The modified Lapidus fusion: a systematic review of biomechanical studies

in EFORT Open Reviews
Authors:
Martin Riegger Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland

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Nermine Habib Department of Orthopedic Surgery, Hopital fribourgeois (HFR) – Freiburger Spital (HFR), Fribourg, Switzerland

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Enrique Adrian Testa Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Bellinzona, Switzerland

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Jochen Müller Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland

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Marco Guidi Department of Plastic Surgery and Hand Surgery, Kantonsspital, Aarau, Switzerland

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Christian Candrian Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland

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Correspondence should be addressed to M Riegger: martin.riegger@googlemail.com or martin.riegger@eoc.ch

(M Riegger and N Habib contributed equally to this work as first authors)

*(M Guidi and C Candrian contributed equally to this work)

Open access

Purpose

  • The biomechanical characteristics of different techniques to perform the modified Lapidus procedure are controversial, discussing the issue of stability, rigidity, and compression forces from a biomechanical point of view. The aim of this systematic review was to investigate the available options to identify whether there is a procedure providing superior biomechanical results.

Methods

  • A comprehensive literature search was performed by screening PubMed, Embase, and Cochrane databases until September 2021. There was a wide heterogeneity of the available data in the different studies. Load to failure, stiffness, and compression forces were summarized and evaluated.

Results

  • Seventeen biomechanical studies were retrieved – ten cadaveric and seven polyurethane foam (artificial bone) studies. Fixation methods ranged from the classic crossed screw approach (n = 5) to plates (dorsomedial and plantar) with or without compression screws (n = 11). Newer implants such as intramedullary stabilization screws (n = 1) and memory alloy staples (n = 2) were investigated.

Conclusion

  • The two crossed screws construct is still a biomechanical option; however, according to this systematic review, there is strong evidence that a plate–screw construct provides superior stability especially in combination with a compression screw. There is also evidence about plate position and low evidence about compression screw position. Plantar plates seem to be advantageous from a biomechanical point of view, whereas compression screws could be better when positioned outside the plate. Overall, this review suggests the biomechanical advantages of using a combination of locking plates with a compression screw.

Abstract

Purpose

  • The biomechanical characteristics of different techniques to perform the modified Lapidus procedure are controversial, discussing the issue of stability, rigidity, and compression forces from a biomechanical point of view. The aim of this systematic review was to investigate the available options to identify whether there is a procedure providing superior biomechanical results.

Methods

  • A comprehensive literature search was performed by screening PubMed, Embase, and Cochrane databases until September 2021. There was a wide heterogeneity of the available data in the different studies. Load to failure, stiffness, and compression forces were summarized and evaluated.

Results

  • Seventeen biomechanical studies were retrieved – ten cadaveric and seven polyurethane foam (artificial bone) studies. Fixation methods ranged from the classic crossed screw approach (n = 5) to plates (dorsomedial and plantar) with or without compression screws (n = 11). Newer implants such as intramedullary stabilization screws (n = 1) and memory alloy staples (n = 2) were investigated.

Conclusion

  • The two crossed screws construct is still a biomechanical option; however, according to this systematic review, there is strong evidence that a plate–screw construct provides superior stability especially in combination with a compression screw. There is also evidence about plate position and low evidence about compression screw position. Plantar plates seem to be advantageous from a biomechanical point of view, whereas compression screws could be better when positioned outside the plate. Overall, this review suggests the biomechanical advantages of using a combination of locking plates with a compression screw.

Introduction

Multiple treatment strategies exist for metatarsus primus varus and hallux valgus deformities. The Lapidus arthrodesis of the first metatarsocuneiform (MTC) joint is one of the most common surgical procedures, including the fusion of the second metatarsus and/or the second cuneiform bone. After being mentioned by Truslow (1) and Kleinberg (2), it was Lapidus who named this procedure in 1934 (3, 4). Since then, it has been widely used to treat arthritis, instability, and deformity of the fore- and midfoot. Various modifications have been described afterward by several authors, such as Butson or Giannestras (5, 6), aiming at achieving stability of the first MTC joint. Today, the modified Lapidus procedure is considered the arthrodesis of the MTC joint alone.

The most established method for the modified Lapidus procedure comprises a fusion of the first MTC joint using two crossed screws (Fig. 1). However, this procedure is known for its high non-union rate, up to 20% (7). Accordingly, in the past two decades, several implants and surgical techniques have been introduced (8), as shown in Figs. 2, 3, and 4. These include locking plates in a medial, plantar, and dorsal position (Figs. 2A, B, and C), interosseous or intramedullary stabilizers (Fig. 3), as well as the so-called memory staples (Fig. 4). All of them have been tested biomechanically to detect one another's superiority in improving patient safety by allowing early weight-bearing. Yet, it remains unknown which method is better or which material has the best outcomes. Rapid mobilization and return to everyday life after surgery are crucial for the patient to avoid complications such as secondary dislocation, deep-venous thrombosis, or non-union. In this light, evidence-based data could guide surgeons in understanding the biomechanical properties of the different options to choose the most suitable implant and provide the best fixation strategy.

Figure 1
Figure 1

Classic crossed screw fixation consisting of a full-threaded compression screw and a partial threaded screw.

Citation: EFORT Open Reviews 8, 4; 10.1530/EOR-22-0069

Figure 2
Figure 2

Different surgical techniques for plate application. Plate design changes in different positions. Thirteen different plates were retrieved in this systematic review: (A) schematic illustration of a medial plate; (B) schematic illustration of a dorsal plate; (C) schematic illustration of a plantar plate.

Citation: EFORT Open Reviews 8, 4; 10.1530/EOR-22-0069

Figure 3
Figure 3

Intramedullary stabilization in a dorsoplantar position. Plantar–dorsal position has also been investigated.

Citation: EFORT Open Reviews 8, 4; 10.1530/EOR-22-0069

Figure 4
Figure 4

A schematic metatarsocuneiform joint fusion with two memory alloy staples. However, the use of one staple has also been investigated.

Citation: EFORT Open Reviews 8, 4; 10.1530/EOR-22-0069

The aim of this systematic review was to investigate the biomechanical characteristics of the different options proposed for the MTC joint arthrodesis. It represents an analysis of what has been tested in the literature in vitro on cadaveric models or artificial bone material. It gives evidence as to what implant is preferable from a biomechanical point of view. It focuses on the controversial debate of which implant provides more stability and safety to the patient during the healing process. Secondarily, it sheds light on what has been developed for this kind of surgery, overviewing and analyzing the results of the different studies.

Methods

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), a guideline that describes the items required for reporting in systematic reviews and meta-analyses (9, 10). Furthermore, specific suggestions for systematic reviews of diagnostic imaging studies were followed (11). A meta-analysis was not performed due to heterogeneity among the studies, a large number of different implants, and different study settings. A homogeneous testing protocol for the in vitro models in the different studies was unavailable.

Search strategy

Two co-authors (MR and MG) performed independently a comprehensive literature search of PubMed/Medline, Embase, Google Scholar, and the Cochrane library databases to find relevant published articles related to the review focus: biomechanical studies on the MTC joint fusion in the modified Lapidus technique. This search string based on a combination of keywords, Boolean operators, and truncations (*) was created and used: (A) ‘arthrodesis’ OR ‘fusion’ AND (B) ‘first metatarsocuneiform joint’ OR ‘first tarsometatarsal joint’ AND (C) ‘biomechanical cadaver study’ OR ‘biomechanical Sawbone study’ AND (D) ‘compression plates’ OR ‘crossed screws’ OR ‘locking plate’ OR ‘compression screw’. No beginning date limit nor language restrictions were used. The literature search was updated until September 2021. To expand the literature search, the references of the retrieved articles were also screened for possible additional records.

