Tarsometatarsal Joint Arthrodesis 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.

Assessing the Biomechanical, Kinematic, and Force Distribution Properties of the Foot Following Tarsometatarsal Joint Arthrodesis: A Systematic Review

The Lisfranc joint connects the forefoot to the midfoot. Tarsometatarsal (TMT) arthrodesis is commonly employed for Lisfranc joint injuries; however, there is active discussion regarding the optimal method of fixation for TMT arthrodesis. The purpose of this systematic review is twofold: to assess the stability of various constructs used in TMT arthrodesis and to evaluate joint motion and force distribution in the foot following arthrodesis. The PubMed, CINAHL, MEDLINE, and Web of Science databases were searched for articles evaluating biomechanical and kinetic properties of TMT arthrodesis constructs in accordance with PRISMA guidelines. The preliminary search yielded 367 articles and the final review included 14 articles with 195 cadaveric and 70 synthetic bone constructs. Plantar plates and intramedullary screw fixation at the first TMT joint were consistently found to bear significantly greater loads and resist diastasis more effectively than crossed screws. Furthermore, whole foot and lateral column arthrodesis significantly elevate calcaneocuboid and lateral column pressures. This increase was not observed with isolated fourth or fifth TMT arthrodesis. TMT arthrodesis should aim to avoid the lateral column and fuse as few joints as possible. Overall, plantar plates are an effective construct for first TMT arthrodesis due to their ability to withstand both compressive and tensile forces while maintaining stable alignment of the foot via reinforcement of the transverse arch. Intramedullary fixation devices are an alternative option that provide a high degree of active compression across the joint space while avoiding irritation of surrounding soft tissue structures.

Adverse events related to triplanar 1st tarsometatarsal joint arthrodesis: 5-year analysis of the united states food and drug administration manufacturer and user facility device experience database

BackgroundThe Lapiplasty® 3D Bunion Correction™ system represents an instrumented, jig-guided system to facilitate performing triplanar 1st tarsometatarsal joint arthrodesis. Literature available for this system is positive, although the vast majority is from inventor/consultant surgeons. The purpose of this manuscript is to review adverse event submissions recorded in the Manufacturer and User Facility Device Experience database specific to this system. MethodsThe Manufacturer and User Facility Device Experience database was retrospectively reviewed from inception to 30 June 2023 for adverse events submitted for the Lapiplasty® 3D Bunion Correction™ system. Submissions that involved a medical device product other than this system, duplicate entries, and submissions with data extracted from already published literature were excluded. ResultsA total of 180 unique reports that met inclusion criteria during the 5-year period available were reviewed. The mean time between event occurrence and submission was 46.7-days. The most common entity submitting to the database were the manufacturer company representative or distributor in 66.4%. The most frequently encountered patient problems were pain in 41.9%, non-union in 18.2%, and hardware-related irritation in 11.7%. Reports that detailed a revision surgery described partial/complete hardware removal in 62.7% and revision with additional hardware implantation in 23.3%. ConclusionWhile no direct conclusions regarding the Lapiplasty® 3D Bunion Correction™ system can be drawn from the data as it consists of only adverse event reports, this study demonstrates the need for more non-inventor/consultant literature to further investigate adverse events related this particular system.

Determination of the Inter- and Intra-rater Reliability of Fusion Assessment in First Tarsometatarsal Joint Arthrodesis Using CT Scan: An Observational Study.

