Biomechanical evaluation of naviculocuneiform fixation with lag screw and locking plates

Naviculocuneiform joint arthrodesis in a cohort of 36 patients

BACKGROUND

Arthrodesis of the naviculocuneiform joint (NCJ) can be performed in isolation or in conjunction with arthrodesis of other joints, often in the presence of deformity. In the literature there is relative rarity of articles reporting on results and complications of NCJ arthrodesis.

PATIENTS AND METHODS

Thirty-six patients (36 feet) with symptomatic NCJ arthritis underwent arthrodesis. Mean age was 59.1 years (SD 13.1; range 26-78) and 24 were women. Adjuvant procedures were performed simultaneously in 29 patients, whilst 17 had planovalgus and 1 had cavovarus foot deformity.

RESULTS

Union of the NCJ arthrodesis was achieved in 35 out of 36 (97.2 %) patients, whilst one patient developed non-union. Mean time to union was 13.1 weeks (SD 3.8; range 8-24). Two patients (5.6 %) developed deep infection and 5 patients (13.9 %) required secondary surgical procedures. Twenty-three patients (63.9 %) rated the outcome as good or excellent, 11 (30.6 %) as fair and 2 (5.6 %) as poor.

CONCLUSIONS

NCJ arthrodesis was part of a more complex procedure in most of the patients. Whilst union was achieved in almost all patients and complication rate was acceptable, only 64 % rated their outcome as good or excellent.

LEVEL OF CLINICAL EVIDENCE

IV.

Comparison of 4 Different Fixation Strategies for Midfoot Arthrodesis: A Retrospective Comparative Study

BACKGROUND

Midfoot arthrodesis is a common procedure performed both for arthritis and correction of deformity. The optimal fixation for midfoot arthrodesis has not been established, though numerous studies have been investigating the fixation techniques of midfoot arthrodesis. The purpose of this study was to compare the union rate of midfoot arthrodesis using 4 different fixation strategies and investigate risk factors of nonunion following midfoot arthrodesis.

METHODS

A retrospective chart review was performed for patients who underwent midfoot joint arthrodesis between January 2014 and May 2019. The rates of nonunion and postoperative complication were compared among 4 different fixation constructs: staple fixation, compression plate fixation, compression plate with lag screw fixation, and compression screw fixation. Predictors of nonunion following midfoot arthrodesis were investigated through a multivariable logistic regression analysis. A total of 95 patients (99 feet), including 240 midfoot joints were included in this study. The mean follow-up period was 78.4 weeks.

RESULTS

Overall, bony union was achieved in 86 out of 99 (86.9%) patients, which included 218 out of 240 (90.8%) midfoot joints. A significant difference in the nonunion rate according to the type of fixation construct was found (P = .011); the compression screw alone fixation construct was noted to have a significantly higher nonunion rate than other fixation constructs. Diabetes mellitus (odds ratio [OR] = 0.179 [95% CI: 0.059, 0.542]), the type of fixation construct (compression screw alone; OR =1.789 [95% CI: 1.071, 2.978]), lack of adjuvant bone graft (OR = 2.803 [95% CI: 1.081, 7.268], and postoperative nonanatomical alignment (OR = 3.937 [95% CI: 1.278, 12.126]) were identified as independent predictors of nonunion following midfoot arthrodesis.

CONCLUSION

The rate of nonunion following midfoot arthrodesis among 4 different commonly used fixation constructs was compared in this study. Risk factors of nonunion were investigated revealing that diabetes mellitus, compression screw fixation alone, lack of adjuvant bone graft, and postoperative nonanatomical alignment are independent predictors of nonunion following midfoot arthrodesis.

LEVELS OF EVIDENCE

Level III: Comparative cohort study.

The Navicular Cuneiform Joint: Updates on Avoiding and Managing a Nonunion

Naviculocuneiform arthrodesis, while often used to support the medial column during management of primary/post-traumatic arthritis, deformity correction, or in the surgical treatment of progressive collapsing foot deformity, can develop nonunion. Addressing this condition hinges on the assessment of various parameters such as patient/host factors and recognition of the etiology of the nonunion. In this article, methods of optimizing this surgical intervention through anatomic and physiologic considerations are highlighted. Further, information is provided to assist foot and ankle surgeons in performing a comprehensive work-up to allow for successful reconstruction and optimal patient outcomes.