Figure 5
Figure 5

Flow chart of the search for eligible studies on biomechanical studies of the modified Lapidus procedure.

Citation: EFORT Open Reviews 8, 4; 10.1530/EOR-22-0069

Sudy selection

All biomechanical studies comparing different types of MTC joint arthrodesis were included in this study. We selected both cadaveric studies and Sawbone® studies (polyurethane foam).

The exclusion criteria for the systematic review were: (a) articles not within the field of interest; (b) reviews, editorials, letters, comments, and conference proceedings; (c) all clinical studies; (d) biomechanical studies different from cadaver studies or Sawbone® studies; as well as (e) biomechanical studies comparing the modified Lapidus procedure with the classic Lapidus operation and trans cuneiform stabilization.

Two co-authors (MR and MG) independently screened the abstracts of the retrieved articles, applying the predefined inclusion and exclusion criteria. Subsequently, the researchers independently reviewed the selected articles' full text to assess their inclusion eligibility in the systematic review. Any disagreement was solved through a consensus among the researchers performed at the Department of Foot and Ankle Surgery at the Ospedale Civico di Lugano in September 2021 via ‘zoom©’ virtual communication platform.

Data extraction

For each selected article, information was collected on the basic study characteristics (authors, year of publication, country, and study design). Missing data were labeled as not reported (NR).

Quality assessment

The quality assessment of the studies included in this systematic review was critically appraised using the QUality Appraisal for Cadaveric Studies scale (QUACS scale). The scale consists of a checklist encompassing 13 items. Each is to be scored with either 0 (no/not stated) or 1 (yes/present) point. Points are only assigned if a criterion is met without any doubt. As one item (‘Applied statistics are appropriate’) is not always applicable, the maximum score is 12 or 13 depending on the study content. To enhance comparability of results, quality rating is expressed as a percentage value (reached score/maximum score (%)) (12).

Results

Literature search

Overall, 97 records were identified through the comprehensive literature search of the PubMed/Medline, Embase, Google Scholar, and Cochrane library databases. After screening 92 abstracts, 72 records were excluded because they were not in the field of interest, 48 being patient studies and not biomechanical studies, 20 being reviews/editorials/letters, and 4 being case reports or small case series to the modified Lapidus fusion. Twenty articles were selected, and their full text was retrieved. No additional records were found screening the references of these articles, whereas further three articles were excluded after the analysis of the full text. Despite being biomechanical cadaveric investigations, the studies of Ray et al. and Ehredt et al. were excluded because the classic Lapidus procedure was compared with the modified Lapidus operation (7, 13). Li & Myerson wrote a narrative review focusing on the evolution of the Lapidus procedure. The study did not focus on biomechanical analyses and was excluded (14). Therefore, 17 articles were included in the qualitative analysis (systematic review) (8, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29). The characteristics of the 17 studies included in the systematic review are presented in Tables 1 and 2.

The flowchart of the literature search is described in Fig. 5.

Table 1

Basic study details and technical aspects.

Reference Year Country DEXA Operation technique Material tested Testing method n Plate position
Biomechanical cadaver study
 Cohen et al. (15) 2005 USA Yes Four-point bending 20 Dorsal
Crossed screws 4.0 mm cannulated screws (DePuy)
Locking plate, no compression screw H-locking plate (Normed Medizin Technik)
 Gruber et al. (16) 2008 USA Yes Four-point bending 20 Dorsal
Crossed screws 4.0 mm cannulated screws (DePuy)
Locking plate with compression screw Lapidus plate and dorsal compression screw (Darco International)
 Scranton et al. (17) 2009 USA No Cantilever bending 20 Medial
Crossed screws 4.0 mm cannulated screws (Synthes)
Locking plate with compression screw Lapidus plate and plantar compression screw (Arthrex)
 Klos et al. (18) 2010 Switzerland Yes Four-point bending 16 Medial
Crossed screws 4.0 mm cannulated screws (Synthes)
Locking plate with compression screw X-plate and partially threaded compression screw (Synthes)
 Klos et al. (19) 2011 Switzerland Yes Cantilever bending 12 Dorsomedial vs plantar
Locking plate medial with compression screw H-shaped DARCO LPS locked plate (Wright Medical) + 4.0 mm compression screw
Locking plate plantar with compression screw DARCO plantar plate (Wright Medical) +4.0 mm compression screw
 Cottom et al. (20) 2013 USA No Cantilever bending 20 Medial
Plate with plantar compression screw Lapidus plate LPS (Arthrex) + compression screw from plantar
Plate with interplate compression screw Lapidus plate LPS (Arthrex) + compression screw in the plate
 Roth et al. (21) 2014 Germany Yes Four-point bending 14 Plantar
Interosseous fixation IO FIX® (Extr. Medical) + compression screw
Plantar plate with compression screw Plantar locking plate (Wright Medical) + compression screw (Königssee Implant)
 Baxter et al. (22) 2014 USA Yes Four-point bending 20 Dorsomedial
Crossed screws 4.0 mm cannulated screws (Synthes)
Compression plate, no compression screw Claw II® Polyaxial Compression Plating System (Wright Medical)
 Graham et al. (25) 2016 USA No Cantilever bending 14 Dorso- medial
Open wedge plates Osteo-WEDGE™ (GraMedica)
Intact bone Intact cadaver bone
 Cottom et al. (27) 2017 USA NR Cantilever bending 16 Medial vs plantar
Plate with plantar compression screw Lapidus plate LPS (Arthrex) + compression screw from plantar
Plate with interplate compression screw Lapidus plate plantar (Arthrex) + compression screw in the plate
Biomechanical Sawbone® Study
 Aiyer et al. (23) 2015 Australia NR Four-point bending 10 Dorsal
Plate no compression screw Claw II® (two hole) compression plate (Wright Medical)
Crossed screws 4.0 mm cannulated screws (Synthes)
Single staple BME Speed™ Staple (Biomedical Enterprises)
Two staples BME Speed™ Staple (Biomedical Enterprises)
 Russell et al. (24) 2015 Australia NR 3p-/4p-/cantilever 10 NR*
Single staple BME Speed™ Staple (Biomedical Enterprises)
Two staples BME Speed™ Staple (Biomedical Enterprises)
 Hoon et al. (30) 2016 Australia NR Four-point bending 18 NR**
Plate no compression screw Eight-hole quarter tubular plate (Synthes)
Single staple BME Speed™ Staple (Biomedical Enterprises)
Double staples BME Speed™ Staple (Biomedical Enterprises)
 Knutsen et al. (26) 2016 USA NR Four-point and

cantilever bending
16 Dorsal
Crossed screws 3.5 mm crossed lag screws (Synthes)
Dorsal locking plate no compression screw 2.7 mm 5-hole locking plate (Synthes) no compression screw
Intraosseous fixation IO FIX® (Extr. Medical) + plantar dorsal
Intraosseous fixation IO FIX® (Extr. Medical) + dorsal plantar
 Burchard et al. (28) 2018 Germany NR Cantilever bending 9 Plantar vs medial
Plantar plate fixation PEDUS L Plantar Plate® (Axomed)
Medial plate fixation Double Bridge Plate® (Königsee)
Intraosseous fixation IO FIX® (Extr. Medical) + dorsal plantar
 Dayton et al. (29) 2018 USA NR Cantilever bending 20 Dorsomedial

vs plantar
Plate dorsal-medial PLANTAR-PYTHON Plate® (Treace Medical Concepts, Inc.)
Plate medio-plantar PLANTAR-PYTHON Plate® (Treace Medical Concepts, Inc.)
 Drummond et al. (8) 2018 USA NR Cantilever bending 27 Medial vs dorsal vs plantar
Crossed screws with: 4.0 mm cross. screws (Zimmer Biomet)
Medial plate Minifragment plates (Zimmer Biomet)
Dorsal plate Minifragment plates (Zimmer Biomet)
Plantar plate Minifragment Plates (Zimmer Biomet)

*No plate has been tested; **No anatomic model: only synthetic bone block in testing protocol.

