Abstract
Background
First metatarsophalangeal joint (MTP) arthrodesis is a common operative management for end-stage hallux rigidus. The purpose of this study is to present an evidence-based literature review and evaluation of the literature regarding the efficacy of different fixation methods and postoperative weight-bearing status for first MTP Arthrodesis.
Methods
A comprehensive literature review was conducted across three databases: Medline, Embase, and Cochrane, in September 2024. Exclusion criteria included biomechanical, cadaveric, and non-human studies, review articles, letters, and technical tips. The included articles were analysed and categorised according to their level of evidence (level I-V). A grade of recommendation (A, B, C, or I) in favour of or against each modern fixation method and weight-bearing status for first MTP arthrodesis for hallux rigid was determined by collective review of the categorised articles.
Results
86 of the 1390 identified articles were included. There is fair evidence (grade B) for fixation with screws, plates, and plate with a compression screw, as well as both immediate postoperative weight-bearing and non-weight-bearing, according to the current literature. Insufficient evidence (grade I) for staple and novel fixation methods exists.
Conclusions
The results of this comprehensive review provide the most up-to-date recommendations for fixation and postoperative protocol for surgical management of first MTP arthritis. The best available published peer-reviewed literature demonstrates that both immediate weight-bearing or non-weight bearing are viable postoperative protocols for first MTP arthrodesis, giving similar clinical outcomes. Additionally, the literature supports the use of screws, plates and plates with a compression screw as fixation methods. It is evident that additional high-quality level I and II studies are required to compare and validate these fixation methods and weight-bearing statuses to allow for stronger recommendations.
Level of evidence
Level III, Systematic review.
1
Introduction
Hallux rigidus is the most prevalent foot arthritis, affecting roughly 2.5 % of the population over 50 years old , . Those with hallux rigidus suffer significant impact to their quality of life. Hallux rigidus can be managed initially with non-operative measures, including modified footwear, analgesics, non-steroidal anti-inflammatory medications, intra-articular steroid injections, and activity modification . Operative intervention is indicated when conservative treatment fails to manage symptoms, this can be in the form of joint sacrificing (arthrodesis or arthroplasty) or joint sparing operations (cheilectomy or Osteotomy). First metatarsophalangeal joint (MTP) Arthrodesis has the most robust evidence base supporting its efficacy and as such, has been established as the gold standard for advanced Hallux Rigidus treatment , . Several fixation methods have been utilised for this, including screw fixation, dorsal plate fixation with or without the addition of an interfragmentary compression screw across the arthrodesis site, and bone staples. Additionally, several novel fixation systems have been developed recently. Historic fixation techniques including Kirschner wires, Cerclage wires, sutures, Steinmann pins, and external fixation, are not commonly utilised today as there is evidence that they are insufficient for long-term fixation .
In addition to the fixation method, the postoperative weight-bearing regime is important in first MTP arthrodesis. Traditionally, prolonged immobilisation and non-weight-bearing were prescribed to protect the fusion site, promote healing, and decrease non-union and complication risk . However, previous studies have suggested that non-weight-bearing theoretically may increase the risk of adverse effects and complications such as muscle atrophy, stiffness, thrombotic events, and prolonged recovery times . Early weight-bearing has become more popular, especially in patients with rigid internal fixation that can tolerate early mechanical stress. However, no consensus exists on the ideal weight-bearing approach , .
This study aimed to review and assess the quality of literature supporting the efficacy of fixation methods and postoperative weight-bearing status for metatarsophalangeal joint arthrodesis for hallux rigidus.
