Arthrodesis Of Joint Research Articles

Arthrodesis of the first metatarsophalangeal joint for severe hallux valgus in adolescents with cerebral palsy: A retrospective comparison study of three surgical techniques.

We compared the outcomes of arthrodesis of the first metatarsophalangeal joint for severe hallux valgus in 31 adolescents with cerebral palsy, using three different methods of fixation: K-wires, non-locking plates, and locking plates. Clinical outcomes included time to weight-bearing, fusion rates and surgical complications. Radiographic assessment included comparing pre- and post-operative hallux valgus angles, intermetatarsal angles, interphalangeal angles, and lateral metatarsophalangeal angles. Patient-reported outcomes included pre- and post-operative visual analogue scales addressing bunion pain and concerns, difficulties with wearing shoes and braces, and difficulties with foot hygiene. Of the 31 adolescents (16 male), 10 patients had K-wire fixation, 11 had a non-locking dorsal plate, and 10 had fixation with a dorsal locking plate. Mean age at surgery was 16 years (12-18 years) and mean follow-up was 4 years (2.7-6.5 years). Patients with K-wire fixation had delayed weight-bearing and had more complications than those managed by dorsal plating. There were significant improvements in radiographic parameters (except interphalangeal angle) and in patient-reported outcomes, in all groups (p < 0.001). However, radiographic and clinical outcomes were better in the dorsal plating groups compared to the K-wire group. Arthrodesis of the first metatarsophalangeal joint gave good correction of deformity with improvements in symptoms and radiographic parameters in adolescents with cerebral palsy. We recommend dorsal plating that allowed early weight-bearing and had fewer complications with better clinical and radiographic outcomes, than K-wire fixation. IV: Retrospective case series.

Evaluating the Biomechanical Integrity of Various Constructs Utilized for First Metatarsophalangeal Joint Arthrodesis: A Systematic Review.

The first metatarsophalangeal (MTP) joint is a frequently loaded joint, handling loads up to 90% of bodyweight. First MTP arthrodesis is a frequently performed procedure designed to improve pain in patients with degenerative MTP joint disease. There are a wide variety of fixation constructs for this procedure without consensus on the most effective method. The purpose of this study was to compare the biomechanical integrity of various constructs utilized for first MTP arthrodesis. A systematic review of the literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, CINAHL, MEDLINE, and Web of Science databases were searched from inception to 18 June 2023. Articles discussing the biomechanics of first MTP arthrodesis constructs were included. A total of 168 articles were retrieved. A total of 20 articles involving 446 cadaveric and synthetic bone constructs were included in the final review. Of the six articles comparing dorsal plating with compression screws to crossed interfragmentary screws, five found that dorsal plating had significantly higher stiffness. All three studies assessing shape-memory staples found them to be significantly less stable than crossed screws or dorsal plates alone. Both studies evaluating fully threaded screws found them to be stronger than crossed cancellous screws. Wedge resections have been shown to be 10 times stronger than standard planar or conical excision. Dorsal plating with compression screws is the gold standard for MTP arthrodesis. However, more research into newer methods such as fully threaded screws and wedge resections with an increased focus on translation to clinical outcomes is needed.

3D Printed Titanium Wedges for Distraction Arthrodesis of the Subtalar Joint

Category: Hindfoot Introduction/Purpose: Distraction arthrodesis of the subtalar joint is performed to restore height and correct deformity in the case of subtalar joint arthrosis, malalignment of the rear foot, calcaneal fracture, or other pathologies. Historically, autograft or allograft bone blocks were used to restore natural alignment and improve hindfoot function. Although successful use has been reported, complications associated with donor site morbidity and size limitation for autograft, as well as additional complications including nonunion, graft collapse, and loss of alignment are common. Recently, innovative advancements have enabled the use of 3D printed porous titanium implants for use, improving the union rates and reduced risk of subsidence and graft collapse. Methods: 6 patients with subtalar collapse and anterior ankle impingement were indicated for distraction subtalar arthrodesis. Surgery was performed with a lateral approach for the distraction arthrodesis using an off the shelf 3D printed subtalar wedge and a nitinol pseudoelastic fusion rod for stabilization and fixation. Patients were followed 6 months post op for fusion and alignment. Fusion was confirmed at 3 months with CT scans and alignment was monitored with weightbearing ankle X-rays. Results: 3D wedge incorporation and sustained correction of height and alignment was maintained over time at the subtalar joint. There were no nonunions, 2 patients reports skin healing issues due to tension on the skin with wound closure. These healed with local wound care. Improvement in preoperative to postoperative tibiotalar sagittal plane alignment was observed in all patients. Conclusion: The use of a 3D printed titanium wedge for distraction Arthrodesis of the subtalar joint is a safe procedure and useful procedure in short-term follow-up. This procedure does provide improvement in the patients alignment and fusion occurs with in 3 months of surgery.