First tarsometatarsal joint arthrodesis is a common procedure performed by podiatrists and orthopedic surgeons. There remains debate on how useful CT scans are in assessing fusion status in the post-operative patient. The purpose of our study was to determine the reliability among both orthopedic surgeons and radiologists in reviewing both postoperative radiographs and CT in order to determine if fusion had occurred in patients undergoing 1st tarsometatarsal arthrodesis. A secondary purpose of this study was to determine if CT offered improved inter- and intra-rater reliability when compared to plain radiographs. Patients who underwent 1st tarsometatarsal arthrodesis were retrospectively reviewed and those who underwent CT post-operatively for persistent pain were identified. Orthopedic surgeons and radiologists then analyzed the radiographs and CT of these patients for union with a threshold for union being set at 50% of the joint being fused. Imaging was then re-evaluated by the same provider 6months later. 24 patients were identified meeting inclusion criteria. Inter-rater reliability and intra-rater reliability for assessment of 1st tarsometatarsal arthrodesis were better with CT compared to radiographs; however, this association was not deemed reliable. Both imaging modalities were not able to assess union status confidently and reliably across reviewers, although CT scan had better intra-rater reliability. While CT is frequently used to assess fusion in patients who have underwent 1st tarsometatarsal arthrodesis, it was not found to be better than radiographs. Practitioners should reconsider the use CT as the gold standard when assessing fusion in this population.

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.

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.

Biomechanical Comparison of Medio-Plantar and Plantar Plate Fixation for First Tarsometatarsal Joint Arthrodesis.

Plantar plate positioning has been demonstrated as biomechanically superior. However, some operators remain resentful about the morbidity of the surgical approach. To provide improved plate fixation for first tarsometatarsal joint arthrodesis with respect to the tibialis anterior tendon, a medio-plantar plate was developed. The purpose of this biomechanical study was to compare its construct stability to that of a plantar plate construct. Twelve pairs of fresh frozen human specimens were used in a matched pair test. Each pair was fixed with a 4 mm compression screw and either a plantar locking plate or a medio-plantar locking plate. A cantilever beam test was performed in dorsiflexion. Before and after cyclic loading (5000 cycles; 40 N), bending stiffness and relative movements at the joint space were monitored in a quasi-static test including optical motion tracking. Maximum load and bending moment to failure were investigated in a load-to-failure ramp test. The bending stiffness of both groups did not significantly differ before (plantar 49.9 N/mm ± 19.2; medio-plantar 53.9 N/mm ± 25.4, p = 0.43) or after (plantar 24.4 N/mm ± 9.7; medio-plantar 35.3 N/mm ± 22.0, p = 0.08) cyclic loading but decreased significantly in both groups (p < 0.01) after cyclic loading. Relative movement increased significantly during cyclic testing in both groups (p < 0.01) but did not differ significantly between the groups before (p = 0.29) or after (p = 0.16) cyclic loading. Neither load nor bending moment to failure were significantly different (plantar 225 N ± 78, 10.8 Nm; medio-plantar 210 N ± 86, 10.1 Nm, p = 0.61). Both plate constructs provided equivalent construct stability, both being well suited for Lapidus arthrodesis.

Radiographic Evaluation of First Tarsometatarsal Joint Arthrodesis for Hallux Valgus Deformity: Does the Fusion of the First to the Second Metatarsal Base Reduce the Radiological Recurrence Rate?

Modified Lapidus arthrodesis (MLA) is a well-established treatment option for symptomatic hallux valgus deformity (HVD). However, recurrence of the deformity remains a concern. The goal of this study was to evaluate the effect of an additional intermetatarsal fusion on the radiographic recurrence rate after first tarsometatarsal (TMT-I) arthrodesis. This is a retrospective evaluation of 56 feet that underwent TMT-I arthrodesis for moderate to severe HVD. Twenty-three feet received an isolated arthrodesis of the TMT-I joint (TMT-I), whereas 33 feet received an additional fusion between the base of the first and the second metatarsal bone (TMT-I/II). Various radiological parameters were determined preoperatively, 6 weeks and at a mean of 2 years postoperatively. The intermetatarsal angle (IMA) and the hallux valgus angle (HVA) were significantly lowered at both follow-up evaluations in both groups. In the TMT-I/II group, the initial reduction of HVA was significantly higher (29.3° vs 21.1°). This difference disappeared by the second follow-up, leaving no significant differences between both techniques at final follow-up. Radiological recurrence rates of HVD were comparable in both groups. Isolated TMT-I arthrodesis provides reliable radiological results in the correction of HVD. Whether additional fusion of the first and second metatarsal base should be routinely performed remains unclear. Level 3.