2
Methods
A comprehensive literature search was developed with university research librarians and was conducted across the Medline, EMBASE, and Cochrane databases on the 17th of September 2024. PubMed was excluded due to its substantial overlap with Medline. Search terms were developed for Medline and modified for other databases are shown in full in Appendix A. Additional studies were identified through reference extraction. Published clinical studies in English were included. Biomechanical, cadaveric, and non-human studies, review articles, letters, technical tips, and studies without English translations were excluded. Participants in the reviewed studies were adults over 18 years old. Studies with unclear fixation methods or which utilised multiple methods but did not separate results were excluded. The focus of this study was modern fixation methods still widely in use, including but not limited to screws, plates, and staples. Studies which utilised outdated fixation methods, including K-wires, Cerclage wire, sutures, Steinmann pins, and external fixation, were excluded from the review. The search results were consolidated, and duplicate studies were removed. Title and abstract screening was undertaken, and articles that did not meet the exclusion criteria were then selected for full-text review.
The included studies were grouped and analysed according to fixation method and weight-bearing status. The methodology of this study was based on that of Glazebrook et al. . Included articles were assigned a level of evidence ranging from I to V, in accordance with the Journal of Bone and Joint Surgery “Levels of Evidence for Primary Research Questions” as described by Wright et al . ( Table 1 ). Finally, a grade of recommendation (A-C, or I) in favour or against fixation methods and weight-bearing status, was assigned to each group in accordance with the “Grading and Assignment Category of Recommendations for Summaries or Reviews of Orthopaedic Studies” as described by Wright et al. ( Table 2 ). In this review, studies were classified as immediate postoperative weight bearing if patients in the included studies were mobilised to bear weight on the operated leg, in any form of footwear, within the first three days postoperatively. Studies where patients did not bear weight within this period were classified as non-weight bearing. Studies with unclear protocols or variable weight bearing strategies within the same patient group were deemed inconsistent or mixed weight bearing and were not assigned to either category.
Table 1
Levels of Evidence for Therapeutic Studies.
Adapted from Wright et al .
| Level | Therapeutic Studies Investigating Results of Treatment |
|---|---|
| Level I | High-quality randomized control trials with a statistically significant difference or no statistically significant difference but narrow confidence intervals. Systematic reviews of Level I RCTs (with homogeneous study results). |
| Level II | Lesser-quality RCTs (e.g., inappropriate randomisation, lack of blinding or <80 % follow-up). Level I studies with inconsistent results. Prospective comparative studies. Systematic reviews of Level II studies. |
| Level III | Case-control studies. Retrospective comparative studies. Systematic reviews of Level III studies. |
| Level IV | Case series: Prospective or Retrospective |
| Level V | Expert opinion |
Table 2
Grading and Assigning a Category of Recommendation for Summaries or Reviews of Orthopaedic Studies.
Adapted from Wright et al .
| Grade | Evidence |
|---|---|
| A | Good evidence (Level I studies with consistent findings) for or against recommending intervention. |
| B | Fair evidence (Level II or III studies with consistent findings) for or against recommending intervention. |
| C | Poor-quality evidence (Level IV or V studies with consistent findings) for or against recommending intervention. |
| I | Insufficient or conflicting evidence not allowing a recommendation for or against intervention. |
3
Results
3.1
Search results
The comprehensive literature search across three electronic databases generated 1390 results and 16 additional articles were identified from other sources. Removing duplicated studies resulted in 972 articles, screened by title and abstract based on the eligibility criteria. This resulted in 171 remaining articles being included for full-text review, which resulted in 86 articles that met the inclusion criteria ( Fig. 1 ).
PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) flow Diagram of the search process for published literature included in this study.
3.2
Summary of quality and quantity of the literature
The grade of recommendation for or against each fixation method and weight-bearing status are summarised in Tables 3 and 4 . For fixation methods, there is fair evidence within the literature (grade B, level-II or III studies with consistent findings) to support the use of screws, plates alone, and plates with an interfragmentary compression screw. There is insufficient evidence (Grade I) supporting the use of staples. Insufficient evidence (Grade I) to support fixation using novel fixation methods. There is a fair evidence base (grade B, level-II or III studies with consistent findings) for postoperative weight-bearing and non-weight-bearing following first MTP arthrodesis. Only articles with the highest levels of evidence in each classification or those representing trends or deviations from trends within the literature were discussed as individual articles. The fixation methods and postoperative weight bearing protocols of the included studies are summarised in Table 5 .
