Topical review: locking plate technology in foot and ankle surgery

Lateral Locking Plate Fixation of Simple Weber B Fibula Fractures Without a Lag Screw Yields Excellent Radiographic Results

BACKGROUND

The most common first-line fixation technique for simple Weber B fibula fractures is a lag screw with lateral neutralization plate. The most common surgical technique for unstable Weber B fibula fracture is one-third semi-tubular plate and cortical screws, implemented with lag screw when appropriate. However, the lag technique can be technically challenging in osteoporotic bone or within fibulas of smaller diameter, and in some cases can result in fragmentation at the fracture site, malreduction, or peroneal irritation. The purpose of this study is to examine an alternative first-line method for routine treatment of simple Weber B fibula fractures.

METHODS

Fifty-two consecutive patients undergoing open reduction internal fixation (ORIF) of a Weber B fibula fracture by a single surgeon were included in this retrospective study. After reduction, a lateral locking plate was applied with cortical screws proximally and locking screws distally. No screw crossed the fracture in any case. Per published precedent, nonunion was defined as either a gap of >3 mm between fracture surfaces >6 months postoperatively or a fracture line >2 to 3 mm wide and sclerosing of the fracture surfaces. Similarly, malunion was defined as one or more of the following: talar tilt >2º, talar subluxation >2 mm, or tibiofibular clear space ≥5 mm.

RESULTS

The mean (± standard deviation) age of the 52 included patients was 44.2 ± 16.2 years, the mean body mass index was 27.7 ± 6.6 kg/m2, and 63.5% of patients identified themselves as female sex. The mean follow-up was 6.2 (range: 1.5-15) months. In addition to undergoing fixation of the lateral malleolus, 21 patients also underwent fixation of the posterior malleolus, 27 underwent fixation of the medial malleolus, 29 underwent fixation across the syndesmosis, and 7 underwent repair of the deltoid. In all patients, bony anatomic union of the fibula and congruence of the mortise were achieved with no cases of malunion or nonunion.

CONCLUSIONS

The Arbeitsgemeinschaft für Osteosynthesefragen (AO) fixation technique for simple Weber B fractures with a lag screw and lateral neutralization plating has provided good outcomes for decades. We present an alternative technique for ORIF of these fractures with a lateral locking plate and no lag screw. In our series, we evaluated radiographic union and alignment as our primary outcome measures and found no cases of nonunion or malunion. Prospective cohort testing of lateral locking plates versus traditional fixation in the context of patient-centered value is warranted.Level of Evidence: Level III.

A comparison of outcomes of locking versus non-locking plate fixation for the distal fibula fractures: a systematic review and meta-analysis

PURPOSE

A locking plate (LP) or non-locking plate (NLP) can be used for distal fibula fracture fixation. However, the advantages of LP over NLP in patients with distal fibula fractures are not clear. In terms of indications, the role of the two plates probably differs; however, to draw comparative conclusions, we conceptualized this systematic review and meta-analysis of studies that directly compared the two plates, wherein both groups' indications and baseline parameters were similar.

METHODS

An electronic literature search was performed using PubMed/Medline, Embase, Scopus, and Cochrane Library databases for studies comparing the LP versus NLP fixation for the lateral malleolus fracture. A total of 18 studies were included in qualitative and quantitative analysis. A subgroup analysis was performed for patients aged < 55 years and patients aged > 55 years. The statistical analysis was performed by Review Manager Software version 5.4.1.

RESULTS

A meta-analysis of 4243 fractures was performed across 18 studies. The rate of fracture union and overall complication rates did not differ between the two fixation groups with an OR of 0.71 (95% CI 0.26, 1.96, p = 0.51 and 1.11 (95% CI 0.84, 1.47, p = 0.47, respectively. There is no difference in the reoperation rate due to minor or major complications between the two groups. There was no difference in functional outcome (MD -0.85, with 95% CI -5.63, 3.93, p = 0.73), but NLP has a shorter surgical duration (MD 3.0, with 95% CI 0.26, 5.75, p = 0.03). A leave-one-out sensitivity analysis performed for overall complications affected the final outcome of the meta-analysis.

