• Please review the updated member agreement. Included is a new statement supporting the scientific method and evidence-based medicine. Claims or statements about disease processes should reference widely accepted scientific resources. Theoretical medical speculation is encouraged as part of the overall scientific process. However, unscientific statements that promote unfounded ideological positions or agendas may be removed.
  • Free admissions webinar for pre-vets! “Apply Smarter” Webinar

SLCpod

Staff member
Moderator
7+ Year Member
Nov 28, 2011
821
586
The West
Status
Resident [Any Field]
Journal club overview:
- An article will be selected and posted each month. Please PM me an article you are interested in and I will select one. Please keep them as recent as possible.
- We will discuss how we can use what we learned from the selected article in practice and perhaps share some clinical experiences (remember not to disclose specific patient information)

This is open to DPM's, students and pre-pods!! All are invited.

 
  • Like
Reactions: Weirdy

ldsrmdude

Back in the saddle again
Staff member
Administrator
10+ Year Member
Feb 20, 2007
1,982
961
Status
Podiatrist
Weightbearing status after surgical procedures is a popular topic of discussion and an area where a lot of changes have happened in clinical practice. While I certainly understand the need for biomechanical studies on synthetic and cadaveric bone, I seem to always come away somewhat let down. This article is no different. As a brief overview of the paper, the authors set up an experiment to test failure loads with 4 different constructs for 1st MTPJ fusion: unlocked plate, locked plate, 2 crossing screws, lag screw plus unlocked plate. They tested all 4 on synthetic bone and tested the 2 with the highest stiffness (crossed screws, lag screw plus plate) on cadaveric bone. Not surprisingly, the 2 stiffest were crossing screws and lag screw and plate. The paper doesn't mention, I don't think, whether the plates provided compression or not. The conclusion of the paper is that "no construct could withstand weight-bearing as tolerated."

The questions I would have that I hope we can get some discussion on are:
- For those that let their patients bear weight early, what construct is being used?
- Which construct didn't they test that is common?
- Does their conclusion mean that we shouldn't let patients bear weight after a 1st MTPJ?
- Are the models that they used clinically applicable to practice?

I hope that some current students will chime in their thoughts as well as the residents and attendings here
 

AttackNME

Podiatrist
10+ Year Member
Feb 22, 2007
452
311
I guess the one construct they didn't test is locked plates and a screw, I image it would be more stiff than unlocked plate and screw. We don't know if experiments on stiffness correlates with successful fusions, this has yet to be studied. I did find it interesting how the cadaveric specimens found cross screws to be stiffer than the plate plus screw (though not statistically significant, p=0.08) it was contrary to the results of the synthetic specimens which found the stiffest construct to be plate plus screw. I would probably never tell a patient it's okay to walk on any arthrodesis procedure since I'm a new attending and want to minimize my complications, but I think what the article is saying is that they believe the stiffest construct is the plate plus screw, and blamed the different findings of the cadaveric specimens on the fact that the cadavers can have a lot of factors that alter their intrinsic bone strength, and that they could only get 5 cadavers (10 feet). I think they ultimately conclude that it may be advisable to use the stiffest construct which is plate plus screw for those whom you suspect noncompliance. I would probably continue to use cross screws anyway because its cheaper and what I'm trained to use, I'll definitely still have them NWB. But I'll definitely use plate plus screw for any revisions.
 
  • Like
Reactions: ldsrmdude
About the Ads

ldsrmdude

Back in the saddle again
Staff member
Administrator
10+ Year Member
Feb 20, 2007
1,982
961
Status
Podiatrist
I guess the one construct they didn't test is locked plates and a screw, I image it would be more stiff than unlocked plate and screw. We don't know if experiments on stiffness correlates with successful fusions, this has yet to be studied. I did find it interesting how the cadaveric specimens found cross screws to be stiffer than the plate plus screw (though not statistically significant, p=0.08) it was contrary to the results of the synthetic specimens which found the stiffest construct to be plate plus screw. I would probably never tell a patient it's okay to walk on any arthrodesis procedure since I'm a new attending and want to minimize my complications, but I think what the article is saying is that they believe the stiffest construct is the plate plus screw, and blamed the different findings of the cadaveric specimens on the fact that the cadavers can have a lot of factors that alter their intrinsic bone strength, and that they could only get 5 cadavers (10 feet). I think they ultimately conclude that it may be advisable to use the stiffest construct which is plate plus screw for those whom you suspect noncompliance. I would probably continue to use cross screws anyway because its cheaper and what I'm trained to use, I'll definitely still have them NWB. But I'll definitely use plate plus screw for any revisions.
Yes, like you mentioned, the construct that they didn't test but I think they should have is a locked plate and screw. It's actually the construct that I have the most experience with. I think that a general philosophy for weightbearing could be that we should be trying to get patients weightbearing as soon as possible, so a construct that allows earlier weightbearing should be used. I'd be interested in hearing thoughts on this philosophy.
 

