In vivo comparison of screw versus plate and screw fixation for first metatarsophalangeal arthrodesis: does augmentation of internal compression screw fixation using a semi-tubular plate shorten time to clinical and radiologic fusion of the first metatarsophalangeal joint (MTPJ)?

Crossed screws versus plating supplemented with an interfragmentary screw in first metatarsophalangeal joint fusion: A systematic review and meta-analysis

First metatarsophalangeal joint (MTPJ) fusion is an effective surgical intervention for conditions such as hallux valgus and hallux rigidus. This systematic review and meta-analysis aims to compare the safety and efficacy of crossed screws versus plating supplemented with an interfragmentary screw. A literature search of the Scopus, Embase, Web of Science, and MEDLINE databases was performed to identify all studies directly comparing the two techniques. Meta-analysis was carried out using RevMan Web. Nine studies with 976 patients (1,035 toes in total, 512 toes in the crossed screws group, and 523 toes in the plate supplemented with screws group) were included. There was no significant difference in union rates (OR=0.75, CI 0.45 - 1.27, p = 0.29), overall complication rates (OR = 1.13, CI = 0.71 - 1.77, p = 0.61), superficial complications, (OR = 0.41, CI = 0.10 - 1.68, p = 0.22), revision surgery (OR = 1.92, CI 0.81 - 4.57, p = 0.14), hardware removal (OR = 1.07, CI = 0.55 - 2.08, p = 0.85), and malunion (OR = 1.63, CI 0.27 - 10.00, p = 0.60). Plate and screws had a significantly shorter time to fusion than crossed screws (MD = 0.51, CI = 0.10 - 0.92, p = 0.02). No significant difference was noted in patient-reported outcome measures or in postoperative hallux valgus, intermetatarsal, and lateral metatarsophalangeal angles. Other potential factors that should influence the decision to use one technique over the other include the indication for MTPJ fusion, the patient's bone quality, and the differing costs of surgery.

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.

Minimally invasive arthrodesis of the first metatarsophalangeal joint: A systematic literature review

AIM

Currently, cohort studies reported the use of minimally invasive arthrodesis of the first metatarsophalangeal joint (MTP I). The aim of this systematic literature review was to analyse clinical, radiological outcome and complications with this technique.

METHODS

A systemic literature search of the databases Google Scholar, PubMed, Scopus, EMBASE and Cochrane to identify studies reporting on clinical, radiological outcome or complications of minimally invasive MTP I arthrodesis was conducted.

RESULTS

A total of 6 studies (1 Level V, 5 Level IV) reporting on 109 minimally invasive MTP arthrodesis in 105 patients were included. Validated scores were reported in 103 cases. Clinical outcome improved in 57 cases from a mean of 36.9 to 82.6 points American Orthopedic Foot and Ankle Score (AOFAS) and in 46 cases from 38.7 to 18.4 points Manchester Oxford Foot Questionnaire (MOXFQ). Radiological fusion rate was 87% (n = 94 out of 109) achieved after 6-12 weeks. Overall complication rate was 11.9% (13 cases) leading to revision surgeries in 5.5% (6 cases). Most common complications Most common complications were symptomatic non-union (n = 6, 5.5%), asymptomatic non-union (n = 2, 1.8%) and subsequent interphalangeal joint arthritis (n = 2, 1.8%).

CONCLUSION

Minimally invasive MTP I arthrodesis is a promising technique with comparable clinical, radiological outcome and complication rates to open surgery in hallux rigidus and rigido-valgus. Future studies are needed providing higher level of evidence to prove the potential benefit of minimally invasive compared to open MTP I arthrodesis.

Biomechanical Comparison of Low-Profile Contoured Locking Plate With Single Compression Screw to Fully Threaded Compression Screws for First MTP Fusion

BACKGROUND

Open metatarsophalangeal (MTP) arthrodesis using locked plates produces good clinical outcomes. However, arthroscopic fusion with new-generation fully threaded compression screws is emerging as an alternative. The purpose of this study was to compare low-profile contoured locked plates with fully threaded compression screws for first MTP fusion, in a biomechanical cadaveric model.