CONCLUSION

This meta-analysis demonstrates no clear benefit in selecting LP over NLP for the fixation of lateral malleolus fractures.

Locking versus nonlocking plates for the treatment of posterior malleolar ankle fractures: A retrospective cohort study and cost analysis

BACKGROUND

We hypothesized that, as posterior malleolar ankle fractures usually present one or two main fragments, the buttress plating principle can be successfully achieved either with conventional nonlocking or anatomic locking posterior tibia plates, and no clinical differences should be found. The aim of this study was to evaluate the outcomes of posterior malleolar ankle (PM) fractures treated with conventional nonlocking (CNP) or anatomic locking plates (ALP), and also to compare both constructs in terms of crude costs.

METHODS

A retrospective cohort study was designed. CNP was used in 22 patients and ALP was used in 11 patients. American Orthopedic Foot and Ankle Society (AOFAS) score was registered at four weeks, 3-6 months, 12 and 24 months to assess all patients' functional status. The primary outcome was ankle and hindfoot AOFAS score at 12 months follow-up visit. All complications, radiographic evaluation and implant construct costs were also registered and compared. The average follow-up was 25.4 (range, 12-42) months.

RESULTS

No significant difference was observed between both cohorts, in terms of AOFAS score and complication rate (P > .05). We found that ALP construct is 17 times more expensive than CNP construct in our institution (P < .001).

CONCLUSION

Anatomic locking posterior tibial plates may be an interesting device when poor bone quality is present or when a true multifragmentary pilon fracture is faced. Anatomic locking posterior tibia plate should not become a regular implant for any PM fracture since equivalent clinical and radiological results were obtained in our study using CNP with a significant reduced cost.

Arterialization of plantar venous system via vein graft: A novel technique for reconstruction of heel pad degloving injuries

BACKGROUND

Patients with heel pad degloving injury frequently develop ischemic necrosis of the area, necessitating soft-tissue reconstruction surgery. We have developed a technique for arterialization of the plantar venous system via vein graft (APV) as the primary revascularization treatment. The objective of this study was to clarify both the utility of APV for the preservation of degloved heel pads and the impact of this preservation on clinical outcomes.

METHODS

Ten consecutive cases of degloving injury with devascularized heel pad were treated at a single trauma center from 2008 to 2018. Five cases underwent APV and five underwent conventional primary suture (PS) as the initial treatment. We evaluated the course according to the frequency of heel pad preservation, additional intervention after heel pad necrosis, post-operative complications, and outcomes using the Foot and Ankle Disability Index score (FADI) at the time of last follow-up.

RESULTS

Among the five cases that underwent APV, the heel pad was preserved in three cases and flap surgery was required in two cases. All cases that underwent PS developed necrosis of the heel pad, requiring skin graft in one case and flap surgery in four. One skin graft case and one free flap case after PS developed plantar ulcers. The three cases with preserved heel pads exhibited higher FADI than the seven cases that developed necrosis.

CONCLUSION

APV showed a relatively high frequency of heel pad preservation, which otherwise was uniformly lacking. Functional outcomes were improved in cases with preserved heel pad compared to those that developed necrosis and underwent additional tissue reconstruction.

Talo-navicular and calcaneo-cuboid fusion with PEEK H-pode™ vs. Titanium Maxlock™ locking plates: Comparison of functional and radiographic outcomes

BACKGROUND

Locking plates are increasingly used to achieve hindfoot fusion. The objective of this study was to compare hindfoot fusion outcomes with the PEEK H-pode™ (Biotech™) locking plate and the titanium Maxlock™ (Tornier-Wright™) locking plate.

HYPOTHESIS

A polyetheretherketone (PEEK) H-pode™ locking plate provides similar fusion rates to a titanium Maxlock™ locking plate for talo-navicular and calcaneo-cuboid arthrodesis.

