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Interfragmentary screw with dorsal locking diamond plate (IS-DLDP): A novel use of a midtarsal construct for first metatarsal phalangeal joint arthrodesis

Open AccessPublished:June 09, 2022DOI:https://doi.org/10.1016/j.fastrc.2022.100216

      Abstract

      Arthrodesis is an indication for treating a variety of pathologies to the first metatarsophalangeal joint (MTPJ), which include arthritis, deformities related to traumatic injuries, and other derangements. This case report describes a novel technique utilizing an interfragmentary screw with a two-hole dorsal locking diamond plate (IS-DLDP) midfoot construct for the first MTPJ arthrodesis. Studies describing the biomechanical superiority of the dorsal plate with a lag screw construct for the first MTPJ fusion have frequently referenced the four-hole and five-hole plates. The current study aims to justify the IS-DLDP midfoot construct with an interfragmentary screw as an alternative to the four-hole or five-hole plate with an interfragmentary lag screw construct for the first MTPJ. The IS-DLDP construct offers deformity correction with an ultra-low-profile plating system, short operating time due to ease of placement, decreased radiation and anesthesia exposure, easy visualization of bone healing in all radiographic foot views, DVT prevention through immediate weight-bearing, and transition to pain-free ambulation in sneakers by four weeks.

      Keywords

      Introduction

      The first metatarsophalangeal joint (MTPJ) arthrodesis is a salvage procedure that aims to achieve; pain relief, reduce deformity, reproducible outcomes, and restore normal functional alignment. This procedure is popular due to its low revision rate, broad patient age range, early weight-bearing, and positive healing characteristics.
      • Dayton P.
      • Feilmeier M.
      • Hunziker B.
      • Nielsen T.
      • Reimer R.A.
      Reduction of the intermetatarsal angle after first metatarsal phalangeal joint arthrodesis: a systematic review.
      Many fixation techniques for first MTPJ arthrodesis are described in the literature, from Kirschner wires (K-wire) to the dorsal plate with an interfragmentary screw. The latter is biomechanically superior.
      • Politi J.
      • John H.
      • Njus G.
      • Bennett G.L.
      • Kay D.B.
      First metatarsal-phalangeal joint arthrodesis: a biomechanical assessment of stability.
      Historically the IS-DLDP plating system has been utilized for midfoot pathologies with planar joint types. This case report provides evidence and justification for the novel use of a midfoot arthrodesis construct for the first MTPJ, an interfragmentary screw with a two-hole dorsal locking diamond plate (IS-DLDP). This case report evaluates the technique, approach, and advantages of the IS-DLDP construct for the first MTPJ arthrodesis with a three-year follow-up. To our knowledge, there have been no reports in the independent literature of a midfoot two-hole IS-DLDP construct utilized for arthrodesis of conical joints, specifically at the first MTPJ.

      Case

      The patient is female, 69-years-old a former smoker with a history of seizures and anemia. She presented to the clinic with chronic pain described as debilitating in the left first MPJ. The patient noted a Visual Analog Pain Scale (VAS) of 7/10. She sought surgical intervention following failed conservative treatment consisting of supportive sneakers, custom foot orthotics, and pain medication.
      The physical examination revealed 0 degrees of dorsiflexion at the first MPJ on weight-bearing and 10 degrees of dorsiflexion off-weight-bearing. In addition, there was a pain-to-palpitation at the medial eminence and sesamoids. No additional musculoskeletal findings were reported. Neurovascular examination revealed no abnormalities with a capillary refill time (CRT) of less than three seconds and palpable pulses 2 out of 4 at the dorsalis pedis and posterior tibial arteries.
      Pre-operative radiographic studies reveal subchondral sclerosis and decreased joint space to the first metatarsal head with a tibial sesamoid position (TSP) of 5, intermetatarsal angle (IM) of 12 degrees, and hallux abductus angle (HA) of 22 degrees on the dorsal-plantar view. In addition, the lateral view showed mild to moderate degenerative changes to the first MTPJ and sesamoids (Fig. 1).
      Fig. 1
      Fig. 1Preoperative radiograph: A. The dorsal-plantar view shows the square-headed first metatarsal with subchondral sclerosis. There is evidence of mild to moderate arthritic changes to the first metatarsal head with an increased intermetatarsal angle. B. The lateral radiographic view provided evidence of mild arthritic changes to the first metatarsal sesamoid joint.
      The patient was diagnosed with structural hallux limitus grade 2, moderate hallux abducto-valgus, and mild to moderate osteoarthritis at the left first MTPJ. Her preoperative AOFAS metatarsophalangeal-interphalangeal (MTP-IP) score was 52 (Table 1).