METHODS

The first rays of 8 matched pairs of fresh frozen cadaveric feet underwent dissection and dual-energy x-ray absorptiometry (DEXA) scanning to measure bone mineral density (BMD). The "plate" group was prepared with cup-and-cone reamers, and fixation of the MTP joint with 1 compression screw and low-profile dorsal locked plate. The matched-pair "screws" group was prepared through a simulated arthroscopic technique, achieving fixation with 2 new-generation fully threaded compression screws. The plantar MTP gap was recorded with an extensometer during 250 000 90-N cyclic loads followed by a single load to failure.

RESULTS

The screw group demonstrated significantly greater stiffness, 31.6 N/mm (plates) and 51.7 N/mm (screws) (P = .0045). There was no significant difference in plantar gapping or load to failure, 198.6 N (plates) and 290.1 N (screws) (P = .2226). Stiffness and load to failure were highly correlated to BMD for the screw group, r =0.79 and r = 0.94, respectively, but less so for the plate group, r = 0.36 and r = 0.62, respectively. The maximum metatarsal head height measured on the lateral view was strongly correlated with load to failure for both the plate- and screw-only groups (r > 0.9).

CONCLUSION

These data demonstrate that hallux MTP arthrodesis utilizing fully threaded compression screws had similar plantar gapping and load to failure when compared with the low-profile locking plate, but with significantly more stiffness. These results support an increased role of fully threaded screws for MTP arthrodesis using either the arthroscopic or open technique. However, with decreased BMD plate fixation may remain the better fixation choice.

CLINICAL RELEVANCE

Our data suggest that with regard to construct stability, fully threaded headless compression screws may be just as effective as low-profile locking plates, but BMD and MTP joint fluoroscopic measurements should be considered in the decision-making process for fixation.

Progression of Healing on Serial Radiographs Following First Ray Arthrodesis in the Foot Using a Biplanar Plating Technique Without Compression

A review of 195 first ray arthrodeses fixated with a twin-plate biplanar construct, without interfragmentary compression, is presented. This fixation construct was evaluated in a consecutive cohort of patients undergoing first metatarsophalangeal joint (MTP) arthrodesis or the first tarsometatarsal joint (TMT) arthrodesis. Multiple radiographs were used to assess the progression of healing at the following postoperative time frames: 4 to 9 weeks, 10 to 12 weeks, >12 weeks, and the final follow-up. In total, 85 feet underwent first MTP arthrodesis, and 110 feet underwent first TMT arthrodesis. At the final radiographic follow-up, 97.44% of all cases had shown progressive osseous gap filling at the arthrodesis site, stable position of the bone segments, and intact hardware without loosening, 98.24% of the first MTP arthrodesis group and 96.82% of the first TMT arthrodesis group. Five (5.43%) feet had the presence of lucency at the fusion interface at the final follow-up, without positional change or hardware failure. Four (1.8%) feet had a failure of the hardware, loss of position, or frank gapping at the fusion site. Lucency decreased consistently over time in this series of patients (p < .00001). Progressive increase in callus density at the fusion site on serial radiographs was noted to be a consistent finding for both procedures and was the primary indicator of secondary bone healing at the noncompressed, relatively stable arthrodesis site. Our results confirm that biplanar plating construct without interfragmentary compression produces high fusion rates following the first MTP or TMT arthrodesis, with early weightbearing.

