A Guide To Hybrid Screw Fixation In Lesser Metatarsal Surgery

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Author(s): 
By Michael Salcedo, DPM, and Michael Motyer, DPM

     During the past five years, there has been a large influx of non-traditional bone screws on the orthopedic market for small bone fixation of the foot. Some of these designs have been effective at providing long-term surgical fracture stability with reduced osteotomy fixation morbidity. Additionally, these bone screw designs have found their way into a variety of applications in hindfoot surgery with headless screws, locking plate screws and cannulated self-tapping screws.

     When trying to assess the technology available in small fragment fixation, it behooves the foot and ankle surgeon to have an adequate understanding of the proper applications of these screws. Additionally, one must consider the biomechanical forces associated with metatarsal osteotomies that facilitate early postoperative weightbearing and joint mobilization. Unlike traditional AO screw application, hybrid screws typically have unique application protocols to ensure proper purchase and compression of unstable bone fragments.

     Improper application of hybrid screws can lead to a higher than normal fixation complication rate. A deviation from application protocols can lead to screws potentially backing out, distraction of osseous fragments and failure to provide appropriate interfragmentary compression. Additionally, hybrid screws can carry a significant increase in cost per unit. This factor alone may sway the foot and ankle surgeon away from using this technology, especially in this day and age of managed care and cost containment in hospitals and surgery centers.

What You Should Know About Forefoot Pain And Metatarsalgia

     Forefoot pain associated with metatarsophalangeal joint (MPJ) dysfunction is a common malady. There are a multitude of etiologies to these disorders with both local and systemic comorbidities that are beyond the scope of this article.1 However, MPJ dysfunction can lead to significant disability and morbidity with pain that is associated with an abnormal increase in plantar pressures and arthrosis.

     Once one has made an appropriate diagnosis, surgical goals are focused on relieving plantar metatarsophalangeal joint pressure and restoring normal joint function. Surgeons commonly perform distal metatarsal osteotomies (multiple or single), plantar joint planing procedures and metatarsal head resections along with some level of digital surgery and capsule tendon balancing to relieve forefoot pain.

Understanding The Benefits Of The Weil Osteotomy

     Lowell Scott Weil Sr., DPM, was the first to describe an intraarticular distally placed oblique osteotomy for the treatment of MPJ dysfunction.2 This procedure has enjoyed a high level of scrutiny on the lecture circuit and in peer-reviewed podiatric and orthopedic journals with very favorable results.3

     The Weil osteotomy allows the foot and ankle surgeon a great deal of latitude in obtaining the proper position of the metatarsal head fragment. Surgeons may correct the deformity by modifying the metatarsal fragment reduction through translocation and/or angulation.4 The metatarsal head usually decompresses proximally after the osteotomy, resulting in shortening.

     Additionally, one can transpose the capital fragment medial or lateral, or angulate it in the frontal plane to reduce varus and valgus deformity. The surgeon can elevate the capital fragment by removing additional bone by wedging or employing double thickness osteotomy saw blades. Surgeons often accompany this procedure with digital fusions to stabilize digital deformities as well as flexor tendon transfers.5

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