No abstract

BACKGROUND: Arthrodesis of the first metatarsophalangeal joint (MTPJ) is a common and frequently performed procedure in the practice of orthopaedic foot and ankle surgery. Fusion techniques and preferred surgical implants have significantly evolved during recent years. It is however still under debate which surgical device provides the best outcome. One of the modern techniques described includes the use of a dorsal anatomical locking plate. These plates are usually used in combination with an additional compression cross screw across the arthrodesis site. The aim of this study was to assess the outcome of arthrodesis of the first MTPJ using a dorsal locking plate without making use of additional compression cross screw fixation. METHODS: We retrospectively assessed data at an orthopaedic practice specialising in foot and ankle surgery. All patients who had a first MTPJ arthrodesis with an anatomical locking plate system between 2010 and 2016 were identified. No additional compression cross screw fixation was done in any of these cases. Standard standing dorsoplantar and lateral X-rays of the foot were taken six weeks after surgery. As a primary objective, these radiographs were assessed to determine the rate of radiological union. As a secondary objective, any other complications that occurred in the post-operative period were recorded. RESULTS: We included 115 patients in the study. Fifteen of these patients underwent bilateral first MTPJ arthrodesis surgery, making the total number of feet included in the study 130. Of these, 86% (n=99) were female and 14% (n=16) were male. The mean age at the time of surgery was 54.7 years (range 37-74). An observed radiological union rate of 97% at three months after surgery was recorded. A total of four cases (3%) presented with symptomatic non-union. Two of these were successfully revised and progressed to union before the nine-month follow-up. One patient had bilateral surgery for severe rheumatoid arthritis with poor bone quality. No union was achieved even after a revision procedure with bone grafting. A Keller-type resection arthroplasty was eventually performed in this patient. Another secondary complication that was recorded is an overall infection rate of 2%. CONCLUSION: The results of this retrospective study suggest that high union rates and a low incidence of complications can be expected when fusing the first MTPJ with the use of a locking plate system without the need for an additional compression cross screw Level of evidence: Level 4 Keywords: first metatarsophalangeal joint, fusion, arthrodesis, locking plate, union

Background: The Schatzker classification is the most widely accepted system used to classify tibial plateau fractures. The presence of posteromedial fragments in the more severe fracture types is known, but the presence of posteromedial fragmentation in the less severe fracture types is unknown. The ability of the Schatzker classification to predict posteromedial fragmentation was evaluated. Methods: Two hundred patients were reviewed of which only 67 met the inclusion criteria. The X-rays were reviewed by three independent orthopaedic surgeons and classified according to the Schatzker classification. A radiologist reviewed the CT scans and noted the presence or absence of a posteromedial fragment and if present, the largest diameter of the fragment was measured. Results:The mean age of the sample was 44.79 (SD: 14.03) years. Seventy-five per cent of the females (n=33) presented with posteromedial fragmentation compared to 65.20% of the males (n=44) (chi²-test, P=0.399). The incidence of posteromedial fragmentation varied between 15.8 and 26.3% for Schatzker 1 and 2 fractures and 73.7 and 84.2% for Schatzker 3 to 6 (chi 2 -test, p<0.001) based on the three independent assessments. The mean length of the posteromedial fragmentation ranged from 41.87 to 47.77 mm for Schatzker 1 and 2 fractures, and 44.74 to 46.12 mm for Schatzker 3 to 6 for the three assessors (statistically not significant [T-test, P=0.536, P=0.551 and P=0.652]). Conclusion:The Schatzker classification by itself is not adequate to identify all fractures with posteromedial fragmentation. There is a higher association of posteromedial fragmentation with fracture types 3 to 6. There is a high probability of missing a significantly sized posteromedial fragment in Schatzker type 1 and 2 fractures if a CT scan is not performed which might influence and compromise fracture stability, joint congruency and the ability to rehabilitate optimally.