Adjacent Joint Arthritis Incidence Rate Following Fusion of the First Tarsometatarsal Joint as Treatment for a Forefoot Deformity

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Nontraumatic forefoot deformities such as hallux valgus (HV) are common causes for patients seeking reconstructive surgery. Known as a “bunion,” HV is characterized by 1-2 intermetatarsal angle widening and first metatarsal head medial drift, resulting in the great toe pointing laterally. Surgery is indicated for patients who fail to find relief with conservative management. However, there is no consensus among orthopedic surgeons on whether osteotomy or first tarsometatarsal (TMT) arthrodesis is the better surgical treatment method. Additionally, no known studies have explored the development of adjacent joint arthritis in patients who have received a first TMT fusion. This study aims to investigate the rate of arthritis development in the adjacent joints following arthrodesis of the first TMT joint. Methods: A retrospective chart review at a tertiary foot and ankle clinic was performed on subjects who received a first TMT fusion between January 2004 and December 2017. This included subjects who received concomitant gastrocnemius recession, tendo-achilles lengthening, 1-2 intermetatarsal arthrodesis, 1-2 intercuneiform arthrodesis, hammertoe corrections, and other soft tissue releases deemed by the senior authors to be inconsequential in the case of adjacent joint arthritis development. Pre- operative, operative, and post-operative indications will be evaluated throughout this thorough chart review, and charts will be continually reviewed for inclusion and exclusion criteria. Patient information gathered includes age, sex, height, weight, BMI, activity level, smoking history, medications, time spent with hardware retained, the method of arthritis diagnosis (x-ray alone, CT, MRI, bone scan), relevant additional diagnoses, and operative data. Pre- and post-operative pain levels and satisfaction scores will follow the AOFAS Score Criteria. Results: Preliminary Results: 899 subjects (148 males, 751 females) are included in this study. The age range was 67 years (18 - 85), with an average age of 56.6 at surgery. Patient BMI varied from 12.7 to 53.1. Concurrent operative soft tissue procedures: gastrocnemius recession (749), tendo-Achilles lengthening (13), and a combination of the two (1). Concomitant fusions: isolated 1- 2 intermetatarsal arthrodesis (799) and combined with 1-2 intercuneiform arthrodesis (695). Clinical follow-up ranged from three to 186 months, averaging 34 (2 years, ten months). Presently, radiographic assessment has been performed for 154 of the 899 patients included in this study. Of these, 11 had developed adjacent joint arthritis at last radiographic follow-up (7.1%); two with naviculocuneiform arthritis, eight with talonavicular arthritis, and one with both. Conclusion: Based on preliminary data, a successful fusion of the first TMT joint, as treatment of a forefoot deformity such as HV, does not appear to accelerate the development of arthritis in the adjacent joints.

Screw Only Fixation vs Plate Fixation For 1st MTPJ Arthrodesis: A Comparative Retrospective Study

Category: Midfoot/Forefoot; Other Introduction/Purpose: First metatarsolphalangeal joint (MTPJ) arthrodesis is a commonly performed surgical procedure for end- stage arthritis. Various fixation techniques have been described. The most commonly used are screw-only fixation (either crossed or parallel) or plate fixation (with or without independent lag-screws). A recent systematic review reported that union rates for screw fixation were lower compared to plate constructs. The aim of this study was to compare union rates, complication rates and functional outcomes between screw-only fixation and plate fixation in a recent cohort of patients undergoing first MTPJ arthrodesis at a tertiary foot ankle orthopaedic institution. Methods: This was a retrospective cohort study. After institutional review board approval, a database search was conducted to identify patients who underwent primary first MTPJ arthrodesis between 2015 and 2022. All patients had a dorsal approach, preparation of joint surfaces with cup and cone reamers and fixation with either crossed cannulated screws or a dorsal pre- contoured locking plate (with or without an independent lag-screw). Demographic, operative (fixation type) and outcome data was collected. The primary outcome was the incidence of arthrodesis at 6 months postoperatively. Secondary outcomes included complications at 6 months postoperatively and change in functional outcome scores from preoperatively to 6 months postoperatively as assessed by the Functional Ankle Ability Measure (FAAM) and Visual Analog Pain scores (VAS). Statistical analyses included descriptive statistics as well as univariable and multivariable analyses to determine if one fixation method was associated with a higher incidence of arthrodesis. Results: There were 108 patients identified, 54 in the screw-only group (mean age 62.9 years, 79.6% female, mean body-mass index (BMI) 28.6 kg/m2) and 54 in the plate-fixation group (mean age 63.2 years, 81.5% female, mean BMI 30.0kg/m2). Arthrodesis at 6 months in the screw-only group occurred in 52 of 54 patients (96.3%) and in 50 of 54 patients (92.6%) in the plate-fixation group, p=0.68. Fixation type was not a predictor of non-union on multivariable analysis. The complication rate was 11.1% (n=6) in screw-only patients (four hardware removals, two non-unions) and 14.8% (n=8) in plate-fixation patients (four non-unions, two hardware removals, two wound infections), p=0.57. Both groups reported increases in VAS and FAAM scores at 6 months from baseline, with no significant between-group differences. Conclusion: The arthrodesis rate for screw-only fixation was higher than patients receiving plate-fixation, however, this difference did not reach statistical significance. Similar complication rates were observed in each group. These results provide evidence for the safety and efficacy of screw-only fixation constructs, however, further adequately powered prospective studies are required. Future studies should also include a cost effectiveness analysis and a comparison of radiation exposure and operative time between groups to determine the optimal fixation method for patients undergoing this procedure.