Early Weight-Bearing After Arthrodesis of the First Metatarsal-Phalangeal Joint: A Systematic Review of the Incidence of Non-Union

Arthrodesis of the first metatarsal-phalangeal joint is a reliable procedure for correction of both hallux limitus/rigidus and severe hallux abducto valgus deformities. However, 1 potential contraindication to the procedure is the extended period of non-weight-bearing immobilization that is typically associated with the postoperative course. The objective of this investigation was to perform a systematic review of the incidence of non-union after early weight bearing in patients who underwent arthrodesis of the first metatarsal-phalangeal joint. We performed a review of electronic databases with the inclusion criteria of retrospective case series, retrospective clinical cohort analyses, and prospective clinical trials with n ≥ 15 feet, a mean follow-up of ≥12 months, a defined postoperative early weight-bearing protocol (defined as ≤2 weeks), a clear description of the fixation construct, a reported incidence rate of non-union, and patients who underwent primary surgery for hallux abducto valgus or hallux limitus/rigidus deformities. Seventeen studies met our inclusion criteria, with a total of 898 feet analyzed. Of these, 57 (6.35%) were described as developing a non-union. This would likely be considered an acceptable crude, heterogeneous incidence of non-union when considering this procedure. It might also indicate that arthrodesis of the first metatarsal-phalangeal joint does not always require an extended period of non-weight-bearing postoperative immobilization.

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.

Effect of joint pathology, surface preparation and fixation methods on union frequency after first metatarsophalangeal joint arthrodesis: A systematic review of the English literature

BACKGROUND

The aim of this systematic review was to perform a qualitative synthesis of the current literature to determine the union frequencies for first metatarsophalangeal joint arthrodesis as well as the influence of pathology, joint preparation and fixation methods on union.

METHODS

MEDLINE and EMBASE were searched to identify relevant studies reporting on first metatarsophalangeal joint union frequencies.

RESULTS

26 studies with 2059 feet met our inclusion criteria. The mean age was 60 years (range 18-84) and the mean follow-up was 32.6 months (range 1.5-156). The union frequency was 93.5% (1923/2059). The union frequencies were significantly higher when low velocity joint preparation methods were used (P<0.0001, Chi Square 22.5) and the pathology was hallux rigidus (P=0.002, Chi square 9.3). There were similarly high union frequencies with crossed screws, locking plate and non-locking plates.

CONCLUSIONS

High union frequency can be expected following first metatarsophalangeal arthrodesis, especially when low velocity joint preparation methods are used in patients with hallux rigidus.

Quality of Early Union After First Metatarsophalangeal Joint Arthrodesis

The aim of the present retrospective cohort study was to assess the quality of union and the clinical outcomes in patients who had undergone first metatarsophalangeal joint (MTPJ) fusion using a dorsal plate and plantar lag screw. From March 2011 to December 2012, the clinical and radiographic data of 39 patients (41 feet) who had undergone first MTPJ fusion using a compressive locking plate were retrospectively reviewed. All patients had undergone postoperative computed tomography at 6 weeks postoperatively to assess union. The average metatarsophalangeal angles improved from 23° ± 16° preoperatively to 14° ± 5° postoperatively. The dorsiflexion of the hallux at the preoperative assessment averaged 17° ± 11° and 23° ± 5° postoperatively. At 6 weeks postoperatively, the computed tomography scans demonstrated 3 complete fusions (7.3 %) and 38 partial unions (92.7%). Also at 6 weeks, the mean ± standard deviation joint bridging was 54% ± 14.6%. The forefoot American Orthopaedic Foot and Ankle Society scale score had improved significantly from 50 ± 13 preoperatively to 80 ± 7 at >1 year of follow-up (p = .001). Hardware removal was performed in 8 cases because of pain in 7 and infection in 1. Revision arthrodesis was required in 2 cases because of nonunion. At 6 weeks postoperatively, partial bony joint bridging could be observed in most cases after arthrodesis of the first MTPJ with the dorsal fusion plate.