DEXA, dual energy X-ray absorptiometry (for meauring bone density); NR, not relevant.

Location of the companies mentioned are as follows - Arthrex: FL, USA; Wright Medical: MI, USA; Extremity Medical: NJ, USA; Königsee Implantate : Thuringen, Germany; GraMedica: MI, USA; Biomedical Enterprises Treace Medical Concepts: FL, USA; Zimmer: IN, USA; Axomed: Freiburg im Breisgau, Germany

Table 2

Diagnostic accuracy data (presented as mean n/mm) of tested materials in the included studies. The order of the included studies is chronological.

Reference/ operation technique Maximum load to failure Initial stiffness of construct Final stiffness of construct Bending moment Cycles to failure Plantar gapping
Cohen et al. (15)
 Crossed screws 140.1 83.1 NR NR NR NR
 Locking plate, no compression screw 58.1 20 NR NR NR NR
Gruber et al. (16)
 Crossed screws 120.4 47.9 NR NR NR NR
 Locking plate with compression screw 110.8 60 NR NR NR NR
Scranton et al. (17)
 Crossed screws 78.0 NR NR 4.4 NR NR
 Locking plate with compression screw 108.0 NR NR 6.0 NR NR
Klos et al. (18)
 Crossed screws NR 1.35† NR NR 2512.5 NR
 Locking plate with screws NR 1.45† NR NR 3056.2 NR
Klos et al. (19)
 Locking plate medial plus compression screw 110.0 30.70 7.0 5.3 NR NR
 Locking plate plantar plus compression screw 192.6 33.9 24.8 9.1 NR NR
Cottom et al. (20)
 Medial plate plus dorsal compression screw 205.5 NR NR 8.2 NR NR
 Plantar plate plus interplate compression screw 383.2 NR NR 15.3 NR NR
Roth et al. (21)
 Plantar plate with compression screw 167.1 131.0 188.1 NR 7517 NR
 Interosseous fixation 68.6 43.3 63.4 NR 2996 NR
Baxter et al. (22)
 Crossed screws NR NR NR NR NR 1.1
 Plate, no compression screw NR NR NR NR NR 3.2
Aiyer et al. (23)
 Plate, no compression screw 531.8 233.1 NR NR NR 7.0
 Crossed screws 1030.4 439.7 NR NR NR 1.71
 Single staple 501.8 214.2 NR NR NR 3.29
 Two staples 610.6 263 NR NR NR 4.62
Russell et al. (24)
 Single staple NR 217.1* NR NR NR 4.71**
 Two staples NR 250.7* NR NR NR 2.79**
Graham et al. (25)
 Open wedge plates 120 4.1 NR 5.6 NR NR
 Intact bone 108 14.2 NR 6.1 NR NR
Hoon et al. (30)
 Plate, no compression screw 19.50 10.8 NR NR NR NR
 Single staple 51.1 9.3 NR NR NR NR
 Double staples 108.4 29.0 NR NR NR NR
Knutsen et al. (26)
 Crossed screws NR NR NR NR NR NR
 Dorsal plate, no compression screw NR NR NR NR NR NR
 Intraosseous fixation NR NR NR NR NR NR
 Intraosseous fixation NR NR NR NR NR NR
Cottom et al. (27)
 Medial plate with planto-dorsal compression screw 255.4 25.7 NR 10.2 NR NR
 Plantar plate with interplate compression screw 197.5 17.3 NR 7.9 NR NR
Burchard et al. (28)
 Plantar plate fixation 324 NR NR NR NR 0.03
 Medial plate 377 NR NR NR NR 0.06
 Intraosseous fixation 173 NR NR NR NR 0.08
Dayton et al. (29)
 Plate dorsal-medial 210.9 NR NR NR 102 MR
 Plate medio-plantar 247.3 NR NR NR 207 NR
Drummond et al. (8)
 Screws with medial plate 260.4 NR NR NR NR NR
 Screws with dorsal plate 285 NR NR NR NR NR
 Screws with plantar plate 351.9 55.7 NR NR NR NR

*Stiffness at 4pt dorsal bending; **Plantar gapping at a bending of 3 mm; †indicates n/degrees.

NR, not reported

Qualitative analysis (systematic review)

Basic study and patient characteristics

After screening the selected databases, 17 articles evaluating different types of the modified Lapidus arthrodesis of the first MTC joint in a biomechanical study model were included in the qualitative analysis (Table 1) (8, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29). Out of these, ten articles were cadaver studies (56.3%) and seven articles were polyurethane foam type IV Sawbone® studies (43.7%). All selected articles were published in the last 15 years (from 2005 to 2021) by research groups from different continents (America, Europe, and Australia), with studies from America being the most represented (56.3%). Three articles were from Australian research groups (18.7%), 2 from both Switzerland and Germany (12.5% each). All studies compared different types of MTC joint arthrodesis. Twelve articles investigated two different operation methods for MTC fusion (68.8%), four articles compared three different types of MTC joint fusion (25%), and one article compared four different materials for MTC joint arthrodesis (6.2%). In the 17 included studies, 13 different types of plates were investigated.

Technical aspects and main findings

The main characteristics and technical aspects of the investigated variables are summarized in Tables 1 and 2. The different operation techniques utilized are summarized in Figs. 1, 2, 3 and 4.

Biomechanical testing

Ten of the 17 studies were on cadaver bones, while the remaining seven studies were on artificial full bone models (Sawbone®). The artificial bone models consisted of full bone models without joints or ligaments, and the cadaveric bones were fresh-frozen specimens with full feet and exarticulated at the level of the ankle joint.

Crossed screws vs plate

Several studies presented a similar setting using a four-point bending test model (15, 16, 18, 22, 23), Scranton et al. (17) used a cantilever model, while Knutsen et al. (26) described both a four-point bending and a cantilever loading scenario.

Five of them tested the two crossed screws vs different kinds of plate fixation in a cadaver study setting (15, 16, 18, 22), while Aiyer et al. added alloy staples to the comparison and performed the study on artificial bone models (23).

Cohen et al. tested catastrophic failure and stiffness of construct. They found significantly higher load to failure and higher stiffness of construct in 4.0 mm cannulated crossed screws (DePuy) vs an angle stable H-locking plate (Normed Medizin Technik) (15).

Gruber et al. used the same test setting using 4.0 mm cannulated crossed screws (DePuy) vs a Lapidus plate (Darco International), adding a compression screw dorsally. This study's findings showed no significant difference between the two groups in terms of stiffness and catastrophic load to failure (16). They concluded that biomechanically a compression screw would improve stability.

Klos et al. tested 4.0 mm crossed screws (Synthes) and an X-shaped plate (Synthes). To simulate weight-bearing while walking, the testing protocol was modified to a cyclic loading model. Failure was defined as a gapping of the construct on the plantar side of 3 mm. The result showed a significantly higher number of cycles to failure in the plate with the dorsal compression screw group vs the two crossed screw group (18).

Baxter et al. compared the Claw II polyaxial compression plating system (Wright Medical) with two crossed cannulated screws finding the construct of two crossed lag screws to provide significantly greater stability than the plating construct (22).