Morphologic analysis of the 1st and 2nd tarsometatarsal joint articular surfaces

Tarsometatarsal joint arthrodesis is used to treat a variety of injuries and deformities in the midfoot. However, the surgical technique has not been optimized, in part due to limited knowledge of morphologic features and variation in the related joints. Previous research has relied primarily on dissection-based anatomical analysis, but quantitative imaging may allow for a more sophisticated description of this complex. Here, we used quantitative micro-CT imaging to examine dimensions, distance maps, and curvature of the four articular surfaces in the first and second tarsometatarsal joints. Image segmentation, articular surface identification, and anatomic coordinate systems were all done with semi or fully automatic methods, and distance and size measurements were all taken utilizing these anatomic planes. Surface curvature was studied using Gaussian curvature and a newly defined measure of curvature similarity on the whole joint and on four subregions of each surface. These data show larger articular surfaces on the cuneiforms, rather than metatarsals, and define the generally tall and narrow articular surfaces seen in these joints. Curvature analysis shows minimally curved opposing convex surfaces. Our results are valuable for furthering knowledge of surgical anatomy in this poorly understood region of the foot.

Complications of First Tarsometatarsal Joint Arthrodesis

Category: Bunion Introduction/Purpose: Hallux valgus, a term introduced by Carl Hueter (1) to define static subluxation of the first metatarsophalangeal joint characterized by lateral deviation of the hallux and medial deviation of the first metatarsal, (1,2) is a disease for which different corrective surgical techniques can be used, depending on its severity. First tarsometatarsal joint (TMTJ) arthrodesis, also known as Lapidus, is one of the surgical procedures used in the treatment of severe hallux valgus, among other alterations (3-5). Despite the high satisfaction rate and high corrective power, this technique is not without complications. The main com- plications include delayed union, malunion, chronic edema, persistent pain, nonunion, joint stiffness, recurrent deformity, and varus deformity (6). However, there is little scientific evidence of these complications after first TMTJ arthrodesis. The purpose of this study was to report the complications of first TMTJ arthrodesis performed by orthopedic surgeons specializing in foot and ankle surgery. Methods: This study was approved by the institutional research ethics committee and registered at Plataforma Brasil. We evaluated 16 patients undergoing first TMTJ arthrodesis, who denied any comorbidities. The procedures were performed by 7 different orthopedic surgeons specializing in foot and ankle surgery with different levels of experience, ranging from 1 to 29 years of experience in the field. All patients underwent arthrodesis with plates and screws. The plate was placed on the plantar aspect of the first tarsometatarsal in 4 patients and on the anteromedial aspect in all other patients. The dorsomedial incision was used, centered on the first TMTJ, for the 12 cases in which the plate was positioned in the dorsomedial region, and the medial incision was used for the 4 cases in which the plate was positioned on the plantar aspect. Also, articular cartilage was resected using a chisel and microperforations. All 16 patients were followed up in an outpatient clinic at 1, 2, 4, 6, 12, and 24 weeks postoperatively. The follow-up visits included the evaluation of anteroposterior, lateral, and oblique radiographs of the foot, clinical alignment of the hallux, and patients' signs and symptoms. For all patients, postoperative care included immobilization in a non-weight-bearing cast for 4 weeks, initiation of physical therapy with range of motion gain at 4 weeks, and partial weight- bearing at 6 weeks Results: We evaluated 16 patients operated on over an 18-month period (from February 2017 to August 2018). We measured preoperative and postoperative hallux valgus and intermetatarsal angles (Table 1). Eight patients had either major or minor complications (Table 2). Three patients had recurrent deformity (1 with associated nonunion), 2 had delayed union, 2 had hardware loosening (Figure 1) - 1 with associated nonunion (Figure 2), and 1 had wound dehiscence. Conclusion: Based on our study, we can conclude that first TMTJ arthrodesis requires greater care in choosing the surgical technique for the treatment of hallux valgus. In addition, some points should be considered to avoid complications as much as possible, such as the use of implants to increase stability, instruments for better articular cartilage resection, and improvement in the correction of the pronation deformity of the hallux. The limitations of our study prevent us from drawing a robust conclusion and defining consistent parameters related to the main factors that may affect the various complications described in the study. Therefore, we believe that data are still scarce to provide a concrete basis, and further studies are needed to make substantiated conclusions.

