assessments 63.33% of the time (95 of 150; range 56.67% to 73.33%), with a kappa of 0.220. With respect to whether the radiographs were >8 or <8 postoperative weeks, surgeons made accurate assessments 60.0% of the time (90 of 150; range 53.33% to 70.0%), with a kappa of 0.203. With respect to the estimation of the postoperative week of the radiograph, surgeons accurately assessed the radiographs within a 4-week period 34.0% of the time (54 of 150; range 26.67% to 46.67%), with a kappa of 0.425. With respect to allowing the patient to bear weight according to the radiographic findings, the surgeons were in complete agreement 26.67% of the time (8 of 30), with a kappa of 0.251. These results provide evidence against the serial routine use of postoperative radiographs for the first metatarsal-phalangeal joint arthrodesis in the absence of a specific clinical indication.

Complication rates in diabetics with first metatarsophalangeal joint arthrodesis

BACKGROUND

First metatarsophalangeal joint (MTPJ) arthrodesis has been an effective surgical entity when indicated, but a range of severe to mild complications can occur from this procedure. Patients with diabetes mellitus have an increased risk in surgical complications, most commonly associated with soft tissue and bone healing, when compared to non-diabetic patients. The purpose of this study was to evaluate the complication rates of first MTPJ arthrodesis in diabetic patients and compare them to the existing complication rates for the procedure.

METHODS

A retrospective chart review was done on 76 diabetic patients, from June 2002 to August 2012. Thirty-two males and 44 females were included in the study. The authors evaluated many variables that could impact postoperative complications, including age, gender, bone graft incorporation, hemoglobin A1c, tobacco use, body mass index, peripheral neuropathy, hallux extensus, hallux interphalangeal arthritis, and rheumatoid arthritis, and compared them with the complication findings. Patient follow-up was no less than 24 months.

RESULTS

Overall, approximately two-thirds of the patients had no complications and 35.5% of patients had at least one mild or moderate complication. Of the non-union and mal-union complications, 80 and 70% had peripheral neuropathy, respectively. One hundred percent of the patients that had mal-positions or hardware failure also had peripheral neuropathy. No severe complications were seen during follow-up. Only two of the moderate complications needed revisions, and the rest of those with moderate complications were asymptomatic.

CONCLUSION

In conclusion, first MTPJ arthrodesis is overall an effective and beneficial procedure in patients with diabetes mellitus. Diabetic patients with peripheral neuropathy have an increased risk for mild and moderate complications.

Biomechanical comparison of first metatarsophalangeal joint arthrodeses using triple-threaded headless screws versus partially threaded lag screws

BACKGROUND

Triple-threaded, cannulated headless screws of varying thread diameters and pitch are designed to maintain thread length across the arthrodesis plane, provide joint compression, and reduce countersinking. This study tested the biomechanical fixation strength of conventional partially threaded lag screws compared to triple-threaded headless screws in first metatarsophalangeal joint arthrodesis.

METHODS

First metatarsophalangeal joint arthrodesis using a crossed screw technique was performed on 11 paired, preserved cadaver first rays with two 4.0-mm triple-threaded, cannulated headless screws or two 4.0-mm partially threaded, cannulated lag screws. The constructs were tested to failure through dorsally directed cantilever bending.

RESULTS

The triple-threaded, cannulated headless screws displayed significantly greater bending stiffness (p=0.017) and failure load (p=0.040) during load-to-failure testing compared to the partially threaded, cannulated lag screws.

CONCLUSIONS

Triple-threaded, cannulated headless screws may be a viable alternative to partially threaded lag screws in first metatarsophalangeal arthrodesis.

Low-profile titanium plate construct for early weightbearing with first metatarsophalangeal joint arthrodesis

First metatarsophalangeal joint arthrodesis is a useful procedure for various first ray pathologic entities. Multiple constructs for fixation have provided successful fusion. A retrospective study of 21 feet (18 patients) was performed after first metatarsophalangeal joint fusion using crossed Kirschner wires or compression fixation with cannulated screws followed by the application of a 2-hole low-profile partially locking titanium plate. The median age was 59 (range 41 to 76) years, and we had 4 smokers and 3 patients with diabetes in our series. Postoperatively, a compression dressing with a posterior splint was applied. The patients then transitioned to a controlled ankle motion walker, and all patients reported full weightbearing by 2 weeks postoperatively. The mean follow-up duration was 11.43 (range 6 to 27) months. The overall primary fusion rate was 95.24% (20 of 21). Two nonunions occurred; one was asymptomatic and successfully consolidated at 12 months. The second nonunion required revisional surgery with an autogenous bone graft to heal successfully. This patient was noncompliant with the postoperative regimen and had a 48-pack year history of tobacco usage. Our results have shown early weightbearing after first metatarsophalangeal joint arthrodesis can be successfully initiated with splintage or lag screw fixation and a 2-hole, low-profile, partially locking titanium plate.