Plantar Plating Research Articles

Lapidus Arthrodesis for Correction of Hallux Valgus Deformity: A Systematic Review and Meta-Analysis.

The aim of this study was to evaluate and compare different fixation methods to achieve Tarsometatarsal joint I (TMT-1) arthrodesis in patients with hallux valgus regarding radiographic correction, complication profile, and clinical outcomes. A systematic review and meta-analysis included primary literature results of evidence level 1 to 3 studies in German and English. Inclusion and exclusion criteria were established and applied, along with parameters suitable for comparison of data. 16 studies with a total of 1176 participants met the inclusion criteria for this analysis. Twelve evaluation criteria were compared among 3 fixation techniques; comprised of a screw-only, dorsomedial plating- and plantar plating cohort. There was no statistical difference in deformity correction (both intermetatarsal- and hallux valgus angle), or AOFAS score between the cohorts. The complication rate was 13% in the plantar-, 19.5% in the dorsomedial-, and 24.5% in the screw cohort. Nonunion was seen in 0.7% of participants in the plantar, 1.4% in the dorsomedial, and 5.3% in the screw group. The time until complete weightbearing correlated positively with the development of nonunion, with a coefficient of 0.376 (P = .009). Hardware removal was performed in 11.8% of patients in the dorsomedial cohort, 7.7% in the screw cohort, and 3.6% in the plantar cohort. Based on the results of meta-analysis of heterogeneous studies, plantar plating facilitated early weightbearing and patient mobilization compared to the other fixation methods, while carrying the lowest nonunion, hardware removal, and general complication risk. However, owing to the relatively small number of patients in the plantar plating group, more work is necessary to elucidate the benefits of plantar plating for a first tarsometatarsal joint arthrodesis. Development of complications appears to be largely dependent on the fixation model, rather than patient mobilization alone.Level of Evidence: 3.

A novel construct for Lapidus bunionectomy utilizing nitinol staples

The Lapidus bunionectomy is a popular procedure that allows for powerful hallux valgus correction through arthrodesis of the first metatarsal-cuneiform joint. Although widely used since its advent in the 1930s, controversy still exists surrounding what the most superior fixation construct is for this procedure. Commonly used fixation constructs include, but are not limited to, crossed screws, plate and screws, and monorail external fixators. Nitinol staples, although relatively new to the internal fixation world, offer unique advantages that other forms of internal fixation do not. These advantages include easy insertion, dynamic compression, and superelasticity which may impact rates of bunion recurrence, nonunion, and malunion, all of which are of concern with this procedure. This study details a unique surgical technique for the Lapidus bunionectomy utilizing a 2-leg staple dorsally and a 4-leg staple medially in a 90 degree construct. We propose that use of a 4-leg staple medially may mimic the advantages of plantar plating without the difficulty of positioning and obtaining adequate anatomic exposure.

Indications and possible limitations using medio-plantar plate systems in tarsometatarsal 1 fusions – A cadaveric study

BackgroundThe tarsometatarsal 1 arthrodesis is an adequate treatment for moderate to severe hallux valgus deformity and instability of the first ray. Plantar plating arthrodesis has been shown to provide better mechanical stability and fewer postoperative complications than screw fixation or medial plating. The medio-plantar plate is a new plate design for Lapidus arthrodesis. It could combine the biomechanical advantages of the plantar plate and the anatomical overview of a medial plate. However, the implanted material can cause irritation of the tibialis anterior, which in some cases may require removal of the material. The purpose of this study was to examine the possibility of tendon irritation following medio-plantar first tarsometatarsal joint arthrodesis using cadaveric specimens. MethodsThe study involved the simulated surgical procedure of medio-plantar plate arthrodesis on 30 lower extremities. After the plates were fixed, a thorough examination of the feet was conducted to assess any tendon irritation and to determine a recommendation for placement of the medio-plantar plate based on the Olewnik classification. ResultsIrritation of the tibialis anterior tendon components with the medio-plantar plate depends mainly on the anatomic norm variant, classified according to Olewnik et al. A medio-plantar plate is particularly recommended in TA tendon Olewnik type 3 and type 5. The positioning of a medio-plantar plate in Olewnik type 1 and type 2 tendons depends on the anatomic fit of the medio-plantar plate and the bony configuration of the TMT 1 joint. A large portion of the TA tendon must be detached, so a different plate design may be preferred in these patients. ConclusionsTMT 1 arthrodesis with medio-plantar plating of the first tarsometatarsal joint should be performed considering the anatomic TA tendon variations. Level of evidenceLevel V, Expert Opinion includes Case Reports and Technique Tips.