Increased Union Rates in Subtalar Joint Arthrodesis with Hybrid Nitinol Dynamic Compression Device

Category: Hindfoot Introduction/Purpose: Subtalar joint arthrodesis (STJA) is a well-established and widely accepted surgical procedure utilized for the treatment of numerous hindfoot conditions. Several fixation constructs in STJA have been described in the literature. With the current advancements in orthopedic technology, new devices utilizing nitinol elements have been developed in an effort to maintain sustained compression in the event of bony resorption which may occur during arthrodesis healing. The primary aim of our study is to introduce a hybrid nitinol dynamic compression (HNDC) device for STJA which provides dynamic compression without proximal locking fixation and compare union rates with a previous nitinol dynamic compression nail (NDCN) as well as a standard two-compression screw fixation construct. The secondary aim was to compare hardware removal rates amongst the three cohorts. Methods: From May 2019 through February 2022, 26 consecutive patients treated with a novel HNDC for STJA were compared to 15 patients treated with NDCN for STJA and 41 patients undergoing STJA using a two-compression screw fixation method. Patients were included in our study if they were greater than 18 years of age, underwent STJA with the use of one of the internal fixation constructs under investigation, and had a minimum 1-year follow-up with radiographs; there were no other exclusion criteria. Arthrodesis sites were augmented with autologous bone graft with or without bone graft substitute in all patients. Standard postoperative protocols were used amongst all three cohorts. Primary outcomes included subtalar joint union rates determined by radiographic and clinical assessment. The incidence of hardware removal was recorded and compared between groups. Patient-specific risk factors were studied to assess any potential negative effects on STJA union rates. Results: Union rates between the HNDC device and the NDCN group did not demonstrate a statistically significant difference at final follow-up. There was a statistically significant difference in union rates between subjects who underwent STJA with the HNDC device versus those who underwent STJA with a two-compression screw construct. Furthermore, there was a statistically significant increase in union rates in subjects who received nitinol dynamic compression fixation devices, HNDC or NDCN, versus standard compression screws. There was not a statistically significant difference in hardware removal rates among the 3 cohorts. No significant relationship was seen between smoking, diabetes, or alcohol consumption and union rates. Conclusion: Our data supports the HNDC device to have superior union rates to the two-screw fixation group. In addition, the HNDC device provides improved union rates, though not statistically significant, when compared to the NDCN. Furthermore, the HNDC device was found to have lower rates of hardware removal when compared to the two-screw fixation and the NDCN groups though this was not statistically significant. The early results of this HNDC device for STJA are encouraging and appear to offer a further improved alternative fixation construct with excellent union rates and minimal complications.

Return to Alpine Sport and Physical Activity After First Metatarsophalangeal Joint Arthrodesis

Category: Midfoot/Forefoot; Sports Introduction/Purpose: First metatarsophalangeal (MTP) arthrodesis is an effective procedure to alleviate pain and correct deformity. The unique location of our academic center allows us to study an extremely active patient population with high rates of participation in impact sports and particularly alpine specific sports, including Nordic and alpine skiing, snowboarding, hiking, trail running and biking. There is limited literature regarding these specific activities with regards to a 1st MTP arthrodesis. The goal of the study is to better define the ability to return to physical activity, with a focus on alpine and mountain sports. This will help physicians counsel patients appropriately when discussing surgical options. Methods: Patients over 18 years old who underwent MTP arthrodesis with minimum 1 year follow up were identified using CPT code 27850. Patients undergoing concomitant forefoot and hindfoot procedures were excluded. Demographic data and complications were recorded by retrospective chart review. A custom sports questionnaire, PROMIS Physical Function (PF), PROMIS Pain Interference (PI), and Foot and Ankle Ability Measure (FAAM) scores were administered to patients. Postoperative radiographs were analyzed for time to union and fusion position. Results: 96 patients were eligible for analysis. Preliminarily, 34 have completed the follow-up survey. Most common activities were walking, hiking, alpine skiing, biking and running. Compared to preoperatively, patients rated 70.5% of activities as less difficult, 20.5% as the same, and 9.0% as more difficult. 74% of patients returned to their activities by 6 months and 62% of patients reached their maximum level of activity by 9 months postoperatively. Patients who participated in skiing/snowboarding were all able to ski the same level of terrain compared to before surgery, but nearly half (46%) of patients required boot modifications. 43% of patients were able to increase incline when hiking/trail running, and 48% of patients were able to increase their running/walking mileage. Average PROMIS PF was 51.9 (±6.20). Conclusion: Patients are able to participate in a variety of high impact and alpine related sports after 1st MTP arthrodesis. The majority of patients are able to function at similar or increased levels when returning to hiking, walking, skiing and snowboarding. Up to 25% of patients may not reach maximum level of activity until 1 year postoperatively. Additional investigation is required to identify potential risk factors for patients that may experience difficulty returning to activity. Continued survey participation is underway to strengthen these results. Patient counseling on activity participation following hallux MTP arthrodesis is important to optimize outcomes and patient satisfaction.