      Orthotoolkit; AOFAS-mtp-ip. hallux limitus. https://orthotoolkit.com/aofas-mtp-ip/

      Surgical intervention was discussed, including joint sparing procedures. The patient agreed to the fusion of the first MPJ as she is minimally active and wanted a long-term outcome. She provided consent to the first MTPJ arthrodesis utilizing the IS-DLDP construct.
      Table 1Preoperative metatarsophalangeal-interphalangeal (MTP-IP) score of 52

      Orthotoolkit; AOFAS-mtp-ip. hallux limitus. https://orthotoolkit.com/aofas-mtp-ip/

      .

      Procedure

      The patient was prepped for surgery with general anesthesia. The incision was medial to the extensor hallucis longus, from the midshaft of the first metatarsal to the base of the proximal phalanx. The anatomic dissection down to the capsule occurred while protecting neurovascular and anatomical structures. Next, the periosteal and capsular structures were freed to expose the first MTPJ.
      Hypertrophic synovium and articular damage to the central and plantar aspects of the first metatarsal head were noted. A rotary burr denuded the cartilage on both sides of the first MTPJ to the subchondral bone, establishing a cup and cone configuration. The osteophytes were removed with a rongeur. Then, fenestration with a smooth 0.062 K-wire to optimize subchondral bleeding. Aligning the proximal phalanx in a rectus position to the first metatarsal head with 10 degrees of dorsiflexion established the optimal position for a guidewire to be placed across the resected first MTPJ from proximal-medial to distal-lateral and penetrating both cortices with fluoroscopy confirmation. Then a cannulated 4.3 mm partially threaded headless interfragmentary compression screw was inserted.
      To allow the DLDP to sit flush with the surface of the first MTPJ, a rotary burr was used to smooth all uneven surfaces. In addition, plate benders were used to contour the plate to the bone, allowing for slight dorsiflexion.
      A 25 mm two-hole DLDP was placed over the first MTPJ and temporarily secured with a pin distal to the proximal phalanx base. A locking drill guide was threaded into the metatarsal portion of the diamond plate and then the proximal phalanx portion. A guided 2.7 mm drill was then used to create a pilot hole in the metatarsal shaft and proximal phalanx. After measuring the appropriate screw length, 3.5 mm x 18 mm and 3.5 mm x 14 mm locking screws were inserted in the metatarsal and proximal phalanx. The plate position was then confirmed via C-arm. Utilizing a distracting device for additional compression to the fusion site was accomplished by increasing the distance between the two arms of the central plate construct, creating a diamond-shaped appearance.
      Primary closure took place following fluoroscopic review and copious saline irrigation. The patient was placed in a compressive dressing and CAM-boot with immediate weight-bearing.
      Status post one week, the patient's pain was well controlled. The incision was coapted with no signs of infection and intact neurovascular status. Dorsal-plantar and lateral radiographs were recorded and reviewed (Fig. 2). She was advised to continue full weight-bearing in the CAM-boot.
      Fig. 2
      Fig. 2Immediate postoperative radiograph: A. The dorsal-plantar view shows intact IS-DLDP fixation overlying the first metatarsophalangeal joint. Congruent alignment and reduction of the HA and IM angles. B. The lateral radiographic view shows intact hardware and anatomic apposition.
      Status post three weeks, the patient noted decreased pain with VAS of 2. There was mild pain on palpation to the left first MTPJ. The hallux appeared rectus, and the incision was well coapted with no signs of infection, malodor, dehiscence, erythema, or ecchymosis. All sutures were removed, and the patient was advised to continue weight-bearing in CAM-boot for one more week and then transition to sneakers by week four.
      At the five-week follow-up, she denied pain with a VAS of 0, with the incision fully healed. Radiographs at five weeks showed the hardware was intact with complete tricortical consolidation of the left first MTPJ. The radiographic angles showed improvement from pre-op with IM 5, HA 0, and TSP 2. The gait exam revealed no pain, discomfort, or antalgic gait (Fig. 3).
      Fig. 3
      Fig. 3Five weeks after surgery: A. The dorsal-plantar view shows intact IS-DLDP fixation overlying the first metatarsophalangeal joint. Complete consolidation to the first MTPJ is present. B. The lateral radiographic view shows similar findings.
      Three months after surgery, the patient continued to deny pain and ambulated well. The patient was satisfied with the result. The patient was monitored for 36 weeks following surgery from 2019 to 2022 with no reported complications or complaints. Her final MTP-IP score was 90 (Table 2), and her three-year follow-up radiographs showed similar results as those obtained five weeks after the procedure (Fig. 4).
      Table 2Postoperative metatarsophalangeal-interphalangeal (MTP-IP) score of 90.