Innovative techniques and concepts in surgical management of Charcot foot deformities

Abstract There is a growing interest in the surgical treatment of Charcot foot arthropathy following the increase in the prevalence of diabetes. The current gold standard of treatment is total contact casting for early deformity, but in recent years, surgery has been performed earlier in the disease process to create a clinically and radiographically plantigrade foot, with the aim of preventing or treating skin ulceration. This review article focused on types of surgical treatment and outcomes associated with each treatment option. Surgical correction consists of ostectomy, tendo-Achilles lengthening, soft tissue releases, and midfoot osteotomies. Arthrodesis can be performed with internal or external fixation or a combination of the two. The purpose of this review article is to review modern surgical techniques for the management of Charcot midfoot deformities. We searched PubMed, Embase, and the Cochrane Library databases using the following search terms: “Charcot arthropathy,” “neuroarthropathy,” “midfoot,” and “arthrodesis.” Articles were chosen based on relevancy to modern surgical treatment options for Charcot midfoot arthropathy. Internal fixation options include intramedullary column fixation, “beaming,” and superconstructs involving a combination of intramedullary fixation and plantar plating. An additional extramedullary construct is introduced, which involves placing large screws from the base of the metatarsal across the deformity, known as “rafting screws.” Complications of fixation methods are also discussed in detail.

Plantar Plating in the Modified Lapidus Procedure: Evaluation of Function and Impairment of the Tibialis Anterior Tendon

The modified “Lapidus” procedure (MLP) describes the arthrodesis of the first tarsometatarsal joint. We investigate if there are detectable changes of the tendon or the function of the muscle and clinical outcome after MLP. We reviewed 22 feet. All patients underwent magnetic resonance imaging (MRI) at an average of 27 (range, 12-49) months. Clinical outcome was evaluated using the European Foot and Ankle Society score. Strength was measured and complications were assessed. MRI revealed signs of tendinopathy of the tibialis anterior tendon in 13 feet (59%). The mean total European Foot and Ankle Society score at final follow-up was 17 (range, 6-24) points. The mean postoperative Visual Analog Scale score was 1.4 (range, 0-5). Range of motion and force data were not significantly different to the contralateral side. In conclusion, MRI showed signs of tendinopathy in 59%, which does not seem to affect clinical outcome, but has to be considered when choosing the desired implant and placement. MLP leads to high patient satisfaction rates and significant improvement at midterm follow up.

Proximal Fifth Metatarsal Fracture Treated with Plantar Plating: Retrospective Multi-Surgeon Case Series

Category:Midfoot/Forefoot; Sports; TraumaIntroduction/Purpose:Proximal fifth metatarsal fractures are a common foot injury. Previous surgical treatments have consisted of intramedullary screw fixation and a newer technique of plantar plating due to non-union and refractures seen with screw fixation. Purpose of this multi-surgeon case series study is to evaluate clinical and radiographic outcomes and complication rates after fifth metatarsal plating for proximal fifth metatarsal fractures in recreational and elite athletes.Methods:Retrospective multiple surgeon case series involving patients who underwent fifth metatarsal plantar plating for proximal fifth metatarsal fractures with a mean follow-up of 33.1 months (range, 12-52). Elite and recreational athletes were included. Demographic data, radiographic evaluation, and clinical notes were analyzed. Patient phone conversations were made to document complications outside of our electronic medical record.Results:Forty-four patients (45 fractures) were treated with plantar plating technique with a mean age of 37.3 years (range 14- 80). Five patients sustained refractures (11.1% of patients), 2 at previous fracture site, 1 through a screw hole, 1 proximal to plate, and 1 distal to plate. All refractures were treated non-operatively. No wound complications were seen. No secondary revision surgery was needed and union rate was 100% at final follow up.Conclusion:With a one year minimum follow up, plantar plating of proximal fifth metatarsal fractures is a viable option for treatment of both acute and chronic fractures as well as after failed intramedullary screw fixation with low refracture rates and without non-unions. Plantar plating allows the surgeon to have direct visualization of fracture reduction and ease of access for bone grafting. Both elite and recreational athletes can benefit from the plating technique.

