Dan Preece DPM PGY-2

 Authors: Blitz N, Lee T, Williams K, Barkan H, DiDimenico L.  Journal of Foot and Ankle Surgery, Jul/Aug 2010.

 Study Type: Retrospective, multicenter review of 80 patients. (80 feet in 76 pts)  Study Question: Effects of early weightbearing on fusion rates following arthrodesis of 1 st met-cuneiform joint.

 Intro: Early studies used fixation of cat gut or a single screw which showed high levels of nonunions. 6 weeks of NWB became standard of care. However non of these studies were based on today’s fixation techniques.  Limited data has shown that early weight bearing yields very low percentages of non unions with current screw fixation techniques.

◦ 76 patients, 80 feet from ◦ Surgeries performed by two surgeons (Blitz, DiDemenico). ◦ Only surgeries that involved only the first ray were included (muscle-tendon balancing, austin, akin…). ◦ Pre and Post-Op radiographic angles taken (IM, Hallux Valgus angle, lateral metatarsal angle) ◦ Outcomes measured were: trabeculation across osteotomy, pain at surgical site on clinical exam.

◦ Fixation:  Majority solid screws x 3, 11 pts only received 2 screws, 1 pt received 4.  Two screws in sagital plane perpendicular to osteotomy and lagged.  Third screw medial to lateral across 1-2 nd met bases or into intermediate phalanx and not lagged. ◦

◦ NWB in Jones dressing/splint or Cam walker x 2-3 weeks. ◦ After 1 st post-op visit all placed in CAM walker, progression to full WB as tolerated. ◦ All pts were fully WB by 6 week visit.

 Pre-Op HVA: 21  Post-Op HVA: 9  Pre-Op IMA: 13  Post-Op IMA: 6.6  Pre-Op LMA:  Post-Op LMA: 25.8  Days to partial WB: 15  Days to radiographic union: 44.5  Union Percentage: 100%  ** all P values were.001 or smaller

 Joint preparation approach made no difference. Curretage vs planar resection with sagittal saw. Presence or absence of subchondral plate.  2 vs 3 screw fixation had same outcomes.  Autogenous bone graft was used in all cases, either trephine or from exostectomy. No difference.  Obesity and smoking made no difference.

 Data gathering stopped at time of clinical/radiographic fusion. This does not rule out the possibility of a non-union during the course of healing/rehab.  Unclear when weightbearing truly began between the 2nd and 6th week marks. Was advanced as tolerated. Possible that WB only began at week 5 and 6.