METHODS

We conducted a retrospective comparative study in 39 patients (including 21 [54%] with pes planovalgus and 11 [28%] with neurological equinovarus deformities) who underwent talo-navicular and/or calcaneo-cuboid fusion, usually combined with subtalar fusion. The first 17 patients (January 2014-February 2016) were managed with Maxlock™ locking plates and the next 22 patients (March 2016-August 2018) with H-pode™ locking plates. These two cohorts of consecutive patients were comparable regarding age, sex distribution, body mass index, and comorbidities. At last follow-up more than 1year after surgery, we compared functional scores, pain intensity, and fusion assessed by radiographs and computed tomography (CT) (threshold set at 33%).

RESULTS

Mean follow-up was 42months (range: 34-63months) in the Maxlock™ group and 25months (range: 12-36months) in the H-pode™ group. At last follow-up, the two groups were not significantly different for the mean values of the American Orthopedic Foot & Ankle Society score, European Foot & Ankle Society score, and visual analogue scale pain score. Neither were the two groups significantly different for talo-navicular and calcaneo-cuboid fusion by CT. In the Maxlock™ group, we found non-significant trends towards a higher proportion of patients with talo-navicular nonunion (18% vs. 5% in the H-pode™ group) and weaker talo-navicular fusion in patients with pes planovalgus (60.8% vs. 82.0%, respectively). Radiographic results overestimated the fusion rates.

DISCUSSION

Talo-navicular and calcaneo-cuboid fusion was not significantly different with H-pode™ and Maxlock™ locking plates. CT was more accurate than standard radiography to assess fusion. These results underline the usefulness of PEEK locking plates for talo-navicular and calcaneo-cuboid fusion; moreover, the radiolucency of PEEK facilitates the interpretation of radiographs.

LEVEL OF EVIDENCE

IV.

Can 3-Dimensional Printing for Calcaneal Fracture Surgery Decrease Operation Time and Improve Quality of Fracture Reduction?

We investigated whether 3-dimensional (3D) printed models can decrease operation time and improve the quality of reduction for calcaneal fractures. The study involved 48 patients with unilateral intra-articular calcaneal fractures, who were retrospectively case-matched according to Sander's classification, age, and sex. Group A (24 patients) was operated using 3D printed models as a preoperative and intraoperative tool, and group B (24 patients) was operated using standard techniques without 3D printed model. Operation time was significantly shorter for group A, compared to group B (82.3 ± 13.2 vs 91.4 ± 16.0, p = .036). The differences between the radiological parameters of operated calcaneus, compared to the normal side was similar between the 2 groups (Böhler angle, 5.3° ± 3.9° vs 4.2° ± 4.7°, p = .45, Gissane angle, 5.9° ± 12.5° vs 8.4° ± 11.0°, p = .54). The number of screws projecting more than 5 mm from the cortex was lower in group A than in group B (7/187, 4% vs 16/208, 8%, p = .11). The number of screw holes of the plate cut intraoperatively was significantly lower for group A compared to group B (1 vs 138). Although group A started weightbearing 3 to 4 weeks earlier than group B, the radiological parameters were similar between groups that early weightbearing was possible for group A using the 3D printed models (Böhler angle, - 1.5° ± 0.8° vs - 1.8° ± 1.2°, p = .28, Gissane angle, 2.5° ± 2.6° vs 3.5° ± 4.3°, p = .39). The operation time was shorter while using the 3D printed models, compared to that of the standard technique without using the 3D printed model. The radiological parameters were not statistically different, and the quality of fracture reduction seemed similar. However, with the use of 3D printed models, early weightbearing was possible without significant subsidence of reduced fragments or failure of fracture reduction, comparable to non-weightbearing cases.