First Metatarsalphalangeal Joint Arthrodesis: A Retrospective Comparison of Two Methods of Fixation

First metatarsalphalangeal joint arthrodesis is a well established and successful treatment; however there still remains controversy over the best choice of construct. We performed a retrospective study of patients undergoing first metatarsalphalangeal fusion over eighteen months (n=52) using either dorsal non-locking plate with additional compression lag screw fixation or dorsal non-locking plate alone. We found when assessing clinical criteria, patients with dorsal non-locking plates and additional compression lag screw fixation had a significantly higher rate of fusion (100% vs 77.8%), significantly higher rate of fusion within the first two months (55.6% vs 83.3%), significantly earlier time to fusion (52.2 days vs 75.6 days), and significantly lower rate of non-union (0% vs 22.2%). When blindly assessing radiographic criteria, the patients treated with the plate and compression screw had a significantly higher rate of fusion and lower rate of non-union (0% vs 33%). There was no statistically significant difference between the frequencies of complications in the groups. We believe that the interfragmentary compression is a crucial factor in achieving good union rates and recommend the use of non-locking pre-contoured plating with additional interfragmentary compression screw as the fixation method of choice for these procedures.

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.

First metatarsophalangeal joint fusion using a Fyxis plate

PURPOSE

To report the outcome of fusion of the first metatarsophalangeal joint (MTPJ) using the Fyxis plate and compression screws.

METHODS

Medical records of 12 men and 39 women (54 feet) aged 28 to 74 (mean, 58) years who underwent primary fusion of the first MTPJ using the Fyxis plate and compression screws for hallux rigidus (n=38), severe hallux valgus (n=8), or rheumatoid arthritis (n=8) were reviewed. The outcome measures included the fusion rate, time to fusion, complication rate, hallux valgus angle, dorsiflexion angle, and the American Orthopaedic Foot and Ankle Society (AOFAS) scale.

RESULTS

The mean follow-up was 14.8 (range, 12-20) months. The mean time to fusion was 3.2 months. 48 feet achieved complete fusion at 3 months, 5 at 6 months, and one had non-union at 12 months, which was treated with revision surgery. The mean hallux valgus angle improved from 23º to 12º. The mean dorsiflexion angle improved from 22º to 23º. The mean AOFAS scale score improved from 31 to 86. 98% of the feet achieved a score of >72. One patient with non-union had a score of 59. Two feet developed superficial wound infection, which resolved with antibiotic treatment. Two other feet developed numbness over the medial aspect of the great toe, which persisted after one year.

CONCLUSION

The outcome of fusion of the first MTPJ using the Fyxis plate and compression screws was good.

Endomedullary screw fixation for first metatarsophalangeal arthrodesis

BACKGROUND

The purpose of this study was to evaluate the clinical and radiological results in a group of patients who underwent first metatarsophalangeal joint arthrodesis with an endomedullary screw fixation technique (MPA-E).

METHODS

Between 2003 and 2009, 101 metatarsophalangeal arthrodesis were performed in 76 patients. There were 64 women and 12 men with an average age of 68 years. The indication for surgery was osteoarthritis with severe pain and functional limitation. Patients were evaluated radiologically and with the American Orthopaedic Foot & Ankle Society scoring system (AOFAS) at an average follow-up of 32 months (range, 24-92 months).

RESULTS

The success rate was 93%, with an increase of the average preoperative AOFAS from 38.5 points to 85.5 points postoperatively (P < .0001). The consolidation rate after radiological evaluation was 90.1%; there were 5 cases (5.0%) with asymptomatic nonunion and 5 cases (5.0%) with poor results because of symptomatic nonunion. Screw removal was needed in 4 feet (4.0%), and 2 feet (2.0%) had acute postoperative superficial infection. No implant cutout was observed.

CONCLUSION

The MPA-E technique provided consistent and high functional outcomes. This valid and effective alternative should be considered as an option for hallux metatarsophalangeal arthrodesis.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

A retrospective comparison of first metatarsophalangeal joint arthrodesis using a locked plate and compression screw technique

INTRODUCTION

The historic primary treatment for end-stage first metatarsophalangeal (MTP) joint arthritis has been fusion. Traditionally, this has been accomplished by metaphyseal apposition between the proximal phalanx and metatarsal using crossed compression screws. Recently, locked plates have been introduced that help support this technique by offering added stability. We present our experience with 45 first MTP fusions in 45 feet using a locked plate and compression screw.