Naviculocuneiform Arthrodesis for Treatment of Adult-Acquired Flatfoot Deformity

The adult-acquired flatfoot is a complex multiplanar deformity that requires the foot and ankle surgeon to balance soft tissue, correct hindfoot valgus, and address instability of the medial column. The naviculocuneiform joint is historically underappreciated in regard to its involvement in medial column instability relative to the talonavicular and tarsometatarsal joints. Proper clinical and radiographic evaluation of the medial column, specifically evaluating for deformity at each medial column joint, will allow the surgeon to ensure correction of deformity and decrease the recurrence of instability or failure of the reconstruction.

Midfoot Joint Arthrodesis Using Compression Plate With Lag Screw Augmenting With Highly Porous β-Tricalcium Phosphate and Bone Marrow Aspirate Concentrate

BACKGROUND

There is still a controversy regarding the most optimal fixation instruments and bone graft materials for midfoot joint arthrodesis. We present the results of midfoot joint arthrodesis using compression plate with lag screw augmenting with highly porous β-tricalcium phosphate (β-TCP) and bone marrow aspirate concentrate (BMAC).

METHODS

We performed a retrospective review of patients undergoing midfoot joint arthrodesis using compression plate with lag screw augmenting with highly porous β-TCP and BMAC from January 2014 to May 2019. The radiographic bony union rate was investigated. Postoperative complications and reoperations were also reviewed. A total of 36 patients (37 feet) including 75 joints were available in this study.

RESULTS

A high union rate was achieved as of 97.3% in 73 of 75 joints. Nonunion occurred in 2 patients including 2 joints. Other than nonunion, there were no major complications such as deep infection. Minor complications (5 of 75 joints, 6.7%) included hardware irritations. Reoperations were required in 1 patient for revision of arthrodesis and symptomatic hardware removal was performed in all 5 hardware irritation cases.

CONCLUSION

Based on our results, the fixation construct of compression plate with lag screw augmenting with highly porous β-TCP and BMAC is safe and effective for midfoot joint arthrodesis with an excellent union rate and a low complication rate.

LEVEL OF EVIDENCE

IV, retrospective case series.

Biomechanical Evaluation of Tarsometatarsal Fusion Comparing Crossing Lag Screws and Lag Screw With Locking Plate

BACKGROUND

Tarsometatarsal (TMT) arthrodesis is a common operative procedure for end-stage arthritis of the TMT joints. To date, there is no consensus on the best fixation technique for TMT arthrodesis and which joints should be included.

METHODS

Thirty fresh-frozen feet were divided into one group (15 feet) in which TMT joints I-III were fused with a lag screw and locking plate and a second group (15 feet) in which TMT joints I-III were fused with 2 crossing lag screws. The arthrodesis was performed stepwise with evaluation of mobility between the metatarsal and cuneiform bones after every application or removal of a lag screw or locking plate.

RESULTS

Isolated lag-screw arthrodesis of the TMT I-III joints led to significantly increased stability in every joint (P < .05). Additional application of a locking plate caused further stability in every TMT joint (P < .05). An additional crossed lag screw did not significantly increase rigidity of the TMT II and III joints (P > .05). An IM screw did not influence the stability of the fused TMT joints. For TMT III arthrodesis, lag-screw and locking plate constructs were superior to crossed lag-screw fixation (P < .05). TMT I fusion does not support stability after TMT II and III arthrodesis.

CONCLUSION

Each fixation technique provided sufficient stabilization of the TMT joints. Use of a lag screw plus locking plate might be superior to crossed screw fixation. An additional TMT I and/or III arthrodesis did not increase stability of an isolated TMT II arthrodesis.

CLINICAL RELEVANCE

We report the first biomechanical evaluation of TMT I-III arthrodesis. Our results may help surgeons to choose among osteosynthesis techniques and which joints to include in performing arthrodesis of TMT I-III joints.