SLR - November 2018 - Kevin Tootle

First Metatarsophalangeal Joint Arthrodesis with Two Orthogonal Two-Hole Plates

Reference: Fazal M, Wong JH, Rahman L. First Metatarsophalangeal Joint Arthrodesis with Two Orthogonal Two Hole Plates. Acta Orthopaedica et Traumatologica Turcica. 2018 Aug 11: 1–4.

Scientific Literature Review

Reviewed By: Kevin Tootle, DPM
Residency Program: Bethesda Hospital East, Boynton Beach, FL

Podiatric Relevance: First metatarsal phalangeal joint (MTPJ) fusion procedures are a tried and true procedure when treating degenerative joint disease of the first MTPJ. There are various techniques and fixation options when performing a joint destructive procedure like this one. Throughout the years, the literature has highlighted fixation modalities, such as crossing compression screws, a single lag screw with neutralization plating and compression plating alone. This article highlights a fixation technique that uses orthogonal two-hole plates without the use of a compression lag screw to achieve arthrodesis across the first MPJ.

Methods: This publication studied 32 first MTPJ arthrodesis procedures using orthogonal plating at 90 degrees across the MTPJ without the use of a compression screw. The inclusion criteria of this study was intractable pain to the first MTPJ with failure of conservative measures while excluding revisional surgery, charcot neuroarthropathy and simultaneous lesser ray surgery. The mean duration of follow-up was listed as 49 months postoperatively with no loss of patients to follow-up. Radiographic union was assessed by the senior author as osseous bridging of three out the four cortices on AP and lateral images while AOFAS scores were used an objective assessment.

Results: In this study, 27 of the 32 feet went on to a radiographic union while time to union was 94 days. Thirteen of the 32 feet went on to union at six weeks while the remaining took upward of 12 weeks to union and five resulted in nonunions. The mean AOFAS scores improved preoperatively from 37.1 to 80.7 postoperatively.

Conclusions: This study showed a number of positive and negative outcomes. The plates selected were noted to be lower profile and led to a lower rate of reoperation than compared to patients in other studies who required hardware removal or revision operations due to hardware failure. Considering the lower profile nature of the plates used in this study, there was a higher incidence of nonunion when compared to other studies that employed a lag technique with neutralization plating. Therefore, the technique of orthogonal plates at 90 degrees from each other along the first MTPJ to obtain fusion without the use of a compression screw is simple. Unfortunately, the higher incidence of nonunion due to the lack of compression across the fusion site leads this technique to be suboptimal. The limitations of this study was a small cohort and bias on behalf of the observer. There was also lack of knowledge of surgical technique and whether or not compression was achieved intra-operatively through eccentric drilling.

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