Lag Screw with Plantar Plating for Naviculocuneiform Arthrodesis in Progressive Collapsing Foot Deformity

Category:Midfoot/ForefootIntroduction/Purpose:Medial column procedures are a common adjunct to progressive collapsing foot deformity (PCFD) correction. In particular, naviculocuneiform (NC) arthrodesis could be performed when degeneration or instability at the NC joint is contributing to arch collapse. Plantar plate fusion resists gapping along the tension side of the joint, potentially reducing risk of non-union and recurrent deformity. Additionally, by placing the hardware in a plantar location there is an increased soft tissue envelope to function in a protective matter and eliminate the possibility of hardware prominence and tendon irritation. The purpose of this study was to analyze short-term clinical and radiographic outcomes of NC fusion using a lag screw with plantar plating technique.Methods:A single-surgeon retrospective case series was performed on patients with PCFD and medial arch collapse treated with NC arthrodesis using a lag screw plus plantar plating technique between January 2016 and December 2019, with a minimum six month clinical and radiographic follow up. Patients undergoing revision NC joint arthrodesis, patients with incomplete imaging, or an arthrodesis technique that did not utilize NC joint plantar plating were excluded. Demographic data, perioperative data, complications, and reoperations were recorded from electronic medical records. Pre-operative AOFAS midfoot scores were calculated at the initial clinic visit and then again at the patients' most recent follow-up. In the case of most recent follow up occurring prior to six months post-operatively, a telemedicine visit was performed. Anteroposterior (AP) and lateral talo-first metatarsal angles, talonavicular coverage angle, and calcaneal pitch were measured independently by three authors. Fusion was confirmed radiographically and computed topography when union was in question.Results:Nineteen patients (15 female, 4 male; 11 right, 8 left) with a mean age of 56.6 years and a mean follow-up of 21.0 +- 13.4 months were reviewed. A mean 3.4 concomitant procedures were performed at the time of NC fusion. AP talo-first metatarsal angle (18.9° to 5.2°), lateral talo-first metatarsal angel (-18.7° to -4.4°), talonavicular coverage angle (28.1° to 7.4°), and calcaneal pitch (14.6° to 20.1°) all improved significantly (p<0.001). Fusion was confirmed in 15 (79%) patients at a mean 6.1 +- 3.5 months. Mean AOFAS midfoot scores improved from 51.7 +- 13.0 preoperatively to 82.6 +-12.8 (p<0.001) at an average 21.0 +- 13.4 months follow up. Two patients experienced broken hardware, one patient fractured through flexor digitorum longus (FDL) transfer site and experienced non-union requiring revision at 9.5 months, one patient experienced symptomatic lateral column hardware requiring removal, and one patient experienced non-union requiring revision at 13.5 months.Conclusion:Lag screw with plantar plating is a technique for NC arthrodesis that is associated with a higher non-union rate (21%) than what is reported in the literature. Nonetheless, at short term (mean 21 months) follow up, the technique proved capable of correcting medial arch collapse through the NC joint when used in conjunction with adjunctive soft tissue and bony procedures. Plantar plating technique resulted in no instances of symptomatic hardware along the medial midfoot. Addressing medial arch collapse with NC arthrodesis resulted in significant improvement of both radiographic outcomes and patient reported clinical outcomes.

Plantar Plating in the Modified Lapidus Procedure: Evaluation of Function and Impairment of the Tibialis Anterior Tendon

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:Plantar Plating in the Modified Lapidus Procedure (MLP) to treat severe Hallux Valgus deformities (HVD) or hypermobility of the first ray has become more popular. Due to biomechanical considerations, early weightbearing can be achieved. The surgical procedure and some plate designs make a release of the Tibialis Anterior tendon (TAT) necessary and screws have to be placed through or close to its insertion. We investigate if there are detectable changes of the tibialis anterior tendon or the function of the tibialis anterior muscle (TAM).Methods:We retrospectively reviewed 22 Feet (17 patients) after plantar plating for a modified Lapidus procedure. All patients underwent a MRI at an average of 27 months (range 12-49 months) postoperatively for evaluation of the tendon. Clinical outcome was evaluated using the EFAS score. Dorsiflexion strength was measured and compared to the healthy contralateral extremity.Complications and union rates were assessed.Results:The subjective satisfaction was rated at a mean of 8.2 (range, 5 - 10; SD +-1.5) on a scale from 0 to 10. Fourteen (82%) patients would undergo the same surgical treatment again. MRI images showed signs of tendinopathy of the TAT in 13 feet (59%). There were no ruptures, signs of thinning of the tendon or fatty infiltration detected. Complication rate was low with only on case with performed revision surgery. Regarding the Range of Motion, the force data comparing both feet of the patients is statistically close in comparison to the other side without any statistical differences.Conclusion:The MLP using a plantar-positioned locking plate leads to high patient satisfaction rates and provides significant improvement of preoperative deformity in severe HVD at midterm follow-up. Inversion strength was reduced, and MRI showed signs of tendinopathy in more than half of the cases. However, these findings did not seem to have any effect on the clinical outcome. None of the present patients had a high degree of fatty infiltration of the TAM in accordance with the Goutallier grading. Plantar-positioned locking plates do not seem to impair the TAM or the TAT.