Minimally Invasive Surgery vs Open Approach to First Metatarsophalangeal Joint Arthrodesis: A Comparison of Surgical Outcomes

Category: Midfoot/Forefoot; Other Introduction/Purpose: Minimally invasive surgery (MIS) is becoming increasingly popular among foot and ankle orthopaedic surgeons, as it has been shown to have limited complication rates and faster recovery times. Although there is robust data on MIS to treat hallux valgus, few studies have evaluated the role of MIS for 1st metatarsophalangeal (MTP) fusion to treat hallux rigidus - the most common arthritis of the foot. Hallux rigidus affects 2.5% of the U.S. population over age 50. Given this disease prevalence, it is important to characterize outcomes following MTP fusion procedures to optimize surgical approaches. In this retrospective cohort study, we aim to compare (1) patient-reported pain, (2) rate of successful fusion, and (3) rate of complications between groups who underwent open or MIS 1st MTP arthrodesis. Methods: This retrospective cohort study was conducted by evaluating clinical metrics, surgical outcomes, and radiographic data through chart review of 78 patients (25 male, 53 female), who underwent a 1st MTP fusion procedure at a large urban academic medical center from July 2015 through January 2023. 71 patients had a diagnosis of hallux rigidus, with other common diagnoses including hammertoe (24), hallux valgus (24), additional arthritides (11), and metatarsalgia (11). Two patients were excluded from our analysis due to lack of sufficient orthopaedic follow-up preventing evaluation of joint fusion. Pre- and post-operative pain scores were recorded on a 0-10 scale, though some notes documented subjective experience of pain (e.g., “minimal”). Complications were identified using post-operative clinic notes. The following radiographic data were included: hallux valgus angle, intermetatarsal angle, Coughlin classification, presence of arthritis, pre-operative sesamoid position, fusion construct materials, and success of fusion. Results: Of the 80 1st MTP fusion surgeries (two patients received both left and right foot operations), 51 were open and 29 were minimally invasive. There was no significant difference in the change in pre- to post-operative pain between the two groups (p=0.39). MIS patients had a higher successful fusion rate (100.0%) when compared to open surgery patients (94.1%), though this difference was insignificant (p=0.55). There was no significant difference in overall complication rates between MIS and open surgery groups (p=0.79). However, the MIS patients did not have any cases of deep infection or wound dehiscence and all (5/5) of their complications were related to hardware removal after fusion, whereas half of the complications (5/10) for the open surgery patients were related to infection and wounds. Conclusion: This retrospective analysis of 78 patients treated for hallux rigidus with 1st MTP fusion surgery showed no significant difference in rates of successful fusion and complications among patients who received an MIS procedure compared to an open surgery. There was no difference in patient-reported pain improvement between the two groups. Our main limitation is provider specialization, as only one surgeon in this study performed the MIS cases. Further studies should be done to obtain higher-level evidence to elucidate potential benefits of MIS over open surgery for 1st MTP arthrodesis.

Clinical and Radiographic Outcomes of Nitinol Compression Staples for Midfoot and Chopart Arthrodesis

Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: Continuous compression implant (nitinol staples) use in orthopaedic surgery has increased in recent years. There are several advantages of nitinol staples, including a lower profile when compared to traditional fixation methods. They are easy to apply and take up a smaller footprint than most plating techniques, thus decreasing surgical time and dissection. Additionally, continuous compression across the fusion site is maintained during the resorptive phase of bone healing. Biomechanical studies provide useful data supporting the use of nitinol staples in the foot and ankle; however, clinical data is limited. This study’s purpose is to determine the efficacy of nitinol staples to achieve stable, bony healing in midfoot and Chopart joint arthrodesis, and examine their clinical outcomes, complications, and pain scores. Methods: A retrospective chart review was performed on 127 midfoot/Chopart joints (71 patients) that underwent arthrodesis using nitinol staples in isolation over a five-year period (January 2017 – February 2022). The primary outcome variable was radiographic evidence of healing. Radiographs were blinded, randomized, and independently reviewed by three board certified foot and ankle surgeons. Each investigator reviewed digital radiographs independently and recorded their radiographic finding responses. Fusions were deemed healed if greater than 50% of the arthrodesis site contained bridging bone. A partially healed arthrodesis was defined as some bridging bone, but less than 50% of the overall arthrodesis site, and a nonunion was defined as no healing seen radiographically or loss of reduction. There were no cases of complete inter-surgeon radiographic disagreement in this study. Pain scores and clinical outcomes were also collected. Smokers and diabetics represented 27% (n = 19) and 13% (n=9) of the patient population, respectively. Results: Complete/partial union was seen in 89% of all joints (113/127) and 93% of midfoot joints (98/106). Chopart joints had a significantly lower healing rate (15/21; 71%) compared to midfoot joints (p = 0.013) and TMT joints in isolation (86/91; 95%) (p = 0.006). Neuropathy and smoking had no effect on healing but diabetes did (p = 0.004). Joints requiring bone grafting had a worse healing rate (38/49; 76%) (p = 0.002). For all joints, post-operative VAS scores were significantly lower than pre-operative (p &lt; 0.00001). Midfoot and Chopart pre-operative pain scores did not differ (p= 0.30), but differed post-operatively (p = 0.003). Midfoot joints had significantly lower pain scores post-operatively than pre-operatively (p &lt; 0.00001). No such significance existed in Chopart joints (p = 0.070). Conclusion: Isolated nitinol staples are a viable option for midfoot arthrodesis, especially TMT joints, and offer significant pain improvement. Staples are lower profile, decreasing hardware irritation and potential secondary surgeries, and ease of use makes insertion efficient and reproducible. They offer the benefit of continuous compression of the fusion site, and are rigid enough to maintain reduction. Chopart joints, however, may require a more rigid fixation than nitinol staples can provide, given the lower healing rate. Caution should be exercised in diabetics and joints that may require bone grafting.

Comparison of Mini Tightrope Intermetatarsal Fixation and Inter-Cuneiform Screw Fixation in Lapidus

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: First metatarso-cuneiform joint arthrodesis for treatment of metatarsus primus varus was originally introduced by Lapidus in 1934. In his technique, fixation was achieved using heavy chromic sutures between the first and second metatarsals to achieve parallel alignment. Since then, the indications and technique for Lapidus procedure have considerably evolved and many modifications have been introduced to Lapidus’s original description. Despite these modifications, recurrence of hallux valgus remains relatively common, either due to malunion at the TMT arthrodesis or through intercuneiform instability. This has informed the approach for additional fixation between the 1st and 2nd rays. This study aims to compare outcomes of inter-cuneiform screw fixation (ICS) and suspensory intermetatarsal fixation (SIM) using a mini-tightrope in terms of deformity correction and maintaining the correction over time. Methods: This was a retrospective comparative study of prospectively collected data for patients who have underwent a Lapidus procedure for hallux valgus between 2012-2022. The electronic medical records were reviewed for demographics, radiologic parameters, and operative data. Radiographic parameters were intermetatarsal angle (IMA), hallux valgus angle (HVA), and sesamoid station on preoperative, 3 months postoperatively and final follow-up. Hallux valgus station was graded from normal, mild, moderate, and severe based on the method used by Agrawal et al. Using a multivariate regression model, a comparison was conducted between suspensory intermetatarsal fixation(SIM) and inter-cuneiform screw fixation(ICS). Univariate linear regression analysis was conducted with the inclusion of covariates' age, smoking, diabetes, and BMI. Comparison of HVA and IMA was conducted using t-test. Results: 65 patients met the inclusion criteria; 20 had ICS, and 45 had SIM. The pre-op IMA improved from 13.57 (3.84) to 6.14 (2.41) degrees postoperatively in the ICS group (p), and from 13.37(3.84) to 6.16 (2.74) degrees postoperatively in the SIM group (p). The final follow-up IMA was 5.9 (2.1) in the ICS group and 6.84 (2.31) in the SIM group, with no difference from post-op values, p=0.123 and, respectively. There was no statistically significant difference between ICS and SIM groups in IMA at pre-op (p=0.41), post-op (p=0.49), and final follow up (p=0.62). There were no statistically significant differences between SIM and ICS groups in HVA preoperatively [37.47(12.21) vs. 40.38(13.59), p=0.19], postoperatively [18.2(10.82) vs. 18.95(10.1),p=0.36] or at final follow up [20.12(9.72) vs 19.33(9.16) ,p=0.38]. Conclusion: Lapidus procedure remains the procedure of choice for severe hallux valgus with predictable correction. Supplementing the first tarsometatarsal arthrodesis with suspensory intermetatarsal fixation using a mini-tightrope achieved similar deformity correction and preservation of correction to intercuneiform screw fixation.

Outcomes After Hallux Interphalangeal Joint Arthrodesis.