Table 3
Summary of Grade of Recommendation For or Against Fixation Methods for First MTP Arthrodesis in Hallux Rigidus.
| Studies For/Against Fixation Method | ||||||||
|---|---|---|---|---|---|---|---|---|
| Fixation Method | No. Studies | Level I | Level II | Level III | Level IV | Level V | Grade | Recommendation |
| Screws | 30 | – | 1/0 | 8/4 | 14/0 | 3/0 | B | For Intervention |
| Plate | 15 | – | 1/0 | 8/1 | 3/0 | 2/0 | B | For Intervention |
| Plate with cross screw | 39 | – | 2/0 | 13/0 | 20/1 | 3/0 | B | For Intervention |
| Staple | 7 | – | – | 0/1 | 4/0 | 2/0 | I | Insufficient Evidence |
| Staple compression plate hybrid | 1 | – | – | – | 1/0 | – | I | Insufficient Evidence |
| Flexible titanium Intramedullary Nail | 4 | – | – | – | 3/0 | 1/0 | I | Insufficient Evidence |
| IOFix implant: intraosseous post and lag screw construct | 4 | – | – | – | 4/0 | – | I | Insufficient Evidence |
| Allogenic Cortical Bone Screw | 1 | – | – | – | 1/0 | – | I | Insufficient Evidence |
Table 4
Summary of Grade of Recommendation For or Against Postoperative Weight-bearing for First MTP Arthrodesis in Hallux Rigidus.
| Studies For/Against Weight-bearing Status | ||||||||
|---|---|---|---|---|---|---|---|---|
| Weight-bearing Status | No. Studies | Level I | Level II | Level III | Level IV | Level V | Grade | Recommendation |
| Weight-bearing | 51 | – | 3/0 | 10/0 | 37/1 | 1/0 | B | For Intervention |
| Non-Weight-bearing | 17 | – | – | 6/0 | 11/0 | – | B | For Intervention |
Table 5
Included studies fixation and weight bearing details.
| Author and Year | Level of Evidence (Type of Study) | Arthrodesis Fixation Method | Fixation details | Weight Bearing Method |
|---|---|---|---|---|
| Hyer et al . 2008 | Prospective Comparative Study (Level II) | Crossed Screw Fixation versus Plate Fixation |
Crossed partially threaded cannulated screws or Herbert-type “headless” cannulated screws
5-hole low-profile titanium plate (No manufacturer details stated). |
Immediate Heel weight bearing in a postoperative shoe |
| Dalat et al. 2015 | Prospective Cohort Study (Level II) | Plate Fixation | Fyxis Anatomic plate in Ti.6Al.4 V alloy (Fyxis Biotech, Salon de Provence, France) | Immediate full weight bearing in a postoperative boot |
| Lunati et al. 2020 | Prospective Cohort Study (Level II) | Plate with Interfragmentary Compression Screw Fixation | Stryker Anchorage MTP fusion. With a partially cannulated interfragmentary compression screw (Stryker, Mahwah, NJ, USA) | Immediate heel weight bearing in a postoperative shoe |
| Akdemir et al. 2023 | Retrospective Comparative Study (Level III) | Crossed Screw Fixation versus Plate with Interfragmentary Compression Screw Fixation |
Crossed cannulated screws
Distal locking hallux plate (No manufacturer details stated). |
Non-Weight bearing in short splint for 7–10 days and then progressive weight bearing in postoperative boot. |
| Bass et al. 2015 | Retrospective Comparative Study (Level III) | Plate with Interfragmentary Compression Screw Fixation | Three plating systems were assessed: the Integra Hallu-fix™ (Integra Extremity Reconstruction, Plainsboro, NJ, USA), Wright Medical Charlotte™ (Wright Medical, Arlington, TN, USA) and Stryker Memometal Anchorage™ (Stryker, Mahwah, NJ, USA) | Immediate heel weight bearing in rigid soled shoe |
| Beertema et al. 2006 | Retrospective Comparative Study (Level III) | Crossed Screws | Type of screw and manufacturer details not stated | Non-weight bearing in a cast for 6 weeks |
| Choudhary et al. 2004 | Retrospective Comparative Study (Level III) | Staple Fixation | Memory compression staples (No manufacturer details stated) | Immediate full weight bearing in rigid soled shoe |