Radiographic Outcomes of Talonavicular Joint Arthrodesis With Varying Fixation Techniques in Stage III Adult Acquired Flatfoot Reconstruction

Utilization of the talonavicular joint (TN) arthrodesis as an isolated procedure or in combination with hindfoot arthrodesis has been described in the literature for treatment of numerous hindfoot conditions. When used in isolation or with concomitant hindfoot arthrodesis, the TN joint has demonstrated nonunion rates reported as high as 37% in the literature. Despite previous research, there remains a lack of agreement upon the ideal fixation technique for TN joint arthrodesis with and without concomitant subtalar joint arthrodesis. The purpose of this study was to retrospectively compare the radiographic and clinical results of TN joint arthrodesis as part of double arthrodesis procedure utilizing 4 separate fixation constructs in the treatment of advanced hindfoot malalignment in stage III adult-acquired flatfoot deformity. We retrospectively reviewed 105 patients who underwent TN joint arthrodesis as part of double arthrodesis procedure utilizing 4 separate fixation constructs. Our results demonstrated a nonunion rate of 16.2%, with 17 nonunions identified within our patient population. One (2.4%) nonunion was observed in the 3-screw cohort, 7 (33.3%) nonunions were observed in the 2-screw cohort, 4 (16.0%) nonunions were observed in the 2-screw plus plate cohort, and 5 (29.4%) nonunions were observed in the 1-screw plus plate cohort. The difference in nonunion rate between the 4 cohorts was statistically significant. Based on these results, we conclude that the use of a 3-screw construct for TN joint arthrodesis as part of double arthrodesis procedure demonstrates a statistically significant reduction in nonunion rate and should be considered a superior fixation construct for this procedure.

Risk of Reoperation in Simple Ankle Fracture Surgery When Comparing Locking Plate With Nonlocking Plate

Locking plates were initially designed to provide improved stability to ankle fractures with poor bone quality but are currently widely used. The aim of this study was to compare the reoperation risk when using locking plates compared with nonlocking plates in patients with simple ankle fractures. This study was a population-based register study. Data regarding patients with AO type 44A1/2 and 44B1/2 injuries who were treated with either locking or nonlocking plates were obtained from the Danish Fracture Database. The follow-up period was 24 months. Major complications were defined as complications requiring surgical intervention, with the exception of simple hardware removal 6 weeks after primary surgery, which was defined as a minor complication. Multivariate regression analysis was performed to determine relative risk (RR), adjusted for age, sex, American Society of Anesthesiologists physical status classification (ASA)-score, and level of the surgeon's experience. A total of 2177 ankle fractures were included, among which 718 (33%) were treated with locking plates, and 1459 (67%) were treated with nonlocking plates. Data were linked with the Danish National Patient Registry to ensure complete information was obtained regarding reoperations, which were divided into major and minor complications. In both groups, the risks for major and minor complications were 3% and 22%, respectively, resulting in adjusted RRs of 1.00 (0.66; 1.66) for major reoperation comparing locking with nonlocking plates and 0.92 (0.76; 1.11) for minor reoperations. We conclude that no significant association with reoperation exists for locking compared with nonlocking plates among patients with surgically treated simple ankle fractures.

Two Cases of Periprosthetic Fracture After Surgery for Acute Midfoot Charcot

Charcot neuroarthropathy is a rare condition that often results in deformity of the foot and ankle, with a high incidence of ulceration and a high risk of amputation. Traditionally, treatment of the acute stages of Charcot foot has been nonoperative until consolidation. Still, a large number of patients develop deformities, and early operative treatment of unstable Charcot feet has been suggested. To overcome some of the inherent challenges when operating on acute-stage Charcot feet, the superconstruct technique has been proposed. Early surgery for dislocated Charcot foot is sparingly described in the literature. To investigate the utility of the superconstruct technique for acute midfoot Charcot, we planned a prospective cohort study including patients with midfoot manifestation (Brodsky 1) in the active stages of the disease. Patients eligible for the study were treated with open surgery and midfoot arthrodesis using the superconstruct technique. In this report, we present the development of periprosthetic fractures related to early surgery using the superconstruct technique, possibly causing a more proximal Charcot manifestation in 2 patients with >24 months of follow-up. To our knowledge, such complications have been sparsely noted in the literature.