Lapidus with 1st Metatarsal-Intermediate Cuneiform Fixation Improves Rotational Correction of Hallux Valgus

Category: Bunion Introduction/Purpose: The modified Lapidus procedure offers effective correction of the triplanar deformity of hallux valgus; however, complications such as nonunion and recurrence range up to 15% when using a crossing lag screw fixation technique. An alternative form of fixation using a dorsomedial plate and first metatarsal-intermediate cuneiform (1MT-IC) screw has been proposed. This construct may reduce complication rates, facilitate earlier weightbearing and maintain 3-dimensional correction, especially rotation of the first ray. We investigated single-surgeon Lapidus patient cohorts utilizing cross screws (CS) versus plate and 1MT-IC screw (PS) fixation to compare patient reported outcomes, radiologic parameters on pre- and postoperative weightbearing CT (WBCT) and complications. We hypothesized that patients undergoing PS fixation would experience improved correction of first ray pronation. Methods: This single-center, IRB-approved retrospective study identified all patients who underwent first tarsometatarsal joint arthrodesis for hallux valgus by a single surgeon and divided them by CS or PS fixation. Patients were minimum 18 years old with at least 12 months of follow-up. Revision forefoot surgeries, concomitant flatfoot reconstruction or ankle replacement, and patients with history of rheumatoid arthritis or gout were excluded. PROMIS scores in six key domains were compared between groups both preoperatively and at one year postoperatively. Radiographic assessment of hallux valgus angle (HVA) and intermetatarsal angle (IMA) were performed on pre- and postoperative XR. Pronation of the first ray was measured on WBCT using the validated triplanar angle of pronation. Clinical notes were reviewed for complications and reoperations. The PS group began weightbearing at an average 3.6 weeks versus 6 weeks the PS group. Results: We compared 44 patients who underwent Lapidus with PS and 43 with CS fixation. The age, BMI and gender distribution in the two groups were similar. Both groups had significant improvement in HVA and IMA following Lapidus, (p&lt;0.001), with no difference between groups. Average first ray pronation among PS patients was corrected to 26.0 degrees (from 36.6 degrees preoperatively), which was lower than the final pronation of 30.5 degrees in the CS group, (p&lt;0.001). Both cohorts experienced improvement in PROMIS physical function, pain interference, pain intensity and global physical function. There were no differences in PROMIS score improvements between the cohorts. Weightbearing commenced earlier in the PS group without increased complications. Conclusion: The plate and 1MT-IC screw technique for Lapidus fixation has been described to provide better biomechanical stability and potentially maintain the desired hallux valgus correction by spanning the intermetatarsal joint. Prior studies have reported durable radiographic IMA correction with low nonunion rates. We found similar patient-reported outcomes and rates of complications compared with a group of cross-screw fixation patients. However, there was a significant difference in final pronation of the first ray, 26 vs 31 degrees, observed by weightbearing CT. Earlier weightbearing and improved rotational correction are advantages associated with PS fixation of Lapidus bunionectomy.