Aiyer et al. compared the application of either one or two shape memory alloy staples BME Speed™ Staple (Biomedical Enterprises) with Claw II plate (Wright Medical) fixation and with two crossed screws (Synthes). They concluded that crossed screws have the greatest load to failure and less plantar gapping than the other constructs (23).

Concerning the cantilever model, Scranton et al. tested the Lapidus locking plate (Arthrex) with a plantar compression screw vs 4.0 mm crossed screws (Synthes), finding a higher load to failure and bending moment in the plate construct with compression screws (17).

Knutsen et al. compared four groups with three implants: 3.5 mm crossed lag screws (Synthes), 2.7 mm five-hole locking plate (Synthes), no compression screw, IO FIX® (Extremity Medical) + plantar–dorsal, and dorsal-plantar. Results showed significantly higher loading and less gapping at failure with crossed screws and intramedullary fixation when compared to plating without compression screw construct. The plantar position of the IO FIX® had biomechanical advantages (26).

Plate vs plate

Six studies compared different types of plate constructs. Half of the studies are cadaveric studies (20, 21, 28), while the other half was performed on artificial bone models (29, 30).

Klos et al. compared MTC arthrodesis medial plating vs plantar plating and found a significant benefit for medial plating in maximum load to failure, in the initial and final stiffness of construct, and in the bending moment (19).

In 2013, Cottom et al. compared the different possibilities of inserting the compression screw either medially through the plate or from the plantar side outside of the plate. The result was a significantly higher maximum load to failure with a plantar compression screw, with a greater bending moment. The positioning of the interfragmentary compression screw had an impact on the stability of the construct (20). In 2017, they demonstrated that even though there was no statistical difference between the two groups, they confirmed that the medial plate with a plantar compression screw had a higher stiffness, a higher load to failure, and a greater bending moment. In conclusion, the plate with an extra-plate compression screw was advantageous (27).

Burchard et al. compared a medial locking plate (Double Bridge Plate®) in combination with crossed screw, a plantar locking plate (PEDUS L Plantar Plate®) also in combination with crossed screw, and an intramedullary fixation device (IO FIX®). Results showed the greatest stiffness in plantar plating, whereas intramedullary fixation provided a higher compression force (28).

Dayton et al. compared the positioning of the Plantar-Python Plate® (Treace Medical Concepts, Inc.) in a dorsomedial position and in a dorsomedial-plantar position. The results showed a significantly greater number of cycles to failure and a significantly higher load to failure in the tension side dorsomedial-plantar model (29).

Drummond et al. focused their research in a cantilever setting with two crossed screws applicating minifragment plates (Zimmer Biomet) in different positions: dorsal, medial or plantar. They found superior results in plantar and medial plate positions (8).

Staples

Besides the study by Aiyer et al. in 2015 (23) mentioned above, two more studies comparing single to double stables were performed. Both were conducted on Sawbone®.

According to the biomechanical study of Russell et al., who compared the use of one vs two BME Speed™ Staples (Biomedical Enterprises), there was a significantly higher contact force with less plantar gapping in the group with two staples (24).

Hoon et al. found significantly higher mean compression loads and contact areas using two memory BME Speed™ Staples (Biomedical Enterprises) compared to one staple or a quarter tubular plate. They also add that the plate provided significantly higher stability (30).

Intramedullary implants

Compared to the abovementioned studies by Knutsen et al. (26) and Burchard et al. (28) , Roth et al. tested in a cadaveric study with a four-point bending setting the intramedullary implant IO Fix (Extremity Medical™) v a plantar plate (Wright Medical™) both with a compression screw (Königsee) and found the plate construct to be significantly stronger and stiffer (21).

Osteo-WEDGE(™) bone plate locking system

Graham et al. compared in a cadaveric study on full foot models the inherent strength of the first MTC joint and surrounding bones fixated with the osteo-WEDGE(™) bone plate locking system (OW) with that of intact specimens. The results were similar in strength, stiffness, and bending moment, and so they concluded that the mechanical strength of the OW is comparable to that of intact specimens (25).

To summarize, 17 studies were reported with a wide heterogeneity in their measures, without a homogeneous testing protocol. Testing methods ranged from cantilever, three-point bending to four-point bending model. Plates with compression screws were advantageous to the other surgical implants. Crossed screws are inferior to plates when a compression screw is used. Interosseous stabilators and memory alloy staples did not show advantages even though less studies are available. No meta-analysis was performed due to the wide heterogeneity of 13 different plates tested, different testing protocols, as well as different testing models.

Quality assessment (QUACS scale)

The quality appraisal of studies included in the systematic review is reported in Table 3 and briefly described below.

Table 3

QUality appraisal for Cadaveric Studies scale (QUACS scale).

Reference 1 2 3 4 5 6 7 8 9 10 11 12 13 Total score Reached / maximum score %
Cohen et al. (15) 1 1 1 1 0 0 1 1 1 1 1 1 0 10 76.9
Gruber et al. (16) 1 1 1 1 0 0 1 1 1 0 1 1 0 9 69.2
Scranton et al. (17) 1 1 1 1 0 1 1 1 1 1 1 1 1 12 92.3
Klos et al. (18) 1 1 1 1 0 0 1 1 1 1 1 1 1 11 84.6
Klos et al. (19) 1 1 1 1 1 0 1 1 1 1 1 1 1 12 92.3
Cottom et al. (20) 1 1 1 1 0 0 1 1 1 1 1 1 1 11 84.6
Roth et al. (21) 1 1 1 1 0 0 1 1 1 1 1 1 1 11 84.6
Baxter et al. (22) 1 1 1 1 1 0 1 1 1 1 1 1 1 12 92.3
Aiyer et al. (23) 1 1 1 * 0 0 1 1 1 1 1 1 1 10 83.3*
Russell et al. (24) 1 1 1 * 0 0 1 1 1 1 1 1 1 10 83.3*
Graham et al. (25) 1 1 1 1 0 0 1 1 1 1 1 1 1 11 84.6
Hoon et al. (30) 1 1 1 * 0 0 1 1 1 1 1 1 1 10 83.3*
Knutsen et al. (26) 1 1 1 * 0 0 0 1 1 1 1 1 1 9 75*
Cottom et al. (27) 1 1 1 1 0 0 1 1 1 1 1 1 1 11 84.6
Burchard et al. (28) 1 1 1 * 0 0 1 1 1 1 1 1 0 9 75*
Dayton et al. (29) 1 1 1 * 0 0 1 1 1 1 1 1 1 10 83.3*
Drummond et al. (8) 1 1 1 * 1 0 1 1 1 1 1 1 1 11 91.7*
 Overall percentage 83.6

Items of QUACS scale: 1. Objective stated; 2. Basic information about sample is included; 3. Applied methods are described comprehensibly; 4. Study reports condition of the examined specimens; 5. Education of dissecting researchers is stated; 6. Findings are observed by more than one researcher; 7. Results presented thoroughly and precise; 8. Statistical methods appropriate; 9. Details about consistency of findings are given; 10. Photographs of the observations are included; 11. Study is discussed within the context of the current evidence; 12. Clinical implications of the results are discussed; 13. Limitations of the study are addressed. *Sawbone® Study. This question remains unanswered and uncounted. Percentage only on 12 items.

In the seven studies that used polyurethane foam specimen, the scale item 4 (’Study reports condition of the examined specimens’) remained unanswered and uncounted for the percentage as described in literature (12). Concerns in almost all studies except for one were in scale item 6 (’Findings are observed by more than one researcher’). Only Scranton et al. reported about more than one researcher observing the findings (17). In only three studies, the experience of the operating surgeon was stated (scale item 5) (8, 19, 22). The rest of the scale items were generally assessed with good quality. The overall percentage of the quality appraisal of the included studies was 83.6%.