A comparison of bone union and complication rates between locking and non-locking plates in distal fibular fracture: Retrospective study of 106 cases

BACKGROUND

Ankle fractures represents the third most frequent fracture in elderly patients. There is a current tendency to fix long bones fractures with locking plates. However, we rarely find published accounts about the use of locking plates in distal fibula fractures, except for biomechanical ones, studying human cadaveric fibula.

OBJECTIVES

The main objective was to compare radiographic bone union rates at 6 and 12 weeks of follow up, then wound complications and hardware removal rates, and construct cost.

STUDY DESIGN & METHODS

We retrospectively analyzed 105 patients who underwent surgery with locking plates or non-locking plates over a two-year period, out of which 42 patients were treated with non-locking plates (VIVES™ - Stryker^Ⓡ) and 63 with locking plates (VariAx™ - Stryker^Ⓡ,). We analyzed bone union on anterior posterior and lateral X-rays of the ankle. We collected data of wound complications and hardware removal from patient records. Multiple linear regression techniques were performed after identifying dependent variables.

RESULTS

There was no significant difference between non-locking and locking plates in the radiographic bone union rate of distal fibula, respectively at 6 and 12 post-operative weeks (85.71% vs. 81%; p = 0.525 and 97.62% vs. 96.83%; p = 1). No significant difference was found in the wound complication rate between the two groups (11.9% vs. 11.12%; p = 0.9). No significant differences were found in the hardware removal rate, either with or without operative site's infection (respectively: 30.95% vs. 39.68%; p = 0.361 and 21.42% vs. 38.09%; p = 0.071). Cost efficiency is in the favor of non-locking plates.

CONCLUSION

Non-locking constructs are as effective as locking constructs in the treatment of displaced distal fibula fractures at a substantially lower cost. High-quality randomized controlled trials are needed in the future to verify the finding of this study.

Charcot Neuroarthropathy Advances: Understanding Pathogenesis and Medical and Surgical Management

Understanding new theories of the epidemiology of Charcot neuroarthropathy is practice changing. Treatment of Charcot neuroarthropathy is evolving from a passive approach to one that sees the urgency of proactive, early recognition, thereby avoiding the cascading events that lead to the complex, limb-threatening deformities. Preventive medicine is the most efficient at avoiding severe deformity, with prolonged offloading and immobilization as the current mainstay of treatment. However, with recent advancements in medical and surgical modalities, this may become the treatment of the past as clinicians begin to favor medical management and early surgical intervention.

Intra-articular calcaneal fractures. Do locking plates keep the reduction better than conventional plates?

INTRODUCTION

Since the development of locking plates, calcaneal fractures have been considered ideal for this type of fixation, due to the need to maintain the height of the subastragaline joint after depression fractures in a location where bone quality tends to be poor. However, there are no comparative studies that support the theoretical superiority of these plates over conventional plates. The aim of this study was to compare the results of intraarticular calcaneal fractures treated using locking plates vs. conventional plates in terms of radiological reduction, complications and number of reinterventions.

MATERIAL AND METHODS

We designed a comparative study of calcaneal fractures operated in our centre using the "L" approach. Two groups were established: group B, comprising 15 patients operated between 2010 and 2015 with calcaneal locking plates, and group A, comprising a stratified random sample of 23 patients taken from a historical cohort of 90 patients operated in our centre between 1997 and 2007 using conventional calcaneal plates. Demographic data were recorded (age, sex, diabetes mellitus, smoking) and data relating to the fracture (type of fracture according to Sander's classification system, complications, presurgical delay). To evaluate loss of reduction, varus angulation of the calcaneus (measured from the axial view), Böhler's angle and Gissane's angle were assessed radiographically. These angles were measured preoperatively, immediately postoperatively, and at the end of follow-up. Finally, we recorded complications and the number of reinterventions.

RESULTS

There were no differences in terms of age, sex or fracture type between the 2 groups. There was greater loss of varus angulation in group A, 0.6 vs. 0.41°, and there was greater reduction in Böhler's angle in group A, 3.79 vs. 2.6°, while Gissane's angle decreased more in group B, 4.13 vs. 2.52°. There were no significant differences in the proportion of complications and reinterventions between the 2 groups.