First Tarsometatarsal Joint Fusion for Hallux Valgus Deformity: A Retrospective Comparison of Two Fixation Constructs Regarding Initial Maintenance of Correction and Complications: Traditional Crossing Screw Fixation Versus Dorsomedial Locking Plate and Intercuneiform Compression Screw

Various fixation constructs exist to address hallux valgus when performing a first tarsometatarsal joint arthrodesis. The goal of this present study is to compare complication rates, and degree and maintenance of angular correction between a dorsomedial locking plate with intercuneiform compression screw construct versus traditional crossing solid screw fixation construct. The plate plus intercuneiform compression screw construct fixation utilized a combined sagittal saw and curette method of joint preparation while the crossed screw fixation group utilized a curette and bur technique. A retrospective review was conducted of consecutive patients who underwent a midfoot fusion using either constructs. Sixty four total feet in 56 patients were enrolled in the study. Twenty four consecutive patients (32 feet) who underwent a midfoot arthrodesis using the locking plate and intercuneiform fixation were fully fused (100%) by 10 weeks postoperatively, with no incidents of nonunion and one deep vein thrombosis event. Thirty two consecutive patients (32 feet) who underwent midfoot arthrodesis with crossing screw fixation had 2 nonunion events, one that was asymptomatic and the other that required a revision midfoot fusion. There was a statistically significant improvement from the pre-operative intermetatarsal angle, hallux abductus angle compared to the 10 week and 1 year radiographs (p < .05) for the entire cohort for both fixation constructs. There was a statistically significant increase in American College of Foot and Ankle Surgery first ray scores from pre-op to 1 year follow-up for both fixation constructs. Overall, the dorsomedial locking plate plus intercuneiform compression screw fixation construct better maintains Intermetatarsal angle (IMA) correction at midterm follow-up compared to the traditional crossing screw construct. Both cohorts overall demonstrate similar fusion rates at 10 weeks, nonunion events, incidences of broken hardware, hardware removal, deep vein thrombosis, neuritis at 1 year postoperatively, and hallux varus.

First Tarsometatarsal Joint Arthrodesis for Hallux Valgus With and Without Intermetatarsal Screw Fixation: A Comparison of Correction and Maintenance of Correction

Tarsometatarsal joint arthrodesis is a commonly accepted procedure for hallux valgus associated with severe deformity and first ray hypermobility or medial column instability. This study evaluates the correction of hallux valgus deformity and the maintenance of correction with and without the use of a stabilization screw between the first and second metatarsal bases. Through retrospective review of first tarsometatarsal joint arthrodesis within our institution we evaluated 63 patients. Twenty-seven patients did not have a first to second metatarsal base screw and were placed into the no screw cohort. Thirty-six patients did have a first to second metatarsal base screw and were placed into the screw cohort. This study population had an osseous union rate of 95%. Clinical and radiographic recurrence occurred in 5 of 63 patients (8%). At 1-y postop the measurements demonstrated that the screw cohort had an average intermetatarsal angle correction of 11.6 degrees while the no screw cohort had an average correction of 7.8 degrees. Additionally, at 1-y postop the screw cohort had greater maintenance of the intermetatarsal angle correction with an average change of 0.5 degrees compared to 2.3 degrees in the no screw cohort. We conclude that the addition of the stabilization screw improves the first tarsometatarsal joint arthrodesis construct resulting in a greater degree of realignment and maintenance of correction.

Radiographic evaluation of naviculo-cuneiform sag deformity following triplane bunion correction via first tarsometatarsal joint arthrodesis