| Cichero et al. 2021 | Retrospective Comparative Study (Level III) | Plate with Interfragmentary Compression Screw Fixation | Locking plate with either an integrated compression interfragmentary screw engaged into the plate (Stryker Anchorage 1 MTP Cross Plate, Mahwah, NJ, USA) or a compression interfragmentary screw separate to the locking plate construct (Stryker Anchorage 1 MTP plate, Mahwah, NJ, USA) | Immediate full weight bearing in rigid soled shoe |
| Claassen et al. 2017 | Retrospective Comparative Study (Level III) | Crossed Screw Fixation versus Plate Fixation versus Plate with Interfragmentary Compression Screw Fixation | Type of screw and manufacturer details not stated | Immediate full weight bearing in rigid soled shoe (Verbandschuh, Darco International Inc., Huntington, WV, USA) |
| Cone et al. 2018 | Retrospective Comparative Study (Level III) | Plate Fixation versus Plate with Interfragmentary Compression Screw Fixation | Titanium dorsal locking plate with or without compression screw (No manufacturer details stated) | Immediate heel weight bearing in rigid soled shoe |
| Dening et al. 2012 | Retrospective Comparative Study (Level III) | Single Screw Fixation versus Crossed screws Fixation versus Plate Fixation versus Plate with Interfragmentary Compression Screw Fixation |
Single 2.7-mm cannulated, self-tapping lag screw fixation (Bold Screw®, Integra Life Sciences, Plainsburo, NJ, USA)
Crossed 2.7-mm, cannulated, self-tapping lag screw fixation (Bold Screw®, Integra Life Sciences, Plainsburo, NJ, USA) Precontoured titanium alloy, low-profile, nonlocking plate (Hallufix® S-Plate System, Integra Life Sciences) Precontoured, titanium alloy, low-profile, nonlocking plate (Hallufix® S-Plate System, Integra Life Sciences) combined with plantar, 2.7-mm, cannulated, self-tapping lag screw fixation |
Immediate full weight bearing in a forefoot relieving postoperative shoe |
| Filomeno et al. 2018 | Retrospective Comparative Study (Level III) | Crossed screws Fixation versus Plate with Interfragmentary Compression Screw Fixation |
Crossed compression steel screws (3.5-mm small fragment screw, DePuy Synthes, Inc, Raynham, MA, USA)
Dorsal T shaped 2 × 3-hole nonlocking steel plate (2.7-mm small fragment plate, DePuy Synthes, Inc, Raynham, MA, USA) with single solid oblique compression steel screw (2.7-mm small fragment screw; DePuy Synthes, Inc, Raynham, MA, USA) |
Non-Weight bearing for 3 weeks. |
| Fussenich et al. 2023 | Retrospective Case-control Study (Level III) | Single Screw Fixation versus Crossed screws Fixation versus Plate Fixation versus Plate with Interfragmentary Compression Screw Fixation | Type of screw and manufacturer details not stated | Inconsistent or mixed weight bearing strategy |
| Hunt et al. 2011 | Retrospective Comparative Study (Level III) | Locking versus Non-locking Plate Fixation | Locking or nonlocking dorsal plate (Wright Medical, Arlington, TN, USA) | Inconsistent or mixed weight bearing strategy |
| Hyer et al. 2012 | Retrospective Comparative Study (Level III) | Locking Plate Fixation versus Non-locking Plate Fixation versus Locking Plate Fixation with Interfragmentary Compression Screw versus Non-locking Plate Fixation with Interfragmentary Compression Screw | Titanium 4-hole first MTP plate, 3.5- or 4.0-mm interfragmentary compression screw | Non-Weight bearing in splint for 7 days and then progressive weight bearing in postoperative high-tide boot. |