Hallux interphalangeal joint arthrodesis (HIPJA) is indicated for a variety of pathologies. Despite high nonunion rates, techniques remain unchanged. The aim of this study is to examine nonunion and complication rates and describe risk factors for treatment failure. A query of an institutional database was performed to identify all patients undergoing HIPJA procedure over a 10-year period. Records were reviewed to the procedure, evaluate patient factors, indications, and radiographic/clinical arthrodesis. Radiographic union was defined as 2 cortical continuations or bridging at the arthrodesis site, absence of hardware failure, and the absence of lytic gapping of the arthrodesis. Clinical fibrous union was defined as radiographic nonunion with painless toe range of motion and physical examination consistent with fusion across the interphalangeal joint. Two hundred twenty-seven primary HIPJA procedures were identified. Our cohort demonstrated a 25.5% nonunion rate (58/227) and 21.1% reoperation rate (48/227). Patients with diabetes were at higher risk for nonunion (P = .014), but no significant differences were identified based on smoking status or diagnosis of inflammatory arthritis. No difference was seen between implant groups: single screw, multiple screws, screw plus other fixation, nonscrew fixation. Patients with prior hallux metatarsophalangeal joint arthrodesis did not have a significantly higher nonunion rate than patients without prior first metatarsophalangeal joint arthrodesis. Patients diagnosed with radiographic nonunion were at higher risk for reoperation (P < .0001). Our cohort represents the largest single-center series of HIPJA procedures published to date. We found relatively high nonunion and reoperation rates with standard current techniques. Level III, retrospective case series.

The influence of a tension band fixation as an adjunct for arthrodesis of the metacarpophalangeal joint in the horse.

To determine the influence of a stainless-steel cable (SSC) tension band fixation as an adjunct to a locking compression plate (LCP) for arthrodesis of the equine metacarpophalangeal (MCP) joint. Experimental. An ex vivo biomechanical paired equine cadaver limb study. Five MCP joint pairs were collected from adult Thoroughbred horses, euthanized for reasons unrelated to orthopedic disease. Each pair of MCP joints were randomly implanted with either a dorsally placed 5.5 mm LCP and a palmarly placed 2.0 mm SSC or a dorsally placed 5.5 mm LCP alone. Each construct was tested in cyclic loading followed by single cycle to failure in axial compression. Displacement at a target load of 1 kN over 3600 cycles at 1 Hz was recorded prior to single cycle to failure testing. In cyclic testing, displacement was not significantly different between the first and last 5% of testing cycles regardless of construct. Maximum displacement of each construct during cyclic testing was <1.1 mm. In single cycle testing, the observed yield point did not reveal any difference between LCP and LCP-SSC (p = .440). The maximum load at failure was significantly higher in LCP-SSC compared to constructs with the LCP alone (p = .046). The addition of the SSC to the LCP did not statistically affect construct displacement during cyclic loading or construct yield load during subsequent single cycle to failure. This study provided much needed information regarding the necessity of a tension band SSC application in the arthrodesis of the MCP/MTP joint in horses.

Does distal interphalangeal joint arthrodesis affect proximal interphalangeal joint arthroplasty outcomes in the same finger?

The purpose of this study was to analyse the 1-year outcomes after combining a surface replacing proximal interphalangeal joint arthroplasty and a distal interphalangeal screw arthrodesis and to compare the combined surgery with proximal interphalangeal joint arthroplasty alone. To obtain two groups with similar baseline data from our prospective registry, propensity score matching was used to match 23 fingers with the combined operations with 115 fingers with proximal interphalangeal joint arthroplasty alone. One year after surgery, the mean ranges of motion were 60° (95% CI: 53° to 67°) in the combined group and 63° (95% CI: 60° to 66°) in the control group and did not differ significantly. Grip strength, the brief Michigan Hand Questionnaire and pain also did not differ between the groups 1 year after surgery. All the proximal interphalangeal implants in patients treated with a distal interphalangeal screw arthrodesis remained in situ. Combining proximal interphalangeal joint arthroplasty with distal interphalangeal arthrodesis leads to 1-year outcomes that are similar to those achieved by proximal interphalangeal joint replacement alone.Level of evidence: III.

Surgical Treatment of Metatarsalgia and Severe Instability of Lesser Metatarsophalangeal Joints

The main object of this prospective cohort study was to compare surgical treatment options for primary metatarsalgia and the severe instability of lesser metatarsophalangeal joints. The outcomes of triple Weil osteotomy combined with direct plantar plate repair and triple Weil osteotomy, performed with proximal interphalangeal joint arthrodesis, are analyzed and compared. One hundred thirteen patients (117 feet) were enrolled in the study. They were split into 2 groups. In the first group, undergoing Weil osteotomy, combined with the plantar plate repair, good results, including complete pain reduction, elimination of hyperkeratosis, and American Orthopedic Foot and Ankle Society Score improvement, were achieved in 84.7% of the cases. The second group, where the combination of Weil osteotomy and proximal interphalangeal joint K-wire arthrodesis was used, demonstrated good results in 52.4% of the cases. Weil osteotomy, combined with the plantar plate repair, achieves better results in comparison to osteotomy, performed with the interphalangeal joint arthrodesis.