METHODS

A retrospective review of 45 patients who met the study criteria with a hallux rigidus correction using a locked plate with a compression screw was performed. Charts and radiographs were independently reviewed by 2 authors not involved in the index procedures to assess outcomes.

RESULTS

There was a 93% fusion rate (42/45 feet) with 3 nonunions. The mean time to union was 51.1 days (range = 29-116 days, SD = 24.4). The mean patient age was 58.1 years (range = 29-80 years, SD = 10.1). The mean time to partial weight bearing was 7.0 days (range = 0-53 days, SD = 13.8) and the mean time to full weight bearing was 62.0 days (range = 29-57 days, SD = 17.9).

DISCUSSION

We report on the results of first MTP fusion using a compression screw and locked plate technique. The results show that this is an effective means of creating a first MTP joint arthrodesis.

A retrospective comparison of four plate constructs for first metatarsophalangeal joint fusion: static plate, static plate with lag screw, locked plate, and locked plate with lag screw

The primary treatment for progressive first metatarsophalangeal (MTP) joint arthritis is arthrodesis. Multiple fixation types have been used to accomplish fusion including plating. There have been no published articles reporting the outcomes of these 4 plate and/or screw constructs. We present our experience with 138 first MTP joint fusions using these constructs. A retrospective comparison and radiographic chart review of 132 patients (138 feet) was performed to compare different constructs in regards to successful union and time to fusion. All operations were performed by 4 fellowship-trained foot and ankle surgeons. The radiographs were independently read by 2 authors not involved in the index procedures. Radiographic fusion was determined by bridging cortices across the joint line. The mean time to union (in days) and rate of fusion were static plate: 59, 95%, static plate with lag screw: 56, 86%, locked plate: 66, 92%, and locked plate with lag screw: 53, 96%. There was not a statistically significant difference between the groups in regards to patient age, time to weight bearing, time to fusion, or rate of fusion. We report on the results of fusion comparing 4 different plate and/or screw constructs for first MTP joint fusion. The data reveal no significant difference in time to fusion or rate of fusion between static and locked plates, with or without a lag screw.

Arthrodesis of the first metatarsophalangeal joint: a retrospective analysis of plate versus screw fixation

Arthrodesis of the first metatarsophalangeal joint is a commonly accepted technique to treat various afflictions of the hallux. Many techniques have been described to fixate the arthrodesis. However, no superior fixation technique has been identified in regard to nonunion. We performed a retrospective analysis of first metatarsophalangeal joint arthrodeses in our clinic from January 2000 to April 2010, focusing on plate and screw fixation. Our aim was to identify the best fixation construct in regard to fusion rates and radiologic nonunion. We identified 72 arthrodeses performed using 1 oblique (n = 24) or 2 crossed (n = 21) lag screws or a plate (n = 13) or a plate augmented with plantar lag screw fixation (n = 14). Our analysis showed that plate fixation alone results in significantly fewer nonunions than single screw fixation. A comparison of the other fixation types showed no significant differences with regard to nonunion. Although our analysis showed that plate fixation alone is superior to single screw fixation, no definitive conclusion can be drawn owing to methodologic shortcomings. We believe a randomized controlled trial with larger sample sizes is necessary to find the clinically superior fixation technique.

Modern techniques in hallux rigidus surgery

This article is a review of the history, etiology, and clinical and radiographic presentations of hallux rigidus. The focus is on current treatment options being offered for the treatment of hallux rigidus.

First metatarsophalangeal joint arthrodesis: current fixation options

This article reviews the current literature on first metatarsophalangeal joint arthrodesis rates using various forms of fixation, as well as reviewing biomechanical studies comparing the strengths of the different fixation options that are available.