Plantar Plating for Medial Naviculocuneiform Arthrodesis in Progressive Collapsing Foot Deformity.

Background:Medial column procedures are commonly used to treat progressive collapsing foot deformity (PCFD) reconstruction. The aim of this research is to present the clinical results of plantar plating for medial naviculocuneiform (NC) arthrodesis when NC joint pathology contributes to medial arch collapse. The authors hypothesized that lag screws with a plantar neutralization plate would result in a satisfactory NC joint fusion rate.Methods:A single-surgeon, retrospective case series was performed on patients with flexible PCFD who underwent NC arthrodesis using lag screws and a contoured neutralization plate applied plantarly across the medial NC joint as part of PCFD reconstruction. Thirteen patients (11 females, 2 males; mean age 53.1 [34-62] years) between 2016 and 2019 were identified for inclusion. Mean follow-up was 25.2 ± 12.7 months. Preoperative and postoperative anteroposterior talo–first metatarsal angle, lateral talo–first metatarsal angle, talonavicular coverage angle, and calcaneal pitch were measured. Union was evaluated radiologically. AOFAS midfoot scores were recorded at final follow-up.Results:All parameters demonstrated a significant improvement. Fusion was confirmed in 11 of 13 patients (85%) at a mean 5.7 ± 2.1 months. One patient required a revision of their NC fusion because of symptomatic nonunion. There were no cases of symptomatic plantar hardware.Conclusion:The results of this small cohort series suggest that lag screw with plantar plate NC arthrodesis yielded generally improved short-term radiographic and clinical outcomes in PCFD patients with medial arch collapse through the NC joint.Level of Evidence: Level IV, retrospective case series.

Radiographic Outcomes, Union Rates, and Complications Associated With Plantar Implant Positioning for Midfoot Arthrodesis.

Background:Midfoot arthrodesis has long been successfully included in the treatment paradigm for a variety of pathologic foot conditions. A concern with midfoot arthrodesis is the rate of nonunion, which historically has been reported between 5% and 10%. Plantar plating has also been noted to be more biomechanically stable when compared to traditional dorsal plating in previous studies. Practical advantages of plantar plating include less dorsal skin irritation and the ability to correct flatfoot deformity from the same medial incision. The purpose of this study is to report the arthrodesis rate, the success of deformity correction, and the complications associated with plantar-based implant placement for arthrodesis of the medial column.Methods:A retrospective review was undertaken of all consecutive patients between 2012 and 2019 that underwent midfoot arthrodesis with plantar-positioned implants. Radiographic outcomes and complications are reported on 62 patients who underwent midfoot arthrodesis as part of a correction for hallux valgus deformity, flatfoot deformity, degenerative arthritis, Lisfranc injury, or Charcot neuroarthropathy correction.Results:Statistically significant improvement was seen in the lateral talus–first metatarsal angle (Meary angle) and medial arch sag angle for patients treated for flatfoot deformity correction. In patients treated for hallux valgus deformity, there was a reduction in the intermetatarsal angle from 15.4 to 6.8 degrees. The overall nonunion rate was 6.45% in all patients. The rate of nonunion was higher at the NC joint compared to the TMT joint and with compression claw plates. One symptomatic nonunion required revision surgery (1.7%). There were no nonunions when excluding neuroarthropathy patients and smokers. The odds ratio (OR) for nonunion in patients with neuroarthropathy was 6.05 (P < .05), and in active smokers the OR was 2.33 (P < .05).Conclusion:Plates placed on the plantar bone surface for midfoot arthrodesis achieved and maintained deformity correction with rare instances of symptomatic hardware for a variety of orthopedic conditions. An overall clinical and radiographic union rate of 94% was achieved. The radiographic union rate improved to 100% when excluding both neuroarthropathy patients and smokers. The incidence of nonunion was higher in smokers, neuroarthropathy patients, naviculocuneiform joint fusions, use of compression claw plates, and when attempting to fuse multiple joints. Incisional healing complications were rarely seen other than in active smokers.Level of Evidence:Level IV, case series.