A retrospective review of recombinant human platelet-derived growth factor with beta-tricalcium phosphate bone graft substitute use in hindfoot and/or ankle arthrodesis

BackgroundNonunion following foot and ankle arthrodesis can cause chronic pain and disability, poor patient satisfaction, and increased healthcare costs. Nonunion rates are reported in 10%–12% of primary foot and/or ankle arthrodesis procedures, with significantly greater rates among patients with high-risk factors such as smoking, diabetes, obesity, or Charcot neuroarthropathy. Recombinant human platelet-derived growth factor BB-homodimer with beta-tricalcium phosphate (rhPDGF-BB/β-TCP) is a bone graft substitute that has demonstrated efficacy in foot and ankle fusion rates that are comparable to autograft. MethodsCharts and radiographs were retrospectively reviewed on consecutive adult patients undergoing talonavicular, calcaneal-cuboid, subtalar, and/or ankle arthrodesis utilizing rhPDGF-BB/β-TCP bone graft substitute. The primary outcome measures were rate of and mean time to fusion, mean time to return to function, and incidence of adverse events. ResultsThis study reviewed133 patients who underwent 209 hindfoot and/or ankle joint arthrodesis procedures with a mean follow-up 20.34 ± 11.05 months. The overall fusion rate was 92.82% (194/209 joints) with a mean time to fusion of 13.14 ± 2.52 weeks and return to function of 16.56 ± 3.26 weeks. Overall, there were 7 (5.26%) patients who experienced an adverse event (AE) with 15 (7.18%) joints experiencing a nonunion. ConclusionFusion rates with rhPDGF-BB/β-TCP bone grafting material compared favorably to autograft controls when used in hindfoot and/or ankle arthrodesis. No AEwas related to rhPDGF-BB/β-TCP. This study suggests that using rhPDGF-BB/β-TCP is effective in hindfoot and/or ankle arthrodesis, even among patients with comorbidities who are at a higher risk of developing a nonunion. Level of clinical evidence3.

Dual Parallel Intramedullary K-Wires for Arthrodesis of the Finger Distal or Thumb Interphalangeal Joints.

K-wire arthrodesis methods are commonly used during arthrodesis of the finger distal interphalangeal (DIP) or thumb interphalangeal (IP) joints. Here we propose an advantageous approach involving dual parallel intramedullary K-wires with the K-wire tips cut to bury underneath the skin. From January 2017 to December 2021, 35 patients (43 joints) underwent finger DIP or thumb IP joint arthrodesis using this method. Radiographic outcomes were evaluated, while functional outcomes were assessed using the visual analogue scale (VAS) for pain and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. Patients with at least 1 year follow-up were analyzed. The preoperative and postoperative functional results were analyzed using the paired t-test. Arthrodesis union was achieved in 41/43 joints (95.3%). We treated 10 thumb IP joints and 33 finger DIP joints, for which the underlying cause was osteoarthritis and trauma in 37 and six digits, respectively. The average time of K-wire removal was 8.9 (range, 7-10) weeks after surgery. Twenty-four patients (27 joints; 22 women, two men) had at least 1 year follow-up (mean 15.9; range, 12.5-40.8) months. For patients with bone healing, the VAS score improved from 6.6 (range, 5-8) to 0.6 (range, 0-1) (p < 0.001), and the QuickDASH score improved from 57.9 (range, 31.8-77.3) to 14.7 (range, 6.8-20.5) (p < 0.001) at final follow-up. Both of the two failure cases were in the thumb. There were no other complications. This technique is simple and cost-effective and achieves a good union rate. The advantages include the ability to choose variable K-wire sizes according to the size of the medullary canal and the ease of postoperative care.

Defining the Structures at Risk and an Anatomical Safe Zone for Percutaneous Antegrade Subtalar Joint Fixation With a Single Screw: A Cadaveric Study