First metatarsophalangeal arthrodesis for hallux rigidus

Hallux rigidus leads to a restricted and painful motion at the first metatarsophalangeal (MTP 1) joint. Decision making of the appropriate surgical procedure mainly refers to the stage of hallux rigidus. If conservative measures fail, operative procedures can be taken into consideration. Arthrodesis of the MTP 1 joint is widely accepted as the gold standard for end-stage hallux rigidus. Despite the fusion of a key joint, there is little adverse effect on gait, and weight bearing of the first ray can be restored.

First metatarsophalangeal arthrodesis using a dorsal plate and a compression screw

BACKGROUND

Fusion of the first metatarsophalangeal joint is considered a `gold standard' procedure for arthritis and as a salvage procedure for previous failed surgeries. Recent biomechanical studies have shown that a combination of a plate and screw is the most stable construct. Only a few studies have evaluated this combination and they have small cohorts so we are presenting our larger series of patients.

MATERIALS AND METHODS

Forty-six consecutive cases of first metatarsophalangeal joint fusion performed between April 2006 and April 2008 were performed using a dorsal plate and a compression screw. We analyzed the outcome in terms of fusion rate, patient satisfaction and complication rates. The average followup period was 23 (range, 14 to 37) months. The most common indications were hallux rigidus and severe hallux valgus.

RESULTS

Ninety-eight percent of the cases fused uneventfully by four months. The average time to fusion was 3.1 months. There was one non-union, which remained asymptomatic after metal removal which was the only case requiring removal of metal. There was no hardware failure. The patient satisfaction was 100%. The average AOFAS score was 82.1 (maximum, 90).

CONCLUSION

These results show that arthrodesis of the first MTP joint with spherical reamers and a low-profile contoured dorsal titanium plate and compression screw is highly successful, with excellent patient satisfaction and functional outcomes. We recommend the use of specially designed plates against improvised plates as bending leads to poor control over dorsiflexion and may increase the incidence of plate failure.

Arthrodesis of the first metatarsophalangeal joint using a single screw: retrospective analysis of 109 feet

Arthrodesis of the first metatarsophalangeal joint is a recommended technique for hallux rigidus. The preparation of the joint surfaces and the way in which fixation is achieved might be relevant in success or failure of the arthrodesis. All patients were selected from archived records of operations performed at the 'Groene Hart' Hospital in Gouda, the Netherlands, from 1996 until 2005. Patients were operated following a fixed protocol using flat surfaces and a single compression screw bridging the arthrodesis from proximal medial to distal lateral. Their charts were reviewed retrospectively. Answers to questions regarding their current pain, shoe wear, and walking ability were recorded using the criteria of the AOFAS foot score as a template in a questionnaire. Of a total of 109 arthrodesis, 104 (95.4 %) united within 8 weeks without problems. Four feet were re-operated for pseudoarthrosis and one was re-operated for malunion with too much dorsiflexion. Removal of the intramedullary screw was necessary in 85 feet (78%). Of the 79 patients who returned their questionnaire, 58 patients (73.4%) considered their problems solved and 57 patients (72%) were completely satisfied with the result. Our study shows that a single screw fixation method is an effective technique in treating hallux rigidus, with high satisfaction in patients between 40 and 80 years of age.

LEVEL OF CLINICAL EVIDENCE

4.

First metatarsophalangeal joint arthrodesis and revision arthrodesis

Arthrodesis of the first metatarsophalangeal joint is a powerful procedure that can improve the load-bearing capabilities of the forefoot and assist in medial arch stability. It is the mainstay of treatment for patients with severe arthritic deformity of the great toe joint, because it addresses the importance first ray weight-bearing has on the rest of the foot. In select individuals, fusion can also be effective as a primary procedure in the treatment of hallux valgus. Rather than cause detrimental effects to the function of the foot, this article suggests that first metatarsophalangeal arthrodesis can actually improve faulty mechanics secondary to a dysfunctional joint.