Discussion

This systematic review investigated the different implants and techniques utilized for the arthrodesis of the first MTC joint.

The literature addressed this important topic through clinical trials, and a narrative review previously published but with a different focus. Li & Myerson reviewed the evolution of the Lapidus procedure. They gave an overview of the implants utilized but mainly discussed the indications and the techniques of the classic and the modified Lapidus fusion in general (14). Nowadays, evidence-based data are decisive in establishing a treatment protocol aimed at the patient’s safety and well-being. Thus, this study explored this topic with a systematic approach to highlight the evidence by summarizing the biomechanical studies for the MTC joint fusion with the modified Lapidus approach.

The Lapidus procedure has evolved through numerous iterations and advances in both techniques and implants, leading to improved outcomes and accelerated postoperative protocols (8). Yet, there is no agreement on the most suitable material and method of choice neither from a biomechanical nor from a clinical point of view. Gruber et al. found bone marrow density positively correlated with load to failure (16). In patients with good bone quality, screw-only constructs can still be considered the standard of care (8, 17). However, a non-union rate of up to 20% made it necessary to find new fixation methods (7).

A total of 17 studies were included in this systematic review with the aim of comparing the different fixation methods (8, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 15). This study aimed to summarize what has been tested in the literature from a biomechanical point of view.

Biomechanical testing method

From 2000 up to 2014, specimens were used in the retrieved articles. However, only six of the ten cadaveric bone studies did a DEXA testing. The lack of DEXA testing is considered as risk of bias. After 2014, mainly polyurethane type IV artificial models (Sawbone®) were used. Some publications validate polyurethane foam type IV models as comparable to cadaveric bone models (31, 32, 33, 34, 35). However, all validations were made on the tibia and femur. The small articulations of the foot, especially of the Lisfranc joint line, equilibrating mobility and stability, are complex. The use of artificial bone (Sawbone®) should be considered a risk of bias. Within the last two decades, testing methods and protocols were modified in the studies. The initial testing method measured the maximum load to failure and the mean stiffness of the construct. Failure was mainly defined as a gapping of more than 3 mm on the opposite side of where the bending force was applied. Also, catastrophic failure of the construct (e.g. material failure and bone fracture) was documented. Cohen et al., Gruber et al., Scranton et al., and Klos et al. (2010) tested their models with a static loading approach (15, 16, 17, 18). The following studies tested their models with a cyclic loading approach imitating real weight-bearing forces (8, 19, 20, 21, 22, 23, 24, 25, 26, 28, 29, 30).

Crossed screw fixation vs plating and different plate positions (Figs. 1 and 2)

Screw fixation has been the first and most commonly used technique of the modified Lapidus arthrodesis (18). There is a consensus that osteotomies, fractures, and arthrodeses heal with stability and compression forces. Cohen et al. tested two crossed screws vs plate fixation without using a compression screw and found a significantly higher load to failure in the crossed screw group (15). Gruber et al. found a higher initial stiffness utilizing a locking plate with a compression screw with a similar load to failure in both groups: crossed screws and plate with compression screw (16). Scranton et al. and Klos et al. found the locking plate with compression screw to be superior to the crossed screws technique (17, 18). Klos et al. tested, therefore, in a second biomechanical study, two different kinds of plate application (dorsomedial and plantar). Results showed superior stability in the plantar plate group (19). This result was confirmed by the studies of Dayton et al. and Drummond et al. (8, 29). Plantar application of plates or compression screws showed biomechanical advantages in the studies of Cottom et al. and Roth et al. (20, 21). Their works showed in different study settings superior load to failure in plantar applicated fixation methods in either screws or plates (20, 21).

This systematic review shows an advantage in plating vs crossed screws as a fixation method when a compression screw is used. Plantar application of the plate leads to a higher load to failure, a higher bending moment, and more cycles to failure. In actual surgical procedures, the anatomy of the insertion of the tibialis posterior tendon should be considered to guarantee the correct positioning of the plate, as described by Plaass et al. (36). Therefore, a safe and reliable method could be the dorsomedial application of the plate in combination with a compression screw (8, 15, 16, 17, 18, 19, 20, 21, 29). Evidence to this issue is lacking, and the literature shows clinical studies where plantar and dorsomedial application of the plates are feasible methods with union rates up to 98% and equal patients’ satisfaction (37, 38).

Cottom et al. tested a compression screw inside the plate vs a compression screw outside the plate in one study from the medial side and in a second study from the plantar side. The result was a higher load to failure, higher compression forces, and superior stiffness when the compression screw is positioned outside of the plate (20, 27).

Plate designs, varied from angle stable implants to non-angle stable implants, variable angle implants, 2.0 mm implants to 3.5 mm implants, and two-hole plates up to eight-hole plates. These aspects made it difficult to compare and summarize the plating group or to find differences.

Memory alloy staples vs crossed screws vs plating

Russell et al. found two staples superior to one staple (24). It seems to be clear that two implants give more stability than one implant. Also Aiyer et al. found two staples superior to one staple but inferior to a crossed screws construct and equal to the Claw II® (two-hole) compression plate (23). No compression screw was used with the plate, which seems to be an essential aspect for stability and compression forces. The Claw II® plate is a two-hole plate which appears to be weak when confronted to other implants. Hoon et al. compared a non-foot but bone block model of Sawbone®. They found the application of two staples superior to one staple and superior to an eight-hole quarter tubular plate (24). However, compression screw had not been used with the plate.

According to the investigations of Aiyer et al., Russel et al., and Hoon et al., using two shape-memory alloy staples gives superior stability to one staple. However, an advantage to plating constructs could not be found (23, 24, 30). Of the 17 included studies, only three investigated the use of shape-memory alloy staples (18.8%). Further investigations with standardized protocols are necessary to evaluate the actual benefit of these implants. In fact, the plate construct failure could be due to the design within these studies (e.g. no compression screw and weak implant).

Interosseous fixation vs plates vs crossed screws

Roth et al. tested the interosseous implant IO FIX® vs a locking compression plate with a compression screw and found the IO FIX® significantly inferior to the plate. All measured variables were in favor of the plate construct (21). Knutsen et al. tested the IO FIX® vs crossed screws and a locking plate without a compression screw. Interestingly, the interosseous fixation method turned out to be superior to the plate construct, and a plantar positioning of the IO FIX® had advantages compared to the dorsal application (26). However, the lack of a compression screw in or outside the plate construct could have influenced this outcome. Plantar positioning of the implants, either plates or IO FIX®, seemed to have biomechanical advantages. In the study of Burchard et al., the interosseous fixation method was confronted with two different plates (plantar and mediodorsal). The interosseous implant was inferior to both plate constructs (28). The interosseous fixation IO FIX® was tested by Roth et al., Knutsen et al., and Burchard et al. with an inferior result compared to other implants such as plates or crossed screws (21, 26, 28). Three of the 17 retrieved studies investigated the interosseous fixation method (18.8%).

This systematic review of the literature gives a complete overview of the materials tested in biomechanical studies for MTC joint arthrodesis. Despite the strengths of being a systematic review, some limitations and biases should be considered. This study was not registered in any registry. One limitation of all biomechanical studies is that in vivo bone differs from cadaveric and polyurethane type IV foam models. In several studies of the systematic review, Sawbone® models were used. This might have an impact on strength, stiffness, and stability when compared to real bone. A meta-analysis was not possible. There are no studies comparing the different types of plates, which are all considered and summarized as plate constructs. We found a great variety of plates among the different studies, yet none of these studies compared the 13 different plates. The choice of implant is an important risk of bias to the outcome of the different variables, especially compared to other materials and operation techniques.