      Orthotoolkit; AOFAS-mtp-ip. hallux limitus. https://orthotoolkit.com/aofas-mtp-ip/

      Fig. 4
      Fig. 4Three years after surgery: A. The dorsal-plantar view showed intact IS-DLDP fixation overlying the first metatarsophalangeal joint. Complete consolidation to the first MTPJ is present. B. The lateral radiographic view shows similar findings.
      This fixation method allowed for immediate weight-bearing in a CAM-boot and transitioning into sneakers by four weeks postoperatively. This case report identified no complications during the three-year follow-up period.

      Discussion

      Arthrodesis can restore function and quality of life to individuals suffering from first MTPJ pathologies, such as hallux abducto-valgus, hallux limitus, hallux rigidus, hallux varus, arthritis, revisional surgery, or instability (
      • Dayton P.
      • Feilmeier M.
      • Hunziker B.
      • Nielsen T.
      • Reimer R.A.
      Reduction of the intermetatarsal angle after first metatarsal phalangeal joint arthrodesis: a systematic review.
      ,
      • Deorio J.K.
      Technique Tip: Arthrodesis of the First Metatarsophalangeal Joint–Prevention of Excessive Dorsiflexion.
      ,
      • Gregory J.L.
      • Childers R.
      • Higgins K.R.
      • Krych S.M.
      • Harkless L.B.
      Arthrodesis of the first metatarsophalangeal joint: a review of the literature and long-term retrospective analysis.
      ).
      The first MTPJ arthrodesis is typically a highly successful procedure with an overall fusion rate ranging from 90 to 100% in recent literature. Holding to the current standard, the IS-DLDP provides additional benefits to the patient by decreasing the operation time, infection rate, anesthesia, and radiation exposure. In addition, the IS-DLDP permits immediate weight-bearing, thereby reducing recovery time.
      • Storts E.C.
      • Camasta C.A.
      Immediate Weight Bearing of First Metatarsophalangeal Joint Fusion Comparing Buried Crossed Kirschner Wires Versus Crossing Screws: Does Incorporating the Sesamoids Into the Fusion Contribute to Higher Incidence of Bony Union?.
      This current study using the IS-DLDP construct utilized the conical anatomy of the first MTPJ to establish a stable arthrodesis. The dorsal plate fixation with interfragmentary screw construct was deemed the most stable construct to resist micromotion in a study by Mann and Oates. However, they did note increased compression in planar versus conical joints.
      • Mann R.A.
      • Oates J.
      Arthrodesis of the First Metatarsophalangeal Joint.
      In addition, a biomechanical evaluation of planar and conically prepped first MTPJ arthrodesis with an interfragmentary screw in cadaveric models found the increased surface area and intrinsic stability was superior with conical reaming verse planar resection.
      • Curtis M.J.
      • Myerson M.
      • Jinnah R.H.
      • Cox Q.G.
      • Alexander I.
      Arthrodesis of the first metatarsophalangeal joint: a biomechanical study of internal fixation techniques.
      Medical device companies have developed diamond plating systems for the first MTPJ. Arthrex (Dynanite double compression plate), Integra (now Smith and Nephew, Uni-Compression Plate), and Wright medical (now Stryker, Claw plate). These diamond plating systems have prior utilization for midfoot arthrodesis at the tarsometatarsal, intercuneiform, cuneiform-navicular, and talonavicular joints with interfragmentary compression screw fixation.
      • Dang D.Y.
      • Flint W.W.
      • Haytmanek C.T.
      • Ackerman K.J.
      • Coughlin M.J.
      • Hirose C.B.
      Locked Dorsal Compression Plate Arthrodesis for Degenerative Arthritis of the Midfoot.
      In addition, each of these plating systems describes the advantage of improved rigidity and compressive forces (
      • Aiyer A.
      • Russell N.A.
      • Pelletier M.H.
      • Myerson M.
      • Walsh W.R.
      The Impact of Nitinol Staples on the Compressive Forces, Contact Area, and Mechanical Properties in Comparison to a Claw Plate and Crossed Screws for the First Tarsometatarsal Arthrodesis.

      Wright Medical Technology. CLAW ® II Polyaxial Compression Plating System SURGICAL TECHNIQUE Guide, 2015. https://www.orthoracle.com/content/uploads/2015/11/CLAW-II-Surgical-Technique.pdf

      ).
      A diamond plate construct was biomechanically examined in a 2016 study for arthrodesis at the first tarsometatarsal joint. The diamond plate-like construct exhibited longitudinal joint compression without the addition of an interfragmentary screw
      • Aiyer A.
      • Russell N.A.
      • Pelletier M.H.
      • Myerson M.
      • Walsh W.R.
      The Impact of Nitinol Staples on the Compressive Forces, Contact Area, and Mechanical Properties in Comparison to a Claw Plate and Crossed Screws for the First Tarsometatarsal Arthrodesis.
      . Companies that have created the diamond compression plate construct have focused on the ability to provide additional compression to the dorsal plate and interfragmentary screw design by utilizing either nitinol or mechanical expansion of the diamond plate (
      • Aiyer A.
      • Russell N.A.
      • Pelletier M.H.
      • Myerson M.
      • Walsh W.R.
      The Impact of Nitinol Staples on the Compressive Forces, Contact Area, and Mechanical Properties in Comparison to a Claw Plate and Crossed Screws for the First Tarsometatarsal Arthrodesis.