Anatomical Study of Lapidus Arthrodesis using two Different Plantarplate Systems

Category:Midfoot/ForefootIntroduction/Purpose:First tarsometatarsal arthrodesis (modified Lapidus procedure) constitutes a sufficient treatment for moderate to severe hallux valgus deformity and first ray instability. The plantar plate arthrodesis was shown to provide superior mechanical stability and less postoperative complications than screw fixation or dorsal plating. Nevertheless, the in-brought hardware may cause irritation of the tibialis anterior or peroneus longus tendon requiring explanation of the material in some cases. The purpose of this study was to investigate the potential of tendon irritation after plantar first tarsometatarsal joint arthrodesis in a cadaver study.Methods:Plantar plate arthrodesis was performed as in real surgery on twelve pairs of fresh frozen cadaveric feet. Two different plate systems were randomly allocated to each pair of feet. After plate fixation careful dissection of the feet followed to analyze potential tendon irritation and to determine a ‘safe zone’ for plantar plate placement.Results:A ‘safe zone’ between the insertion sties of tibialis anterior and peroneus longus tendon was found and proven to be sufficiently exposed using a standard medio-plantar approach. Both plates were fixed in this zone without compromising central tendon parts. Peripheral tendon parts were irritated in42% using Darco Plantar Lapidus Plating System1 (Wright Medical, Memphis, TN) and in 8% using the Plantar Lapidus Plate1 (Arthrex, Naples, FL). Bending of the anatomically preshaped plates is often necessary to ensure optimal fit on the bone surface.Conclusion:Modified Lapidus procedure with plantar plating of the first tarsometatarsal joint can be performed safely without compromising central tendon parts via standard medio-plantar approach.

Radiographic Outcomes, Union Rates, and Complications Associated with Implants Positioned on the Plantar Bone Surface for Midfoot Arthrodesis

Category:Midfoot/Forefoot; TraumaIntroduction/Purpose:Midfoot fusions have long been used to treat a variety of procedures in the foot. Indications may include hallux valgus correction, first ray instability, midfoot arthritis, pes planovalgus, trauma, and Charcot reconstruction. One of the drawbacks of this procedure is nonunion, which has been consistently reported between 5-10%. Placing implants and obtaining fixation along the plantar surface of the bone may create a tension band implant construct during physiologic loading that helps to compress the arthrodesis site and thereby may further optimize the healing potential. This study reports on the radiographic and clinical outcomes of plantar plating and arthrodesis of midfoot joints for a variety of procedures.Methods:A retrospective review was undertaken of consecutive patients between 2012-2019 that underwent a midfoot fusion with plantar positioned implants by a fellowship-trained foot and ankle orthopedic surgeon at a single institution. 62 patients underwent arthrodesis of the midfoot as part of a correction for hallux valgus, flatfoot deformity, midfoot arthritis, Lisfranc injury, Charcot correction or a combination these diagnoses. Average follow-up was 36.2 months (range, 16-66 months). For those treated for a flatfoot deformity, the lateral talus-first metatarsal (Meary’s) angle and medial arch sag angle (MASA) were compared on preoperative and postoperative imaging to obtain the magnitude of radiographic correction achieved. For those treated for hallux valgus deformity, the inter-metatarsal angle (IMA) was utilized to establish the magnitude of deformity correction. Serial weight-bearing radiographs were independently evaluated for malunion, nonunion, or hardware migration to be logged as complications at the arthrodesis site.Results:The 1st TMT joint was fused in 43 patients, and the NC joint was fused in 23 patients. Five patients had simultaneous fusion of the 1st TMT and NC joints. Two patients underwent arthrodesis of the talonavicular (TN) joint with one patient having simultaneous arthrodesis of the TN and NC joints. We found statistically significant improvement in the lateral talus-first metatarsal-angle (Meary’s) and medial arch sag angle (MASA) for those treated for flatfoot corrections. For those treated for hallux valgus, there was significant reduction in the Intermetatarsal angle (IMA) from 15.4 to 6.8 degrees. The overall nonunion rate was 6.45% in all patients. The nonunion rate was reduced to 3.3%when excluding the Charcot neuroarthropathy patients.There was one symptomatic nonunion requiring revision surgery (1.7%).Conclusion:Deformity correction was successfully maintained in those treated for hallux valgus and flatfoot deformities. There were significant improvements in the IMA, the MASA, and Meary’s angle Plates implanted on the plantar bone surface for midfoot arthrodesis provided and maintained deformity correction without hardware irritation for a variety of orthopedic conditions. A clinical and radiographic union rate of94% (97% when excluding Charcot neuroarthropathy patients) was achieved. The risk of nonunion appeared to be higher in diabetic patients, in smokers, with the utilization of claw plates, and when fusion constructs included the NC joint.