Conclusion

The two crossed screws construct is still a biomechanical option; however, according to this systematic review, there is strong evidence that a plate–screw construct provides superior stability. If a plate is used, a compression screw gives additional stability and compression forces. There is also evidence about plate position and low evidence about compression screw position. Plantar plates seem to be advantageous from a biomechanical point of view, whereas compression screws could be better when positioned outside the plate.

Further studies with standardized protocols are needed for the evaluation of other implants, such as staples and interosseous/intramedullary implants.

Overall, this review suggests the biomechanical advantages of using a combination of locking plates with a compression screw.

ICMJE conflict of interest statement

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.

Funding

This study received no financial funding.

References

  • 1.

    Truslow W. Metatarsus primus VARUS or hallux valgus? Bone and Joint Surgery 1925 7. Available at: https://journals.lww.com/jbjsjournal/Fulltext/1925/07010/METATARSUS_PRIMUS_VARUS_OR_HALLUX_VALGUS_.8.aspx.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Kleinberg S. The Operative cure of hallux valgus and bunions. American Journal of Surgery 1932 15 7581. (https://doi.org/10.1016/S0002-9610(3291000-9)

  • 3.

    Lapidus PW. Operative correction of metatarsus primus Varus in hallux valgus. Surgery, Gynecology and Obstetrics 1934 58 183191.

  • 4.

    Lapidus PW. A quarter of a century of experience with the operative correction of the metatarsus varus primus in hallux valgus. Bulletin of the Hospital for Joint Diseases 1956 17 404421.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Butson AR. A modification of the Lapidus operation for hallux valgus. Journal of Bone and Joint Surgery. British Volume 1980 62 350352. (https://doi.org/10.1302/0301-620X.62B3.6997319)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Giannestras NJ. The congenital rigid flatfoot. Its recognition and treatment in infants. Orthopedic Clinics of North America 1973 4 4966. (https://doi.org/10.1016/S0030-5898(2030504-6)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Ray RG, Ching RP, Christensen JC, & Hansen ST. Biomechanical analysis of the first metatarsocuneiform arthrodesis. Journal of Foot and Ankle Surgery 1998 37 376385. (https://doi.org/10.1016/s1067-2516(9880045-8)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Drummond D, Motley T, Kosmopoulos V, & Ernst J. Stability of locking plate and compression screws for Lapidus arthrodesis: a biomechanical comparison of plate position. Journal of Foot and Ankle Surgery 2018 57 466470. (https://doi.org/10.1053/j.jfas.2017.10.025)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    McInnes MDF, Moher D, Thombs BD, McGrath TA, Bossuyt PM, and the PRISMA-DTA Group Clifford T, Cohen JF, Deeks JJ, Gatsonis C, et al.Preferred reporting items for a systematic review and meta-analysis of diagnostic test accuracy studies: the PRISMA-DTA statement. JAMA 2018 319 388–396. (https://doi.org/10.1001/jama.2017.19163)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Moher D, Liberati A, Tetzlaff J, Altman DG & PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. International Journal of Surgery 2010 8 336341. (https://doi.org/10.1016/j.ijsu.2010.02.007)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Sadeghi R, & Treglia G. Systematic reviews and meta-analyses of diagnostic studies: a practical guideline. Clinical and Translational Imaging 2017 5 8387. (https://doi.org/10.1007/s40336-016-0219-2)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Wilke J, Krause F, Niederer D, Engeroff T, Nürnberger F, Vogt L, & Banzer W. Appraising the methodological quality of cadaveric studies: validation of the QUACS scale. Journal of Anatomy 2015 226 440446. (https://doi.org/10.1111/joa.12292)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Ehredt DJ, Kawalec J, Ligas C, Seidel J, Benson B, Reiner MM, & Connors J. The Lapidus arthrodesis: examining the effect of the metatarsal base transfixion screw. Journal of Foot and Ankle Surgery 2021 60 333338. (https://doi.org/10.1053/j.jfas.2020.05.020)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Li S, & Myerson MS. Evolution of thinking of the Lapidus procedure and fixation. Foot and Ankle Clinics 2020 25 109126. (https://doi.org/10.1016/j.fcl.2019.11.001)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Cohen DA, Parks BG, & Schon LC. Screw fixation compared to H-locking plate fixation for first metatarsocuneiform arthrodesis: A biomechanical study. Foot and Ankle International 2005 26 984989. (https://doi.org/10.1177/107110070502601114)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Gruber F, Sinkov VS, Bae SY, Parks BG, & Schon LC. Crossed Screws versus dorsomedial Locking Plate with Compression Screw for First Metatarsocuneiform Arthrodesis: a Cadaver Study. Foot and Ankle International 2008 29 927930. (https://doi.org/10.3113/FAI.2008.0927)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Scranton PE, Coetzee JC, & Carreira D. Arthrodesis of the first metatarsocuneiform joint: a comparative study of fixation methods. Foot and Ankle International 2009 30 341345. (https://doi.org/10.3113/FAI.2009.0341)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Klos K, Gueorguiev B, Mückley T, Fröber R, Hofmann GO, Schwieger K, & Windolf M. Stability of medial locking plate and compression screw versus two crossed screws for Lapidus arthrodesis. Foot and Ankle International 2010 31 158163. (https://doi.org/10.3113/FAI.2010.0158)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Klos K, Simons P, Hajduk AS, Hoffmeier KL, Gras F, Fröber R, Hofmann GO, & Mückley T. Plantar versus dorsomedial Locked Plating for Lapidus Arthrodesis: a Biomechanical Comparison. Foot and Ankle International 2011 32 10811085. (https://doi.org/10.3113/FAI.2011.1081)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Cottom JM, & Rigby RB. Biomechanical comparison of a locking plate with intraplate compression screw versus locking plate with plantar interfragmentary screw for Lapidus arthrodesis: a cadaveric study. Journal of Foot and Ankle Surgery 2013 52 339342. (https://doi.org/10.1053/j.jfas.2013.02.012)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Roth KE, Peters J, Schmidtmann I, Maus U, Stephan D, & Augat P. Intraosseous fixation compared to plantar plate fixation for first metatarsocuneiform arthrodesis: a cadaveric biomechanical analysis. Foot and Ankle International 2014 35 12091216. (https://doi.org/10.1177/1071100714547082)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    Baxter JR, Mani SB, Chan JY, Vulcano E, & Ellis SJ. Crossed-screws provide greater tarsometatarsal fusion stability compared to compression plates. Foot and Ankle Specialist 2015 8 95100. (https://doi.org/10.1177/1938640014543358)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Aiyer A, Russell NA, Pelletier MH, Myerson M, & Walsh WR. 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. Foot and Ankle Specialist 2016 9 232240. (https://doi.org/10.1177/1938640015620655)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Russell NA, Regazzola G, Aiyer A, Nomura T, Pelletier MH, Myerson M, & Walsh WR. Evaluation of nitinol staples for the Lapidus arthrodesis in a reproducible biomechanical model. Frontiers in Surgery 2015 2 65. (https://doi.org/10.3389/fsurg.2015.00065)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Graham ME, Chikka A, & Goel VK. Inherent strength of the osteo-WEDGETM bone plate locking system for arthrodesis of the first metatarsocuneiform joint: a biomechanical study. Journal of Foot and Ankle Surgery 2016 55 444449. (https://doi.org/10.1053/j.jfas.2015.12.015)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Knutsen AR, Fleming JF, Ebramzadeh E, Ho NC, Warganich T, Harris TG, & Sangiorgio SN. Biomechanical comparison of fixation devices for first metatarsocuneiform joint arthrodesis. Foot and Ankle Specialist 2017 10 322328. (https://doi.org/10.1177/1938640016679698)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Cottom JM, & Baker JS. Comparison of locking plate with interfragmentary screw versus plantarly applied anatomic locking plate for Lapidus arthrodesis: a biomechanical cadaveric study. Foot and Ankle Specialist 2017 10 227231. (https://doi.org/10.1177/1938640016676341)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Burchard R, Massa R, Soost C, Richter W, Dietrich G, Ohrndorf A, Christ HJ, Fritzen CP, Graw JA, & Schmitt J. Biomechanics of common fixation devices for first tarsometatarsal joint fusion—a comparative study with synthetic bones. Journal of Orthopaedic Surgery and Research 2018 13 176. (https://doi.org/10.1186/s13018-018-0876-0)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Dayton P, Hatch DJ, Santrock RD, & Smith B. Biomechanical characteristics of biplane multiplanar tension-side fixation for Lapidus fusion. Journal of Foot and Ankle Surgery 2018 57 766770. (https://doi.org/10.1053/j.jfas.2018.02.012)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Hoon QJ, Pelletier MH, Christou C, Johnson KA, & Walsh WR. Biomechanical evaluation of shape-memory alloy staples for internal fixation—an in vitro study. Journal of Experimental Orthopaedics 2016 3 19. (https://doi.org/10.1186/s40634-016-0055-3)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Cristofolini L, & Viceconti M. Mechanical validation of whole bone composite tibia models. Journal of Biomechanics 2000 33 279288. (https://doi.org/10.1016/s0021-9290(9900186-4)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Heiner AD, & Brown TD. Structural properties of a new design of composite replicate femurs and tibias. Journal of Biomechanics 2001 34 773781. (https://doi.org/10.1016/s0021-9290(0100015-x)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Patel PS, Shepherd DE, & Hukins DW. Compressive properties of commercially available polyurethane foams as mechanical models for osteoporotic human cancellous bone. BMC Musculoskeletal Disorders 2008 9 137. (https://doi.org/10.1186/1471-2474-9-137)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Elfar J, Menorca RMG, Reed JD, & Stanbury S. Composite bone models in orthopaedic surgery research and education. Journal of the American Academy of Orthopaedic Surgeons 2014 22 111120. (https://doi.org/10.5435/JAAOS-22-02-111)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Gardner MP, Chong ACM, Pollock AG, & Wooley PH. Mechanical evaluation of large-size fourth-generation composite femur and tibia models. Annals of Biomedical Engineering 2010 38 613620. (https://doi.org/10.1007/s10439-009-9887-7)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36.