| Koh et al. 2023 | Retrospective Comparative Study (Level III) | Plate with Interfragmentary Compression Screw Fixation | No manufacturer details stated | No postoperative weight bearing strategy stated |
| Mayer et al. 2014 | Retrospective Comparative Study (Level III) | Locking Plate with Interfragmentary Compression Screw Fixation versus Non-locking Plate with Interfragmentary Compression Screw Fixation |
Noncontoured, stainless steel 1/3 tubular non-locking plate
Precontoured, stainless steel locking plate |
Non-weight bearing for 3–6 weeks and then progressive protective weight bearing |
| Patil et al. 2005 | Retrospective Comparative Study (Level III) | Crossed Screw Fixation versus Single Screw Fixation versus Staple Fixation versus K-wire Fixation | No manufacturer details stated | Inconsistent or mixed weight bearing strategy |
| Pinter et al. 2017 | Retrospective Comparative Study (Level III) | Plate Fixation versus Plate with Interfragmentary Compression Screw Fixation |
Titanium dorsal locking plate
Titanium dorsal locking plate with a interfragmentary lag screw |
Immediate heel weight bearing in postoperative shoe as tolerated |
| Raikin et al. 2007 | Retrospective Comparative Study (Level III) | Crossed Screw Fixation | Crossed 4.0 mm cannulated screws | No postoperative weight bearing strategy stated |
| Richter et al. 2023 | Retrospective Comparative Study (Level III) | Crossed Screw Fixation | Crossed fully threaded, cortical thread, non-cannulated, titanium alloy, small fragment screws | Inconsistent or mixed weight bearing strategy |
| Sharma et al. 2008 | Retrospective Comparative Study (Level III) | Single Screw Fixation versus Plate with Interfragmentary Compression Screw Fixation |
Single oblique interfragmentary compression screw
Low-profile, one-quarter tubular neutralization plate with single oblique interfragmentary compression screw |
Immediate heel weight bearing in postoperative shoe |
| Simons et al. 2015 | Retrospective Comparative Study (Level III) | Plate Fixation | Hallufix plate (Newdeal, Integra, Plainsboro, NJ, USA) | Non-weight bearing in a cast for 2 weeks, then 4 weeks of protected weight bearing |
| Storts et al. 2016 | Retrospective Comparative Study (Level III) | Crossed Screw Fixation versus K-wire Fixation |
Crossed 2.7 mm cortical screws
1.4 mm K-wires |
Immediate heel weight bearing in postoperative shoe, with instructions to avoid propelling off the hallux |
| West et al. 2022 | Retrospective Comparative Study (Level III) | Crossed Screw Fixation versus Plate Fixation | Type of screw and manufacturer details not stated | No postoperative weight bearing strategy stated |
| Abben et al. 2018 | Retrospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | Dorsally locking plate with 3.0-mm cannulated interfragmentary screw (No manufacturer details stated) | Immediate full weight bearing in rigid soled shoe |
| Agoropoulos et al. 2001 | Retrospective Case Series (Level IV) | Single Screw Fixation | Single oblique cortical 3.5-mm screw | Non-weight bearing in aluminium splint for 15 days, then full weight bearing as tolerated |
| Asif et al. 2018 | Retrospective Case Series (Level IV) | Crossed Screw Fixation | Crossed partially threaded, 3.5 mm cannulated screws (Ortho Solutions Ltd., Maldon, UK; DePuy Synthes) | Immediate full weight bearing in postoperative shoe with off-loading (OrthoWedge; DARCO International, Huntington, WV, USA) |
| Aslam et al. 2005 | Retrospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | A Luhr vitallium mandibular plate (Howmedica/Stryker, NJ, USA) with oblique interfragmentary lag screw | Non-weight bearing in postoperative shoe for 2 weeks, then heel weight bearing for 4 weeks |