Percutaneous antegrade (anterior to posterior) fixation for subtalar joint (STJ) arthrodesis offers various intraoperative and biomechanical advantages. Currently, the entry point for percutaneous antegrade STJ screw fixation is not clearly described and variable. To our knowledge, there are no publications that evaluate anatomic structures at risk or define an anatomically safe entry point for this fixation. The aim of this investigation was to define an anatomically safe and reproducible entry point for percutaneous antegrade STJ arthrodesis fixation, while also describing anatomic structures at risk when undertaking this method of fixation. We hypothesized that percutaneous single screw antegrade STJ fixation would encroach upon named anatomic structures in more than one cadaveric specimen. Ten cadaver limbs were used in this investigation. A percutaneous guidewire was inserted 5 mm lateral to the tibialis anterior tendon. The midpoint of the talar neck served as the sagittal plane starting point, as seen on the lateral fluoroscopic view. A cannulated 6.5-mm headed screw was inserted antegrade through the STJ into the calcaneus. Each specimen was dissected to assess the distance from the screw to nearby anatomic structures and distance from the tibialis anterior tendon to named structures. Our hypothesis was found to be incorrect, as 0/10 screws invaded neurovascular or tendinous structures. The dorsalis pedis artery and deep peroneal nerve were on average 12.1 ± 2.79 mm and 12.2 ± 2.82 mm lateral to the screw, respectively. These findings are clinically relevant and ultimately allow us to define an anatomic safe starting point for percutaneous antegrade STJ single screw fixation.

Approach for Neglected Calcaneal Fracture-Dislocation and Associated Complications

Calcaneal fractures lead to significant debility that can be increased due to delayed or improper surgical repair and are commonly complicated by nonunion. This report explores a unique case of neglected calcaneal fracture with malalignment complicated by subluxing peroneal tendons, arthritis of the hindfoot, and tear of the peroneal retinaculum. The operative intervention consisted of open Achilles tendon lengthening, bone block distraction arthrodesis of the subtalar joint with talonavicular and calcaneocuboid fusion, along with repair of subluxing peroneal tendons with fibular groove deepening. Postoperative imaging at 25 weeks revealed intact hardware, stable alignment, and complete osseous arthrodesis of involved joints, which was also redemonstrated at 1-year postoperative. Reports of reconstructive options for neglected calcaneal fractures that restore mobility, such as this case, are important due to the significant patient burden these injuries impose and the paucity of viably restorative options currently available. Level of Evidence: Level-IV.

Mid-term Incidence of Tarsometatarsal Joint Arthrodesis Following Open Reduction With Internal Fixation (ORIF) of Lisfranc Injuries

Open reduction with internal fixation (ORIF) of Lisfranc injuries are associated with an increased risk for secondary surgery including hardware removal and salvage arthrodesis. In the current literature, rates of salvage arthrodesis vary due to small sample sizes and a low incidence of Lisfranc injuries. There is little evidence to identify specific surgical and patient-related variables that may result in later arthrodesis. The purpose of this study is to determine the rate of tarsometatarsal joint arthrodesis following Lisfranc ORIF in a relatively large sample size. This retrospective review included patients who underwent ORIF for a Lisfranc injury between January 2007 and December 2012. A total of 146 patients met our criteria. Trans-articular fixation was used in 109 (74.6%) patients, 33 (22.6%) received percutaneous fixation and 4 (2.7%) extraarticular fixation. Five out of 120 (4.2%) patients required a salvage arthrodesis for post-traumatic arthritis that had a follow-up greater than 5 y but up to 10 y. The mean age of patients who underwent arthrodesis after ORIF was 24.5 ± 11.95 (16-48) y compared to 40.9 ± 15.8 (16-85) y. Patients who required an arthrodesis also had earlier hardware removal than patients who did not have an arthrodesis, 71.2 ± 28.3 (38-100) days and 131.4 ±101.2 (37-606) days, respectively. Patients who required salvage arthrodesis tended to be younger and hardware was removed earlier compared to those patients who did not require an arthrodesis. Four of the 5 patients who underwent a secondary arthrodesis had a loss of correction after hardware removal.

Immediate Weightbearing Following First Metatarsal Phalangeal Joint Arthrodesis With 2 Nickel Titanium Alloy Staples

The use of staples has been shown to be a reasonable fixation technique to achieve stability of a first MTPJ arthrodesis. Although it has been shown to be a weaker construct than crossed screws or plate and screw combinations, their ease of insertion, low profile, and stability make them a desirable choice for first MTPJ arthrodesis fixation. However, because of this relative weakness, the question remains whether immediate weightbearing when using staples is advisable. The aim of this study is to determine whether the use of 2 nickel-titanium alloy (NITINOL) staples, placed at 90 degrees to one another is a stable enough construct to support full, immediate weightbearing following first MTPJ arthrodesis. We performed a retrospective chart review of patients undergoing first MTPJ arthrodesis by a single surgeon utilizing 2 NITINOL staples placed at 90 degrees to one another. Patients were allowed to be fully weightbearing immediately postoperatively. Forty-seven of 50 (94%) patients achieved complete radiologic consolidation of fusion at 12 weeks, with only 3 requiring revision surgery for nonunion. All of the patients requiring revision surgery for nonunion, had preoperative diagnosis of hallux abducto valgus. We concluded that the use of 2 NITINOL staples placed at 90 degrees to one another is a viable option for first MTPJ arthrodesis, and immediate weightbearing does not increase rate of nonunion or incidence of revision surgery when compared to other fixation techniques.