      Wright Medical Technology. CLAW ® II Polyaxial Compression Plating System SURGICAL TECHNIQUE Guide, 2015. https://www.orthoracle.com/content/uploads/2015/11/CLAW-II-Surgical-Technique.pdf

      ). Furthermore, the additional rigidity provided by the secondary compression of the diamond plate is a new concept for the first MTPJ and is provided within this IS-DLDP construct. The interfragmentary screw used in this procedure was longer than necessary, leading to 4-5 threads protruding into the first interspace and unrelated to the additional compression provided by the DLDP.
      An advantage of the IS-DLDP in a conical joint configuration includes a minimal footprint to the affected area, decreasing postoperative irritation, and avoiding hardware removal. This diamond plate system has reduced the operating time by limiting the amount of necessary hardware while providing the opportunity for additional compression. The dorsal plating technique and diamond plate design allow for minimal use of the C-arm fluoroscopy intraoperatively due to the accessible visual field. The rigidity of this construct allows immediate weight-bearing following surgery to improve recovery.
      • Storts E.C.
      • Camasta C.A.
      Immediate Weight Bearing of First Metatarsophalangeal Joint Fusion Comparing Buried Crossed Kirschner Wires Versus Crossing Screws: Does Incorporating the Sesamoids Into the Fusion Contribute to Higher Incidence of Bony Union?.
      The cost of the two-hole DLDP is comparable to other rigid solid plates, if not cheaper. There are only two screws needed in this DLDP compared to four to five screws used in the rigid solid plates. The ease of application of this DLDP is one of its advantages, with little to no learning curve needed.
      The IS-DLDP construct is smaller than standard plates for the first MTPJ arthrodesis. This novel modality allows for a smaller incision site, decreased postoperative edema, pain, and risk of surgical site infection.
      • Carvalho R.L.R.
      • Campos C.C.
      • Franco L.M.C.
      • Rocha A.M.
      • Ercole F.F.
      Incidence and risk factors for surgical site infection in general surgeries.
      The subject in this report had comorbidities that could contribute to poor wound healing and risk for non-union. However, these risks did not change the lead author's (SA) postoperative protocols due to no recent smoking history, and the patient quit smoking ten years ago. In addition, the vascular examination revealed normal pedal pulses and CRT. The patient was allowed to weight-bear immediately in a CAM-boot for three weeks until suture removal and then transitioned to sneakers. Radiographic evidence showed consolidation of the bone in 5 weeks with a reduction in IM from 12 to 5 degrees, HA from 22 to 0 degrees, and TSP from 5 to 2 degrees. One of the significant advantages of the diamond-shaped design is its superior visibility of the first MTPJ through the plate in all radiographic views. In addition, dorsiflexion of the plate was accomplished in the contouring step of the procedure, which is reported to reduce malunion rates.

      Marsland, Dani.el, et al. Fusion of the First Metatarsophalangeal Joint: precontoured or Straight Plate? J Foot Ankle Surg, Volume 55, Issue 3, 509–512 https://pubmed.ncbi.nlm.nih.gov/26968232/

      Conclusion

      The IS-DLDP construct in this report of a 69-year-old female with comorbidities and risk for non-union provides anecdotal findings which suggest it is not inferior to the current standard for arthrodesis. The IS-DLDP has the added benefits of better visualization of the joint in all radiographic views, ease of placement, and reduction of anesthesia and radiation exposure. In addition, the risk of DVT is reduced by decreased operation time, tourniquet time, and immediate weight-bearing following the procedure. A call for more data and a more controlled environment is necessary to make definitive statements on the IS-DLDP construct. Still, early results and anecdotal evidence show potential benefits over other fixation constructs. The lead author (SA) has performed many first MPJ fusion procedures using this IS-DLDP construct with the same postoperative protocol, and a retrospective study will follow this paper. Further investigation is needed to expand on the benefits of this plating technique to provide a biomechanical comparison to standard plating techniques. Recommendation for future studies is to examine the mechanical stress index and compare the stress-failure rate between the traditional dorsal four-hole, five-hole, and diamond plate system with interfragmentary screw fixation in cadaveric models.

      Informed patient consent

      Complete informed consent was obtained from the patient for the publication of this study and accompanying images.

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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