CONCLUSION

In our study we observed no significant differences between the 2 groups in terms of radiological reduction, complications or number of reinterventions. However, we did observe a greater loss of reduction of Böhler's angle in the patients who were operated using conventional plates.

Outcomes of Locking-Plate Fixation for Hindfoot Fusion Procedures in 15 Patients

Tibiotalocalcaneal arthrodesis is a salvage procedure for various end-stage foot and ankle pathologic entities. Several factors are known to influence the union rate after these procedures, including construct rigidity. The data on locked plates as a fixation technique have been inconclusive, with variable union rates reported. One recent study suggested that locking plates can lead to high nonunion rates owing to excessive rigidity. The purpose of the present study was to retrospectively examine the outcomes of locking plate fixation. We retrospectively reviewed the cases of 15 patients (7 [46.7%] male, 8 [53.3%] female) who underwent tibiotalocalcaneal, tibiocalcaneal, or tibiotalar arthrodesis fixed with a locking plate from January 2013 to January 2014. The average age was 52.19 ± 5.8 years. The mean follow-up period was 17 ± 5.3 months. We examined the overall union rates and the effects of smoking, diabetes, and rheumatologic status on the union rate. Of the 15 cases, 11 (73.3%) did not achieve union. The mean time to failure was 10 ± 5.3 months. Age, gender, smoking, diabetes, use of augmentation screws outside the plate, and operating surgeon did not have an effect on the failure rate (p > .50). In addition, gender, smoking, and diabetes did not predict for nonunion. The high failure rate of rigid locking plate fixation reported might be attributable to the high incidence of smoking and diabetic comorbidities in our study. However, excessive construct rigidity might play an important role. Larger studies are needed to establish more reliable union rates with the use of locking plates in foot and ankle fusion.

New Fixation Methods for the Treatment of the Diabetic Foot: Beaming, External Fixation, and Beyond

Surgical correction of complex foot and ankle deformities secondary to Charcot neuroarthropathy remains a significant surgical challenge. New technological advancements in hardware have allowed for the use of augmented fixation techniques in midfoot deformity correction, including the use of indication-specific locking plates and beaming techniques that offer enhanced stability. Severe hindfoot deformity management can employ the use of internal fixation, including intramedullary hindfoot nails and circular external fixation frames for limb salvage.

Locking versus non-locking one-third tubular plates for treating osteoporotic distal fibula fractures: a comparative study

INTRODUCTION

Ankle fractures represent the third most common fracture in elderly patients, after hip and wrist fractures. Distal fibula fractures in this population are closely related to osteoporosis, which renders commonly used methods of internal fixation technically demanding and prone to failure. Currently there is a tendency to fix osteoporotic metaphyseal and epiphyseal fractures with locking plates. However, published accounts about the use of this technology in osteoporotic distal fibula fractures are scarce. In this study we compare the results of two groups of patients who underwent surgery for these types of fracture, one group received locking and the other non-locking screws, both using one-third tubular plates.

METHODS

Sixty-two patients, aged over 64 years, underwent surgery for osteoporotic distal fibula fractures between 2011 and 2014. Forty-five of them were stabilized with a non-locking plate and the remaining 17 with a locking plate fixation. Follow-up was performed at 4, 8, 12, 26, and 52 weeks. Results were assessed according to the AOFAS Ankle-Hindfoot Score and radiological criteria for consolidation.

RESULTS

Average time to union and AOFAS scores at 6 and 12 months were similar in both groups, including for the individual categories: function, pain, mobility, and alignment. Only time until partial weight bearing was significantly lower in the locking plate group (4.69 ± 2.63 vs 7.77 ± 4.30, p = 0.03). The most common complications were wound dehiscence and superficial infection (two cases of both).

CONCLUSIONS

Both locking and conventional non-locking plates achieved similar treatment outcomes in this group of osteoporotic patients aged over 64. However, locking plates may offer more benefits in cases that have to take into account immobilization time and concomitant soft-tissue damage.