AttackNME

Podiatrist
10+ Year Member
Feb 22, 2007
452
311
I'd imagine that a lot of people who do early weight bearing would have it done protected in a WB cast or fx boot. I don't think we know how much torque goes through the big toe while in a protected boot but I don't think that is a number that is easily obtainable. We'd have to be able to calculate how much torque a construct could tolerate given the patient's bone stiffness and activity level, as we know that variations in people's bone densities and activity demands exist. While I agree that early weight bearing does lead to better faster recovery, defensive medicine would discourage trying something against what you are trained to do or what the standard of care is in the community you practice.
 

dr.phoot

2+ Year Member
Mar 5, 2016
558
383
Status
Pre-Podiatry
So as doctors, when you read these things what do you do? You go into the office next day and start incorporating it into your practice? (Stupid q, but I don't understand 98% of that stuff at the moment). I'm just curious what you do with what you read.

For the hospital podiatrist, do you discuss these articles with colleagues?
 

ldsrmdude

Back in the saddle again
Staff member
Administrator
10+ Year Member
Feb 20, 2007
1,982
961
Status
Podiatrist
I'd imagine that a lot of people who do early weight bearing would have it done protected in a WB cast or fx boot. I don't think we know how much torque goes through the big toe while in a protected boot but I don't think that is a number that is easily obtainable. We'd have to be able to calculate how much torque a construct could tolerate given the patient's bone stiffness and activity level, as we know that variations in people's bone densities and activity demands exist. While I agree that early weight bearing does lead to better faster recovery, defensive medicine would discourage trying something against what you are trained to do or what the standard of care is in the community you practice.
Good points. And I agree that it would be nice to know the force going through a 1st MTPJ in a fracture boot because that's what I typically use for post-op 1st MTPJ fusions.
 

ldsrmdude

Back in the saddle again
Staff member
Administrator
10+ Year Member
Feb 20, 2007
1,982
961
Status
Podiatrist
So as doctors, when you read these things what do you do? You go into the office next day and start incorporating it into your practice? (Stupid q, but I don't understand 98% of that stuff at the moment). I'm just curious what you do with what you read.

For the hospital podiatrist, do you discuss these articles with colleagues?
After reading an article like this, you have to decide if it's going to change how you practice. It's a good question to ask after reading any article, "How is this going to change how I treat patients?" As far as discussing it with other doctors, that sort of stuff happens more often in an academic setting than a community setting. During school and residency and if you're an attending that is involved with a residency program, you'll be having journal club and discussions on a scheduled, consistent basis. It's easier to be isolated in practice when it comes to these things
 
  • Like
Reactions: dr.phoot

AttackNME

Podiatrist
10+ Year Member
Feb 22, 2007
452
311
You'll understand journals more after reading more of it and talking to people about it. Like ldsrmdude said, typically these discussions are done in academic settings like a university or any place that has a residency program. Sometimes private practice groups have created their own residency programs so they'd read and talk about this stuff too. Usually when I read things like this, I'll either put it in my mental back pocket or file it into my mental treatment algorithm. It may slightly alter what I do based or even drastically change it depending on how good the article is and if it makes sense to me.
 

NatCh

10+ Year Member
May 20, 2007
1,274
345
Oregon
Status
Podiatrist
The questions I would have that I hope we can get some discussion on are:
- For those that let their patients bear weight early, what construct is being used?
- Which construct didn't they test that is common?
- Does their conclusion mean that we shouldn't let patients bear weight after a 1st MTPJ?
- Are the models that they used clinically applicable to practice?