Early Results of Immediate Weightbearing Following First Tarsometatarsal Joint Arthrodesis With Plantar Locking Plate and Dorsal Compression Screw

Arthrodesis of the first tarsometatarsal joint (TMT1) reduces pathologic angles at the anatomic center of rotation of angulation and presents a substantial correction potential in 3 planes in the treatment of hallux abductovalgus. The optimal fixation method remains unclear since prevailing dorsomedial locking plates and/or compression screws depict elevated implant-associated complications. Medical records of 49 patients that underwent 53 TMT1 arthrodeses in hallux abductovalgus interventions were included. Median average visual analog scale scores decreased (p < .001) from 6.8 (range 4-10) to 2.7 (range 0-10), first intermetatarsal angles were reduced (p < .001) from 17.39° (range 12°-28°) to 7.16° (range 3°-12°), standing lateral first metatarsal angles improved (p < .001) from 21.66° (range 12°-29°) to 23.94° (range 14°-31°) and tibial sesamoid positions were plantarized (p < .001) from 6.02° (range 4°-7°) to 2.79° (range 1°-6°). Plantar plating allowed immediate weightbearing with transition to normal shoe gear at 6 weeks. Complications occurred in 6 (11.34%) feet including 1 (1.89%) nonunion, 1 (1.89%) delayed union, 1 (1.89%) hallux varus, 1 (1.89%) incomplete recurrence, 1 (1.89%) minor dehiscence, and 1 (1.89%) hardware irritation. Plantar locking plates combined with a dorsal compression screw presented a favorable tension-side implant location that closed the fusion site under load. This facilitated substantial reductions in complications, pathologic angles, and pain.

Biomechanical Analysis of Conventional Partially Threaded Screws Versus Headless Compression Screws in Proximal Fifth Metatarsal (Jones) Fracture Fixation.

Intramedullary screw fixation of Jones fractures using partially threaded screws is a common method of fixation for these injuries, but refracture continues to be a problem. Various other fixation strategies, such as headless compression screws, plantar plating, and tension-band wiring. have been developed to mitigate these issues. Biomechanical studies with regard to these other fixation strategies are limited. Herein, we investigate the compression strength and angular stiffness of Jones fractures fixed with Herbert-style headless compression screws. Jones fractures were created in 10 fresh-frozen pairs of cadaveric fifth metatarsals. A bone from each pair was instrumented with either a conventional, partially threaded screw 5.0 or 6.5 mm in diameter, or a headless compression screw 5.0 or 7.0 mm in diameter. Sizes were determined via sequential tapping until a snug fit was obtained. Each metatarsal was stressed via cantilever bending over 1000 cycles. We monitored compression and displacement throughout. Headless compression screws achieved a significantly higher amount of stiffness than conventional, partially threaded screws (P = 0.005). There was no statistically significant difference with respect to compression. In a cadaveric model, headless compression screws achieved a greater amount of fracture stiffness versus conventional, partially threaded screws.Levels of Evidence: Therapeutic, Level V: Biomechanical.

Operative Results of Plantar Plating for Fifth Metatarsal Stress Fracture.

