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A Closer Look At An Emerging Plating System For First MPJ Arthrodesis
These authors explore the use of an innovative plating system, which provides more stability and reportedly facilitates immediate protected weightbearing after first metatarsophalangeal joint (MPJ) arthrodesis.
The surgical approach to arthritis of the first metatarsophalangeal joint (MPJ) is a frequently debated topic. Non-surgical management of hallux rigidus with anti-inflammatory medications, corticosteroid injections or shoewear modifications can be successful in appropriately selected patients.1
The research has shown that resurfacing of the metatarsal to treat advanced hallux rigidus has promising results.2 In their review of 58 primary arthrodesis procedures and 36 hemiarthroplasty procedures for osteoarthritis of the first MPJ, Voskuijl and Onstenk found that symptom intensity and the magnitude of disability were similar for both groups at more than one year postoperatively.3 For more advanced cases of hallux limitus and hallux rigidus, joint arthrodesis is a predictable long-term treatment option for addressing joint pain and deformity of the first MPJ.4
Currently, there are many available fixation options including multiple types of screws (headed and headless screws) as well as multiple plates and staples. In our experience, we have found the use of locking plates with a specific compression hole to place a lag screw distal to proximal across the joint to be a reliable and simplified approach to the first MPJ arthrodesis.
The Anchorage Plating System (Stryker) and the CrossCheck Compression Plating System (Wright Medical) provide locking plates that serve the function of placing the “home run” screw directly through the plate. These plating systems also have separately designed plates for use in a Lapidus fusion with specific joint contours for appropriate anatomic alignment. These plates generate compression through the fusion site with the use of a classic lag screw through the joint, but also provide additional stability by pulling the entire construct to the plate, which serves as a buttress.
In our opinion, these plate systems provide superior stability through the design of the plate. This design obviates the need for a separate cross joint screw. Both systems have holes for locking and non-locking 3.0 and 3.5 mm screws.
A Guide To Using The CrossCheck Plating System
While both systems provide superior stability and allow compression fixation of the MPJ arthrodesis, it has been our experience that the CrossCheck Plating System offers fewer steps in its application, greater variability in home run screw placement and effectively “screws the picture to the wall” by fusing the proximal phalanx to the more stable first metatarsal.5 Our anecdotal results with the CrossCheck system have demonstrated a 100 percent radiographic fusion rate at an average of six weeks as well as a high patient satisfaction rate in comparison to other forms of plate fixation.
The aforementioned plating systems both include cup and cone reamers but it is our preference to use curettage and K-wire fenestration in order to preserve the length of the first ray and avoid thermal necrosis. Additionally, we utilize the demineralized bone matrix and calcium sulfate product Augmatrix (Wright Medical) to fill any gap or, in some instances, in between the fragment of the arthrodesis site.
After adequately preparing the joint surfaces, use a provisional guide wire to align and stabilize the construct into the desired position for fusion. Bend the plate and fashion it as necessary to fit. The surgeon can temporarily utilize two olive wires to fix the plate to the bone in the appropriate position and confirm this with fluoroscopic measurements. It is important to ensure the laser mark on the plate is at approximately the level of the joint. We have found placing the laser mark just slightly distal to the joint line allows better capture of the proximal phalanx with the lag screw.
One should first fix the distal holes of the plate through the proximal phalanx in order to ensure appropriate compression across the joint (“the picture to the wall” concept).5 Proceed to place the compression screw, a 3.5 mm non-locking screw, across the joint. A drill guide can help ensure one has the correct angle. After completely compressing the joint, the surgeon can place the most proximal screws with any combination of locking and non-locking screws. One can fill any gaps with Augmatrix.
Comparatively, the Anchorage Plating System requires one to drill a concavity in the dorsal metatarsal neck for a proximal to distal lag screw site,. Doing so commits the surgeon to a purely dorsal placement and reduces the variability of pitch and angle for the lag screw placement.
Final Notes
We have 2.5 years of experience with the CrossCheck Plating System and our retrospective data — assessing the first 14 consecutive patients who have had the implant — demonstrates 100 percent fusion. In these cases to date, there has been no need to remove plate hardware, which we attribute to the low profile nature of the CrossCheck Plating System. The longest post-op time for our patients was 30 months and the average time was 15 months.
Furthermore, this plating system has reduced our operative and tourniquet time due to its lack of additional steps of application of use.
However, we do realize these plates could become symptomatic in the future and potentially require removal. We do counsel patients preoperatively about this possibility.
In conclusion, the CrossCheck Plating System has provided superior stability and allows patients to begin protected weightbearing in a surgical shoe or controlled ankle motion (CAM) boot immediately postoperatively.
Dr. Rice is an Assistant Clinical Professor in the Department of Orthopedics and Rehabilitation at Yale University School of Medicine. He is in private practice at Fairfield County Foot Surgeons in Norwalk, Conn. He is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Russell is in private practice at Fairfield County Foot Surgeons in Norwalk, Conn.
References
1. Hamid KS, Parekh SG. Clinical presentation and management of hallux rigidus. Foot Ankle. 2015;20(3):391-9.
2. Kline AJ, Hasselman CT. Resurfacing of the metatarsal head to treat advanced hallux rigidus. Foot Ankle Clin. 2015;20(3):451-3
3. Voskuljl T, Onstenk R. Operative treatment for osteoarthritis of the first metatarsal joint: arthrodesis versus hemiarthroplasty. J Foot Ankle Surg. 2015; 54(6):1085-8.
4. Rammelt S, Panzner P. Metatarsal joint fusion: why and how? Foot Ankle Clin. 2015; 20(3):465-77.
5. Mark Hofbauer, DPM, Cross Check Plate Workshop, personal observation.