    Plaass C, Claassen L, Daniilidis K, Fumy M, Stukenborg-Colsman C, Schmiedl A, & Ettinger S. Placement of plantar plates for Lapidus arthrodesis: anatomical considerations. Foot and Ankle International 2016 37 427432. (https://doi.org/10.1177/1071100715619607)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37.

    Cottom JM, & Vora AM. Fixation of Lapidus arthrodesis with a plantar interfragmentary screw and medial locking plate: a report of 88 cases. Journal of Foot and Ankle Surgery 2013 52 465469. (https://doi.org/10.1053/j.jfas.2013.02.013)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38.

    Klos K, Wilde CH, Lange A, Wagner A, Gras F, Skulev HK, Mückley T, & Simons P. Modified Lapidus arthrodesis with plantar plate and compression screw for treatment of hallux valgus with hypermobility of the first ray: a preliminary report. Foot and Ankle Surgery 2013 19 239244. (https://doi.org/10.1016/j.fas.2013.06.003)

    • PubMed
    • Search Google Scholar
    • Export Citation

 

  • Collapse
  • Expand
  • Figure 1

    Classic crossed screw fixation consisting of a full-threaded compression screw and a partial threaded screw.

  • Figure 2

    Different surgical techniques for plate application. Plate design changes in different positions. Thirteen different plates were retrieved in this systematic review: (A) schematic illustration of a medial plate; (B) schematic illustration of a dorsal plate; (C) schematic illustration of a plantar plate.

  • Figure 3

    Intramedullary stabilization in a dorsoplantar position. Plantar–dorsal position has also been investigated.

  • Figure 4

    A schematic metatarsocuneiform joint fusion with two memory alloy staples. However, the use of one staple has also been investigated.

  • Figure 5

    Flow chart of the search for eligible studies on biomechanical studies of the modified Lapidus procedure.

  • 1.

    Truslow W. Metatarsus primus VARUS or hallux valgus? Bone and Joint Surgery 1925 7. Available at: https://journals.lww.com/jbjsjournal/Fulltext/1925/07010/METATARSUS_PRIMUS_VARUS_OR_HALLUX_VALGUS_.8.aspx.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Kleinberg S. The Operative cure of hallux valgus and bunions. American Journal of Surgery 1932 15 7581. (https://doi.org/10.1016/S0002-9610(3291000-9)

  • 3.

    Lapidus PW. Operative correction of metatarsus primus Varus in hallux valgus. Surgery, Gynecology and Obstetrics 1934 58 183191.

  • 4.