| Aziz et al. 2022 | Prospective Case Series (Level IV) | Crossed Screw Fixation | Crossed partially threaded, 3.5-mm crossed cannulated screws | Immediate full weight bearing in postoperative shoe with off-loading (OrthoWedge; DARCO International, Huntington, WV, USA) |
| Bauer et al. 2010 | Prospective Case Series (Level IV) | Crossed Screw Fixation | Crossed diameter compression cannulated screws (3.0 mm | Immediate full weight bearing in rigid flat bottomed postoperative shoe |
| Bennet et al. 2005 | Prospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | Six-hole plate from the Synthes Modular Hand Set with interfragmentary lag screw (DePuy Synthes, Warsaw, IN, USA) | Non-weight bearing for 1 week, then heel weight bearing in an Air Cast SP Walker Boot (Aircast, Summit, NJ, USA) for 6 weeks |
| Bennet et al. 2009 | Prospective Case Series (Level IV) | Plate Fixation | Five-hole Accutrak™ congruent first MTPJ plate (Acumed, Hillsboro, OR, USA) | Non-weight bearing for 1 week, then heel weight bearing in an Air Cast SP Walker Boot (Aircast, Summit, NJ, USA) for 6 weeks |
| Besse et al. 2010 | Retrospective Case Series (Level IV) | Staple Fixation | 1.5 mm pure titanium staples (No manufacturer details stated) | Immediate full weight bearing in special (clog type) foot cast for 6 weeks |
| Brodsky et al. 2005 | Retrospective Case Series (Level IV) | Parallel Screw Fixation | Parallel 3.5-mm cortical screws | Non weight bearing for 4 weeks, then progressive weight bearing for 4 weeks in a postoperative shoe |
| Brodsky et al. 2007 | Prospective Case Series (Level IV) | Parallel Screw Fixation | Parallel 3.5-mm cortical screws | Non-weight bearing for 4 weeks, then full weight bearing in rigid postoperative shoe for 4 weeks |
| Bullock et al. 2024 | Retrospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | Either a locking plate with a separate partially threaded cannulated lag screw or a locking plate with a partially threaded lag screw through the plate. (No manufacturer details stated) | Immediate protective weight bearing with a non-propulsive gait in a postoperative shoe for 8–9 weeks |
| Carlucci et al. 2020 | Retrospective Case Series (Level IV) | Crossed Screw Fixation | Crossed 5.5 or 6.5 mm cannulated screws, were possible fully threaded with stepped pitch | Immediate full weight bearing in rigid soled postoperative shoe |
| Challagundla et al. 2021 | Retrospective Case Series (Level IV) | Staple Fixation | Memory Staples (DePuy Synthes, Warsaw, IN, USA) | Immediate full weight bearing as tolerated in rigid soled postoperative shoe (Barouk shoe, DARCO International, Inc, Huntington, WV, USA) |
| Chodaba et al. 2023 | Prospective Case Series (Level IV) | Plate Fixation | Dorsal locking plate (No manufacturer details stated) | Immediate partial weight bearing postoperatively |
| Chraim et al. 2016 | Retrospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | Six-hole non-locked mini-compression plate with interfragmentary lag screw (Charlotte® MTP Fusion System, Wright Medical, Memphis, TN) | Immediate full weight bearing in rigid soled postoperative shoe for 6 weeks |
| Coughlin et al. 1994 | Retrospective Case Series (Level IV) | Plate Fixation | Six-hole mini-compression plate (No manufacturer details stated) | No postoperative weight bearing strategy stated |
| Coughlin et al. 2003 | Retrospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | Six-hole mini-compression plate with interfragmentary lag screw (No manufacturer details stated) | Immediate full weight bearing in rigid soled postoperative shoe |