Use of 3D Printed Bone Plate in Novel Technique to Surgically Correct Hallux Valgus Deformities

Three-dimensional (3-D) printing offers many potential advantages in designing and manufacturing plating systems for foot and ankle procedures that involve small, geometrically complex bony anatomy. Here, we describe the design and clinical use of a Ti-6Al-4V ELI bone plate (FastForward™ Bone Tether Plate, MedShape, Inc., Atlanta, GA) manufactured through 3-D printing processes. The plate protects the second metatarsal when tethering suture tape between the first and second metatarsals and is a part of a new procedure that corrects hallux valgus (bunion) deformities without relying on doing an osteotomy or fusion procedure. The surgical technique and two clinical cases describing the use of this procedure with the 3-D printed bone plate are presented within.

Symptomatic Hardware Removal After First Tarsometatarsal Arthrodesis

Severe hallux valgus deformity with proximal instability creates pain and deformity in the forefoot. First tarsometatarsal joint arthrodesis is performed to reduce the intermetatarsal angle and stabilize the joint. Dorsomedial locking plate fixation with adjunctive lag screw fixation is used because of its superior construct strength and healing rate. Despite this, questions remain regarding whether this hardware is more prominent and more likely to need removal. The purpose of the present study was to determine the incidence of symptomatic hardware at the first tarsometatarsal joint and to determine the incidence of hardware removal resulting from prominence and/or discomfort. A review of 165 medical records of consecutive patients who had undergone first tarsometatarsal joint arthrodesis with plate fixation was conducted. The outcome of interest was the incidence of symptomatic hardware removal in patients with clinical union. The mean age was 55 (range 18.4 to 78.8) years. The mean follow-up duration was 65.9 ± 34.0 (range 7.0 to 369.0) weeks. In our cohort, 25 patients (15.2%) had undergone hardware removed because of pain and irritation. Of these patients, 18 (72.0%) had a locking plate and lag screw removed, and 7 (28.0%) had crossing lag screws removed. The fixation of a first tarsometatarsal joint fusion poses a difficult situation owing to minimal soft tissue coverage and the inherent need for robust fixation to promote fusion. Hardware can become prominent postoperatively and can become painful and/or induce cutaneous compromise. The results of the present observational investigation imply that surgeons can reasonably inform patients that the incidence of symptomatic hardware removal after first tarsometatarsal arthrodesis is approximately 15% within a median duration of 9.0 months after surgery.

Mid-Calcaneal Length After Evans Calcaneal Osteotomy: A Retrospective Comparison of Wedge Locking Plates and Tricortical Allograft Wedges

Evans calcaneal osteotomy remains a cornerstone in the correction of the flexible flatfoot. Although multiple techniques have been used to maintain the length of the lateral column, a low profile wedge locking plate was recently introduced as an alternative to the traditional tricortical allograft wedge. We hypothesized that the wedge locking plate would better maintain the mid-calcaneal length compared with the tricortical allograft wedge. To test this hypothesis, after Evans osteotomy, the mid-calcaneal length was measured in the immediate postoperative period and again at 3 and 6 months. A total of 24 patients met the inclusion criteria. The mean patient age was 48.1 years (range 11 to 66). Of the 24 patients, 9 (37.5%) were treated with a tricortical allograft wedge and 15 (62.5%) with a wedge locking plate. At 3 months postoperatively, the mean decrease in mid-calcaneal length was similar for the tricortical allograft wedge group (1.3 ± 1.9 mm) and the wedge locking plate group (0.5 ± 0.9 mm, p = .275). At 6 months postoperatively, however, the mean decrease in mid-calcaneal length was greater for the tricortical allograft wedge group (2.8 ± 1.7 mm) than for the wedge locking plate group (0.6 ± 0.7 mm, p = .004). The 2 groups demonstrated a similar incidence of dorsally displaced distal calcaneal fragments throughout the study endpoint (p ≥ .052). These results suggest that the wedge locking plate better maintains the mid-calcaneal length over time compared with the tricortical allograft wedge.