I hope that some current students will chime in their thoughts as well as the residents and attendings here
Yes, like you mentioned, the construct that they didn't test but I think they should have is a locked plate and screw. It's actually the construct that I have the most experience with. I think that a general philosophy for weightbearing could be that we should be trying to get patients weightbearing as soon as possible, so a construct that allows earlier weightbearing should be used. I'd be interested in hearing thoughts on this philosophy.

Being NWB for six or more weeks is really difficult on patients, not only physically but also just in terms of activities of daily living (try getting around town on a knee scooter or crutches when there's a foot of snow and ice covering everything for days to weeks on end). It's unfortunate that they didn't test a locking plate with single lag screw, which is my fixation of choice. I use the Synthes VA locking plate -- it's burly and user-friendly. For Medicare patients in the surgery center where I'm not allowed to use expensive hardware I'll use a single lag screw and 0.062 K-wire. I typically allow immediate protected weighbearing in an orthowedge shoe, with possible transition to a flat p/o shoe at week 4, then normal shoes after week 6. No non-unions yet, knock-knock.
 
Mar 12, 2014
128
95
Status
Podiatrist
Maybe it's just the patient population I treat, but no one is ever really NWB for 6 weeks. Locking plates in almost all instances bc I know my patients are essentially going to walk at 2 weeks.
 

NatCh

10+ Year Member
May 20, 2007
1,274
345
Oregon
Status
Podiatrist
Did you guys catch the consensus statement in the most recent issue of JFAS?

http://www.jfas.org/article/S1067-2516(16)30375-1/abstract

"Consensus statement: The panel reached consensus that the statement “Foot and ankle surgical procedures involving arthrodesis of the first ray should use a period of non-weightbearing immobilization” was neither appropriate nor inappropriate.

Arthrodesis procedures involving the first ray (first metatarsal–phalangeal joint and first metatarsal–medial cuneiform joint) have traditionally involved a period of postoperative non-weightbearing cast immobilization until some radiographic evidence of osseous consolidation has been observed at the fusion site (318, 319, 320, 321, 322). In addition to limiting the indication of these procedures to patients able to withstand this protocol, prolonged immobilization inherently has concerns for muscular atrophy and the development of venous thromboembolism. After a review of the contemporary data, our panel reached consensus that it is likely that early weightbearing can be allowed safely for some patients after these procedures.

With respect to first metatarsal–phalangeal joint arthrodesis, we identified a series of investigations that specifically evaluated some form of immediate or early weightbearing (323, 324, 325, 326, 327, 328, 329, 330, 331). Lampe et al (323) performed a prospective and randomized study of 61 participants undergoing first metatarsal–phalangeal joint arthrodesis with full weightbearing in a cast at 2 to 4 days versus non-weightbearing in a cast for 4 weeks. No differences in primary healing rates were observed. Storts and Camasta (324) completed a retrospective cohort study comparing buried Kirschner wire fixation and crossed screws, with both groups bearing immediate weight in a surgical shoe postoperatively. Although no comparative statistical analysis was performed, both groups demonstrated union rates >95%. We additionally identified 7 other retrospective case series of early weightbearing, with union rates ranging from 87.5% to 100.0% (325, 326, 327, 328, 329, 330, 331). We did not identify any study that concluded a negative effect of early weightbearing on outcomes after first metatarsal–phalangeal joint arthrodesis."
 
  • Like
Reactions: SLCpod

dtrack22

10+ Year Member
Apr 20, 2008
2,200
1,419
Status
Podiatrist
I wouldn't use muscle atrophy and DVT as any sort of argument against immobilization in foot surgery...anyways...

I also operate on turds who, more often than not, walk off the table in their posterior splint. I like telling them to be NWB for at least 2 weeks because I don't like how much feet swell when they are hanging down while a person ambulates in a rather apropulsive manner. It looks like a dog that just stuck his snout in a fire ant hill. So I guess in my mind its more of a soft tissue, incision, pain control issue than an osseous/fixation one. Maybe in the future people will go to the guy down the street because he doesn't ask them to stay off of the foot for two weeks. I'll probably change my mind then, gotta keep up with the Joneses...and the NatChes
 
About the Ads