The treatment of fifth metatarsal stress fractures can be challenging. Various operative fixation methods have been reported for fracture management. Among them, intramedullary screw fixation has become increasingly popular. However, recent reports have described failures after screw fixation in athletes. The aim of this study was to determine the rates of clinical and radiographic healing, time to return to sport, and complications of elite athletes with proximal fifth metatarsal fractures treated with plantar plating. Thirty-eight athletes with fifth metatarsal stress fractures treated using a plantar plating technique in 3 hospitals from 2013 to 2018 were evaluated retrospectively. Demographic data, radiographic evaluation, and the time until union and return to sports activities were collected and analyzed. A total of 38 patients underwent the plantar plating for a fifth metatarsal stress fracture with a mean follow-up of 23 (range, 12-49) months. The mean time to the radiologic union, as determined by plain radiography, was 9.3 (range, 8-16) weeks. Although there were no nonunions or delayed unions during follow-up, 4 refractures developed (10.5%). All but 1 patient were able to return to their previous levels of sporting activity at 22.2 ± 4.5 (range, 12-40) weeks. With a minimum of 1-year follow-up, the described plantar plating technique could be an alternative method for the operative treatment of fifth metatarsal stress fractures without nonunion problems. Level IV, case series.

Surgical Results of Plantar Plating for Fifth Metatarsal Stress Fracture

Category:Midfoot/Forefoot, Sports, TraumaIntroduction/Purpose:The treatment of 5th metatarsal stress fractures of the can be challenging and at times can result in significant disability. Intramedullary screw fixation has become a popular surgical method for management. However, many recent reports have described failures after screw fixation in athletes. The aim of this study was to determine rates of clinical and radiographic fracture healing, return to sport, and complications of elite athletes with proximal fifth metatarsal fracture treated with plantar plating.Methods:Thirty-eight patients with fifth metatarsal stress fractures treated using the plantar plating technique in four hospitals from 2013 to 2018 were evaluated retrospectively. All of the patients were elite athletes. Demographic data, radiographic evaluation, and the time until union and return to unrestricted sporting competition were collected and analyzed.Results:A total of 38 patients underwent the plantar plating for 5th metatarsal stress fracture with a mean follow-up of 23 months (range, 12-49 months). The mean time to radiologic union as determined by CT was 9.3 weeks (range, 8-16 weeks). However, during follow-up, there were 4 refractures but no union problems. One patient experienced temporary sensory disturbance that resolved within 3 months. There was one patient with temporary wound complication, two cases with hardware prominence. All but one patients were able to return to their previous levels of sporting activity at 21 ± 4 (range, 18 to 40) weeks.Conclusion:With minimum 1-year follow-up, the described plantar plating technique is a good alternative method for the surgical treatment of fifth metatarsal stress fractures with less complications.

Anatomical study of Lapidus arthrodesis using two different plantar plate systems

BackgroundFirst tarsometatarsal arthrodesis (modified Lapidus procedure) constitutes a sufficient treatment for moderate to severe hallux valgus deformity and first ray instability. The plantar plate arthrodesis was shown to provide superior mechanical stability and less postoperative complications than screw fixation or dorsal plating. Nevertheless, the in-brought hardware may cause irritation of the tibialis anterior or peroneus longus tendon requiring explantation of the material in some cases.The purpose of this study was to investigate the potential of tendon irritation after plantar first tarsometatarsal joint arthrodesis in a cadaver study. MethodsPlantar plate arthrodesis was performed as in real surgery on twelve pairs of fresh frozen cadaveric feet. Two different plate systems were randomly allocated to each pair of feet. After plate fixation careful dissection of the feet followed to analyze potential tendon irritation and to determine a “safe zone” for plantar plate placement. ResultsA “safe zone” between the insertion sties of tibialis anterior and peroneus longus tendon was found and proven to be sufficiently exposed using a standard medio-plantar approach. Both plates were fixed in this zone without compromising central tendon parts. Peripheral tendon parts were irritated in 42% using Darco Plantar Lapidus Plating System® (Wright Medical, Memphis, TN) and in 8% using the Plantar Lapidus Plate® (Arthrex, Naples, FL). Bending of the anatomically preshaped plates is often necessary to ensure optimal fit on the bone surface. ConclusionsModified Lapidus procedure with plantar plating of the first tarsometatarsal joint can be performed safely without compromising central tendon parts via standard medio-plantar approach. Level of clinical evidence5, Cadaver Study.