    Lapidus PW. A quarter of a century of experience with the operative correction of the metatarsus varus primus in hallux valgus. Bulletin of the Hospital for Joint Diseases 1956 17 404421.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Butson AR. A modification of the Lapidus operation for hallux valgus. Journal of Bone and Joint Surgery. British Volume 1980 62 350352. (https://doi.org/10.1302/0301-620X.62B3.6997319)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Giannestras NJ. The congenital rigid flatfoot. Its recognition and treatment in infants. Orthopedic Clinics of North America 1973 4 4966. (https://doi.org/10.1016/S0030-5898(2030504-6)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Ray RG, Ching RP, Christensen JC, & Hansen ST. Biomechanical analysis of the first metatarsocuneiform arthrodesis. Journal of Foot and Ankle Surgery 1998 37 376385. (https://doi.org/10.1016/s1067-2516(9880045-8)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Drummond D, Motley T, Kosmopoulos V, & Ernst J. Stability of locking plate and compression screws for Lapidus arthrodesis: a biomechanical comparison of plate position. Journal of Foot and Ankle Surgery 2018 57 466470. (https://doi.org/10.1053/j.jfas.2017.10.025)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    McInnes MDF, Moher D, Thombs BD, McGrath TA, Bossuyt PM, and the PRISMA-DTA Group Clifford T, Cohen JF, Deeks JJ, Gatsonis C, et al.Preferred reporting items for a systematic review and meta-analysis of diagnostic test accuracy studies: the PRISMA-DTA statement. JAMA 2018 319 388–396. (https://doi.org/10.1001/jama.2017.19163)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Moher D, Liberati A, Tetzlaff J, Altman DG & PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. International Journal of Surgery 2010 8 336341. (https://doi.org/10.1016/j.ijsu.2010.02.007)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Sadeghi R, & Treglia G. Systematic reviews and meta-analyses of diagnostic studies: a practical guideline. Clinical and Translational Imaging 2017 5 8387. (https://doi.org/10.1007/s40336-016-0219-2)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Wilke J, Krause F, Niederer D, Engeroff T, Nürnberger F, Vogt L, & Banzer W. Appraising the methodological quality of cadaveric studies: validation of the QUACS scale. Journal of Anatomy 2015 226 440446. (https://doi.org/10.1111/joa.12292)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Ehredt DJ, Kawalec J, Ligas C, Seidel J, Benson B, Reiner MM, & Connors J. The Lapidus arthrodesis: examining the effect of the metatarsal base transfixion screw. Journal of Foot and Ankle Surgery 2021 60 333338. (https://doi.org/10.1053/j.jfas.2020.05.020)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Li S, & Myerson MS. Evolution of thinking of the Lapidus procedure and fixation. Foot and Ankle Clinics 2020 25 109126. (https://doi.org/10.1016/j.fcl.2019.11.001)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Cohen DA, Parks BG, & Schon LC. Screw fixation compared to H-locking plate fixation for first metatarsocuneiform arthrodesis: A biomechanical study. Foot and Ankle International 2005 26 984989. (https://doi.org/10.1177/107110070502601114)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Gruber F, Sinkov VS, Bae SY, Parks BG, & Schon LC. Crossed Screws versus dorsomedial Locking Plate with Compression Screw for First Metatarsocuneiform Arthrodesis: a Cadaver Study. Foot and Ankle International 2008 29 927930. (https://doi.org/10.3113/FAI.2008.0927)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Scranton PE, Coetzee JC, & Carreira D. Arthrodesis of the first metatarsocuneiform joint: a comparative study of fixation methods. Foot and Ankle International 2009 30 341345. (https://doi.org/10.3113/FAI.2009.0341)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Klos K, Gueorguiev B, Mückley T, Fröber R, Hofmann GO, Schwieger K, & Windolf M. Stability of medial locking plate and compression screw versus two crossed screws for Lapidus arthrodesis. Foot and Ankle International 2010 31 158163. (https://doi.org/10.3113/FAI.2010.0158)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Klos K, Simons P, Hajduk AS, Hoffmeier KL, Gras F, Fröber R, Hofmann GO, & Mückley T. Plantar versus dorsomedial Locked Plating for Lapidus Arthrodesis: a Biomechanical Comparison. Foot and Ankle International 2011 32 10811085. (https://doi.org/10.3113/FAI.2011.1081)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Cottom JM, & Rigby RB. Biomechanical comparison of a locking plate with intraplate compression screw versus locking plate with plantar interfragmentary screw for Lapidus arthrodesis: a cadaveric study. Journal of Foot and Ankle Surgery 2013 52 339342. (https://doi.org/10.1053/j.jfas.2013.02.012)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Roth KE, Peters J, Schmidtmann I, Maus U, Stephan D, & Augat P. Intraosseous fixation compared to plantar plate fixation for first metatarsocuneiform arthrodesis: a cadaveric biomechanical analysis. Foot and Ankle International 2014 35 12091216. (https://doi.org/10.1177/1071100714547082)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    Baxter JR, Mani SB, Chan JY, Vulcano E, & Ellis SJ. Crossed-screws provide greater tarsometatarsal fusion stability compared to compression plates. Foot and Ankle Specialist 2015 8 95100. (https://doi.org/10.1177/1938640014543358)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Aiyer A, Russell NA, Pelletier MH, Myerson M, & Walsh WR. 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. Foot and Ankle Specialist 2016 9 232240. (https://doi.org/10.1177/1938640015620655)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Russell NA, Regazzola G, Aiyer A, Nomura T, Pelletier MH, Myerson M, & Walsh WR. Evaluation of nitinol staples for the Lapidus arthrodesis in a reproducible biomechanical model. Frontiers in Surgery 2015 2 65. (https://doi.org/10.3389/fsurg.2015.00065)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Graham ME, Chikka A, & Goel VK. Inherent strength of the osteo-WEDGETM bone plate locking system for arthrodesis of the first metatarsocuneiform joint: a biomechanical study. Journal of Foot and Ankle Surgery 2016 55 444449. (https://doi.org/10.1053/j.jfas.2015.12.015)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Knutsen AR, Fleming JF, Ebramzadeh E, Ho NC, Warganich T, Harris TG, & Sangiorgio SN. Biomechanical comparison of fixation devices for first metatarsocuneiform joint arthrodesis. Foot and Ankle Specialist 2017 10 322328. (https://doi.org/10.1177/1938640016679698)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Cottom JM, & Baker JS. Comparison of locking plate with interfragmentary screw versus plantarly applied anatomic locking plate for Lapidus arthrodesis: a biomechanical cadaveric study. Foot and Ankle Specialist 2017 10 227231. (https://doi.org/10.1177/1938640016676341)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Burchard R, Massa R, Soost C, Richter W, Dietrich G, Ohrndorf A, Christ HJ, Fritzen CP, Graw JA, & Schmitt J. Biomechanics of common fixation devices for first tarsometatarsal joint fusion—a comparative study with synthetic bones. Journal of Orthopaedic Surgery and Research 2018 13 176. (https://doi.org/10.1186/s13018-018-0876-0)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Dayton P, Hatch DJ, Santrock RD, & Smith B. Biomechanical characteristics of biplane multiplanar tension-side fixation for Lapidus fusion. Journal of Foot and Ankle Surgery 2018 57 766770. (https://doi.org/10.1053/j.jfas.2018.02.012)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Hoon QJ, Pelletier MH, Christou C, Johnson KA, & Walsh WR. Biomechanical evaluation of shape-memory alloy staples for internal fixation—an in vitro study. Journal of Experimental Orthopaedics 2016 3 19. (https://doi.org/10.1186/s40634-016-0055-3)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Cristofolini L, & Viceconti M. Mechanical validation of whole bone composite tibia models. Journal of Biomechanics 2000 33 279288. (https://doi.org/10.1016/s0021-9290(9900186-4)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Heiner AD, & Brown TD. Structural properties of a new design of composite replicate femurs and tibias. Journal of Biomechanics 2001 34 773781. (https://doi.org/10.1016/s0021-9290(0100015-x)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Patel PS, Shepherd DE, & Hukins DW. Compressive properties of commercially available polyurethane foams as mechanical models for osteoporotic human cancellous bone. BMC Musculoskeletal Disorders 2008 9 137. (https://doi.org/10.1186/1471-2474-9-137)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Elfar J, Menorca RMG, Reed JD, & Stanbury S. Composite bone models in orthopaedic surgery research and education. Journal of the American Academy of Orthopaedic Surgeons 2014 22 111120. (https://doi.org/10.5435/JAAOS-22-02-111)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Gardner MP, Chong ACM, Pollock AG, & Wooley PH. Mechanical evaluation of large-size fourth-generation composite femur and tibia models. Annals of Biomedical Engineering 2010 38 613620. (https://doi.org/10.1007/s10439-009-9887-7)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36.

    Plaass C, Claassen L, Daniilidis K, Fumy M, Stukenborg-Colsman C, Schmiedl A, & Ettinger S. Placement of plantar plates for Lapidus arthrodesis: anatomical considerations. Foot and Ankle International 2016 37 427432. (https://doi.org/10.1177/1071100715619607)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37.

    Cottom JM, & Vora AM. Fixation of Lapidus arthrodesis with a plantar interfragmentary screw and medial locking plate: a report of 88 cases. Journal of Foot and Ankle Surgery 2013 52 465469. (https://doi.org/10.1053/j.jfas.2013.02.013)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38.

    Klos K, Wilde CH, Lange A, Wagner A, Gras F, Skulev HK, Mückley T, & Simons P. Modified Lapidus arthrodesis with plantar plate and compression screw for treatment of hallux valgus with hypermobility of the first ray: a preliminary report. Foot and Ankle Surgery 2013 19 239244. (https://doi.org/10.1016/j.fas.2013.06.003)

    • PubMed
    • Search Google Scholar
    • Export Citation