PurposeTo evaluate naviculo-cuneiform joint sag after first tarsometatarsal joint arthrodesis and the possible correlation between the presence of NC sag, loss of anatomic correction, and other radiographic angle measurements such as Calcaneal inclination and Meary's angle. HypothesisWe propose there is no increase in NC sag following 1st TMTJ arthrodesis and that there is no correlation between NC sag and the calcaneal inclination or Meary's angles. However, we do propose that there is a correlation between post-operative NC sag and loss of triplane bunion correction. Procedures/methodsRetrospective chart review to identify patients with first TMTJ arthrodesis from 2017-first half 2021. Eligible patient's had radiographic analysis and chart reviews performed at 2 weeks, 6 weeks, 12 weeks, and 3-6 months post-operatively. Following that, preoperative and 3-month postoperative weight-bearing radiographs, measuring the following radiographic angles: Meary's angle, Calcaneal inclination angle, Talocalcaneal (Kite's Angle), and NCIA (Naviculo-cuneiform incongruency angle). Loss of correction was measured by either an increase in intermetatarsal angle (IMA) and/or deviation of the sesamoids measured by the tibial sesamoid rotation.Statistical analysis was performed using PRISM version 2. Paired Student's T-test was utilized to compare preoperative and postoperative radiographic angle measurements for NCIA. A Pearson's coefficient correlation was also utilized to assess for any correlation between the preoperative NCIA deformity, post-operative NCIA deformity and the values for pre-operative Calcaneal inclination angle, post-operative Calcaneal inclination angle, pre-operative Meary's angle, and lastly, post-operative Meary's angle. Unpaired Student's t-test was utilized to compare the difference in NCIA post- to preoperative between 96 patients with radiographic union and 15 patients with radiographic non-union. Study designRetrospective chart review and radiographic evaluation.

Lesser Tarsal Metatarsal Joint Fusion Using Nitinol Staples, Bone Marrow Aspirate Concentrate and a Calcaneal Bone Dowel: A Retrospective Comparative Analysis

Category:Midfoot/Forefoot; Lesser ToesIntroduction/Purpose:Estimates suggest nonunion rates following lesser tarsometatarsal (TMT) fusion are up to 11.4%. Various techniques have been employed to improve fusion rates; however, none have shown significant improvement compared to other techniques. Autologous bone dowels, bone marrow aspirate concentrate (BMAC) and continuous compression devices (CCDs), such as nitinol staples, have each shown promising fusion rates in orthopedic literature. There is limited data that suggests using these techniques in conjunction with one another has been successfully employed in the fusion of lesser TMT joints. The aim of this study was to describe our technique using autologous calcaneal bone graft, CCDs and BMAC for lesser TMT fusion and to investigate whether this method improves fusion rates and decreases time to fusion in comparison to traditional constructs.Methods:All patients undergoing arthrodesis of the lesser (2nd/3rd) TMT joints from January 2015 to January 2020 were identified. Exclusion criteria included inadequate clinical or radiographic follow-up, those with only 1st TMT joint arthrodesis, and those less than 18 years old. Chart review allowed patient demographics, risk factors and surgical approach to be identified.Twenty patients (28 lesser TMT joints) treated with arthrodesis by the senior surgeon met inclusion criteria. These patients were then divided into two groups: 1) novel treatment (Nitinol staple, BMAC and calcaneal dowel) and 2) traditional treatment (compression plate and screw construct). We then assessed for radiographic union, time to union and complications.Results:All lesser TMT joints in the novel treatment arm went on to successful clinical and radiographic fusion. The radiographic union rate of the traditional treatment arm was 92% (P=.08). Overall time to fusion was 56 and 82 days for the novel and traditional constructs respectively (P <.05). All patients, regardless of construct, had returned to full weight bearing and maintained hardware at most recent follow-up (minimum 6 months).Conclusion:Continuous compression devices such as the nitinol staple and use of biologic adjuvants appear to decrease nonunion rates and significantly shorten overall time to fusion in lesser TMT joints. Further investigation towards identifying patient specific factors for nonunion is warranted.