Biomechanical Comparison of Intramedullary Beaming and Plantar Plating Methods for Stabilizing the Medial Column of the Foot: An In Vitro Study

Charcot neuroarthropathy often results in a rocker-bottom foot deformity, which leads to ulceration, infection, and amputation. Surgical techniques to reconstruct the medial column include intramedullary beaming and plantar plating, with disagreement regarding which approach provides a stronger construct with superior stability and fixation. The objective of the present cadaveric study was to compare the construct rigidity and strength of beaming and plantar plating of the medial column of 5 paired bilateral feet. Cannulated titanium beams and plates were implanted in the right and left feet, respectively. The specimens underwent interval testing to generate load-displacement and load-strain curves, cyclic loading at low loads, and then were loaded to failure. The beamed and plated specimens had statistically similar stiffness (p = .80) with a mean of 11.1 ± 3.9 N/mm and 11.3 ± 5.9 N/mm, respectively. The beamed and plated specimens had a statistically similar mean strain of −164 ± 75.1 µε and −208 ± 87.8 µε on the dorsal (p = .45) and 92 ± 90.4 µε and 221 ± 100.5 µε on the plantar (p = .08) surfaces of the first metatarsal. Three beamed specimens failed from talus fracture (60%), and 2 beams plastically deformed (40%). Two plated specimens failed from talus fracture (40%), and 3 experienced screw pullout (60%). The beamed and plated specimens withstood a mean load to failure of 234 ± 111.4 N and 140 ± 68.9 N, respectively, with the difference statistically significant (p = .04). Overall, beaming was more robust than plantar plating, because it was less sensitive to specimen size and bone quality.

Treatment of Proximal Fifth Metatarsal Fractures and Refractures With Plantar Plating in Elite Athletes.

Fractures of the proximal fifth metatarsal are relatively common foot injuries in elite athletes. Acute fixation with intramedullary screws is the most common operative treatment. However, the rate of nonunion and refracture after this procedure remains a concern. The purpose of this study was to determine rates of clinical and radiographic fracture healing, return to sport, and patient-reported clinical outcomes of elite athletes with proximal fifth metatarsal fracture or refracture treated with plantar plating. An institutional review board-approved retrospective single-surgeon case series investigation assessed athletes (competing at college, Olympic, or professional levels) with proximal fifth metatarsal fracture or refracture, treated with open reduction internal fixation and calcaneal autogenous bone grafting using a plantar plate with a minimum 2-year follow-up. Demographic data, radiographic evaluation, and the time until return to unrestricted sporting competition were collected and analyzed. Means with standard deviations were calculated for continuous data, and frequencies of categorical data were calculated in percentages. Four refractures and 4 primary fractures were treated in 8 male athletes with a mean age of 21.9 ± 1.9 years at a mean follow-up of 3.2 ± 0.4 years. Two patients experienced temporary neuropraxia of the sural nerve that resolved within 6 weeks. There were no incisional complications, delayed unions or nonunions, refractures, hardware loosening, or complaints of hardware prominence. Clinically asymptomatic radiographic union was observed in 100% of the athletes at 6.5 ± 1.1 weeks and full release given at 12.3 ± 1.9 weeks. All athletes returned to sport at the same level of competition. With minimum 2-year follow-up, plantar plating of proximal fifth metatarsal fractures was an effective and safe technique that was used in both primary and revision settings. Level IV, case series.

Stability of Locking Plate and Compression Screws for Lapidus Arthrodesis: A Biomechanical Comparison of Plate Position

Lapidus (first tarsometatarsal joint) arthrodesis is an established and widely used procedure for the management of moderate to severe hallux valgus, especially in cases involving hypermobility of the first tarsometatarsal joint. Multiple fixation methods are available, and several previous investigations have studied the relative strengths of these methods, including dorsomedial and plantar plating comparisons. However, these studies compared plates of varying designs and mechanical properties and used varying modes of compression and interfragmentary screw techniques. The present study mechanically investigated the resulting motion, stiffness, and strength of identical locking plate constructs fixed at various anatomic positions around the first tarsometatarsal joint. In a bench-top study, fourth-generation composite bones were divided into 3 fixation groups, each having identical interfragmentary screw applications, and randomized to 1 of 3 plate positions: dorsal, medial, or plantar. The plates applied in each case were identical locking plates, precontoured to fit the anatomy. Each construct was experimentally tested using a cantilever bending approach. The outcomes obtained were stiffness, yield force, displacement at yield, ultimate force, and displacement at ultimate force. The plantar plate position showed superior initial stiffness and force to ultimate failure. The plantar and medial plate positions exhibited superior force to yield. The medial plate position was superior regarding displacement tolerated before the yield point and catastrophic failure. The dorsal plate position was not superior for any outcome measured. Plantar and medial plating each offered biomechanical benefits. Clinical studies using similarly matched constructs are required to show whether these findings translate into improved clinical outcomes.