Percutaneous Modified Lapidus Procedure with Early Weightbearing: Technique and Early Outcomes of the First 30 Cases

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:Minimally invasive techniques (MIS) have focused on first metatarsal osteotomies in hallux valgus correction. Concurrently, new fixation methods allow early weightbearing protocols with the open Lapidus procedure, with nonunion rates comparable to those of more traditional protocols requiring nonweightbearing. We aimed to assess clinical and radiographic results of an MIS-modified Lapidus technique with axial nail fixation (Phantom Lapidus Intramedullary Nail: Paragon28, Englewood, CO USA) and early weightbearing.Methods:After institutional review board approval, the first 30 consecutive percutaneous MIS-modified Lapidus procedures by a single surgeon were retrospectively reviewed. Indications for surgery included moderate to severe hallux valgus deformity with or without first tarsometatarsal joint (TMT) instability, first TMT arthritis, adolescent bunion, and failed prior surgery. All patients initiated weightbearing within 12 days and returned to regular footwear by 6 weeks postoperatively. Patients had a minimum follow-up period of 3 months (average 8.3 months). The pre- and postoperative visual analog scale (VAS) pain scores, intra- and postoperative complications, and need for revision surgery were recorded. Pre- and postoperative radiographs were used to evaluate the hallux valgus angle (HVA), 1-2 intermetatarsal angle (IMA), and sesamoid station. Postoperative radiographs were evaluated for signs of hardware loosening and union of the first TMT arthrodesis site. A postoperative CT scan was obtained if nonunion was suspected.Results:Thirty consecutive percutaneous modified Lapidus procedures were performed in 28 patients. VAS scores improved from 4.1 preoperatively to 1.8 at final follow-up. The IMA decreased 8.3 degrees to an average of 5.9 degrees. The HVA decreased 19.2 degrees to 11.7 degrees. The medial column was shortened by 0.6%. There were no intraoperative complications. There were two reoperations, including one nonunion requiring revision first TMT fusion with autograft and one hallux valgus recurrence requiring a distal chevron osteotomy. There were no wound complications, surgical site infections, hardware complications, postoperative transfer metatarsalgia, or nerve-related problems.Conclusion:The current study provides clinical evidence that the intramedullary nail is a biomechanically stable construct evidenced by the high union rate, lack of hardware failure, and tolerance for early weightbearing. This percutaneous modified Lapidus technique may allow for a low rate of wound complications, accelerated rehabilitaion, and improved cosmesis.

Complications of first tarsometatarsal joint arthrodesis

Objective: First tarsometatarsal joint (TMTJ) arthrodesis, also known as Lapidus, is a surgical procedure used to treat severe hallux valgus, associated hypermobility of the first ray, and/or osteoarthritis of the first TMTJ. Despite the high satisfaction rate and high corrective power, this technique is not without complications. This study aimed to report the complications of first TMTJ arthrodesis. Methods: This is a case series of 16 patients treated with first TMTJ arthrodesis. Patients were evaluated based on foot radiographs, clinical alignment of the hallux, and signs and symptoms. Results: Eight patients had either major or minor complications. Three patients had recurrent deformity (1 with associated nonunion), 2 had delayed union, 2 had hardware loosening (1 with associated nonunion), and 1 had wound dehiscence. Conclusion: First TMTJ arthrodesis requires greater care in choosing the surgical technique for the treatment of hallux valgus. In addition, some points should be considered to minimize complications as much as possible. We believe that data are still scarce to provide a concrete basis. Level of Evidence IV; Therapeutic Studies; Case Series.

Arthrodesis of the first tarsometatarsal joint for correction of hallux abductovalgus: Technique guide and tips

The treatment of hallux abductovalgus continues to evolve as surgeons better understand first ray biomechanical pathology. Many authors have advocated the use of the 1st tarsometatarsal joint arthrodesis for correction of moderate to severe hallux abductovalgus deformities and those with hypermobility of the 1st ray. There continues to be debate over the best surgical technique, fixation construct, and post operative protocol for the 1st tarsometatarsal joint fusion. We describe a technique with a unique hardware construct that is reproducible and allows for excellent deformity correction and pain relief while minimizing associated complications with this procedure.

Anatomical reconstruction of first ray instability hallux valgus with a medial anatomical TMTJ1 plate

BackgroundFirst tarsometatarsal joint (TMTJ1) arthrodesis is a powerful tool for hallux valgus correction. Past criticism of the TMTJ1 arthrodesis has focused on high non-union rates, and consequent need for delayed weightbearing as prevention. In this study we present a selection and treatment protocol to minimise non-union while allowing early weightbearing. MethodsAll TMTJ1 arthrodesis procedures for hallux valgus performed by the senior surgeon over the period June, 2016 to July, 2019 were included. An anatomically-designed, medial TMTJ1 plate and screw compression was utilised for TMTJ1 arthrodesis. The construct was augmented with synthetic intermetatarsal stabilisation. All patients were kept non-weightbearing for 2 weeks, followed by progressive weightbearing as tolerated for 4 weeks. Minimum follow-up was 1 year. Results300 modified Lapidus procedures were performed for hallux valgus with mean IMA 17° (Range: 14–29). Mean age was 58 years, with 93% female. 284 (94%) had an Akin osteotomy, while 222 cases (74%) were associated with another forefoot procedure. Patients began progressive weight bearing as tolerated from 2 weeks. All were fully weight bearing by 8 weeks post-operatively. There was a 100% union rate in this group. Mean AOFAS Hallux MTP-IP scores rose from 59 pre-operatively to 97 post-operatively. One plate was removed due to tibialis anterior impingement. There were no recurrences at final follow-up. ConclusionsWe describe a selection and treatment protocol for TMTJ1 arthrodesis for hallux valgus. This yields high union rates while allowing early weight bearing. Level of evidence4.

A Comparison of First Ray Length and Dorsiflexion after Arthrodesis, Osteotomy and Suture Button Procedures for Hallux Valgus Deformity

Category:Bunion; Lesser Toes; Midfoot/ForefootIntroduction/Purpose:Shortening and dorsiflexion of the first metatarsal are a known side effect of metatarsal osteotomies for hallux valgus (HV) deformity with the potential to cause transfer metatarsalgia. We compared the effect of the first tarsometatarsal joint arthrodesis (Lapidus), proximal lateral closing wedge osteotomy (PLCWO), and intermetatarsal suture button fixation procedures on the length and dorsiflexion of the first ray.Methods:We retrospectively evaluated 123 feet in 115 patients. The average age was 54. There were 106 females. Eighty-four feet had a Lapidus procedure, 14 had a PLCWO, and 24 had intermetatarsal suture button fixation. Digital radiographic measurements were made for pre- and postoperative hallux valgus angle (HVA) and intermetatarsal angle (IMA), absolute and relative shortening of the first ray, and dorsiflexion.Results:Preoperative HVA and IMA did not differ between treatment groups (p>0.05 for each). Similar corrections of HVA (30.1 to 12.3 degrees) and IMA (14.7 to 7.0 degrees) were achieved in all three groups (p>0.05). There were significant differences in absolute first-cuneiform-metatarsal length (FCML) between Lapidus (-1.5mm), PLCWO (-2.5mm), and intermetatarsal suture button fixation (+1.1mm) (p<0.05). There were also significant differences in relative 1st metatarsal shortening between Lapidus (0.32mm relative lengthening), PLCWO (1.05mm relative shortening), and intermetatarsal suture button fixation (1.24mm lengthening) (p<0.05). Average dorsiflexion differed between the Lapidus (1.95 degrees) and PLCWO groups (0.49 degrees) (p<0.05).Conclusion:The use of the intermetatarsal suture button fixation relatively lengthens the first ray, whereas the Lapidus and PLCWO shorten it. Dorsiflexion may be higher with Lapidus and osteotomy procedures. These findings may be helpful to explain postoperative symptoms of metatarsalgia and for the surgeon’s selection of the appropriate surgical technique for preoperative planning.