| Curran et al. 2022 | Retrospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | NeoFitTM metatarsal phalangeal arthrodesis plate (In2Bones®, Memphis, USA) with 3 mm cannulated interfragmentary compression screw | Immediate full weight bearing in a forefoot relieving postoperative shoe |
| Doty et al. 2013 | Prospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | Precontoured six-hole dorsal titanium plate (No manufacturer details stated) | Immediate full weight bearing in rigid soled postoperative shoe, with instructions to avoid propelling off the hallux and keep foot flat |
| Drampalos et al. 2016 | Retrospective Case Series (Level IV) | Interosseus Post and Lag Screw Implant (IOFix) | IOFix (Extremity Medical, Parsippany, NJ, USA) | Immediate heel weight bearing in a forefoot relieving postoperative shoe |
| Elattar et al. 2023 | Retrospective Case Series (Level IV) | Staple Compression Plate Hybrid Fixation | Crossroads Extremity Staple Compression Plate (Crossroads Extremity systems, Memphis, TN, USA) | Immediate heel weight bearing in rigid soled postoperative shoe (Verbandschuh, Darco International Inc, Huntington, WV, USA) |
| Ellington et al. 2010 | Retrospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | Stainless steel dorsal plate with a 3.0 mm interfragmentary cannulated headless lag screw (Wright Medical, Arlington, TN, USA) | Inconsistent or mixed weight bearing strategy |
| Fanous et al. 2014 | Prospective Case Series (Level IV) | Crossed Screw Fixation | Crossed cannulated 4.0 mm compression screws (Lima, WG Healthcare, Letchworth Garden City, UK) | Immediate heel weight bearing in rigid soled postoperative shoe |
| Fazal et al. 2018 | Retrospective Case Series (Level IV) | Plate Fixation | Two hole locking plates (TriMed, California, USA) | Immediate heel weight bearing in heel wedge postoperative shoe for 6 weeks |
| Ferreira et al. 2023 | Retrospective Case Series (Level IV) | Crossed Screw Fixation | Crossed 3.5 mm cannulated screws (No manufacturer details stated) | Immediate heel weight bearing in rigid soled postoperative shoe for 4 weeks |
| Flavin et al. 2004 | Prospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | Low-profile contoured titanium plate with a compression screw (Hallu®-S Plate, Newdeal, France) | Non-weight bearing for 2 weeks, then progressive heel weight bearing in rigid soled postoperative shoe for 4 weeks |
| Goucher et al. 2006 | Prospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | Precontoured six-hole dorsal titanium plate with 2.7 mm or 3.0 mm interfragmentary spin screw fixation | Immediate heel or lateral border of foot weight bearing in rigid soled postoperative shoe for 12 weeks |
| Gould et al. 2021 | Prospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | Variax 2 CP® first MTPJ fusion plate (Stryker Corporation, Kalamazoo, MI, USA) | Immediate full weight bearing in rigid flat-soled postoperative shoe for 6 weeks |
| Hanslik-Schnabel et al. 2022 | Retrospective Case Series (Level IV) | Human Allogenic Cortical Bone Screw Fixation | Crossed novel human, allogeneic cortical bone screw (Shark Screw®, Surgebright GmbH, Lichtenberg, Austria). | Non-weight bearing for 4 weeks in a cast, then progressive weight bearing in the cast for 2 weeks |
| Hyer et al. 2012 | Retrospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | Dorsal locking plate with a 3.5- or 4.0-mm interfragmentary compression screw (No manufacturer details stated) | Non-Weight bearing in splint for 7 days and then progressive weight bearing in postoperative high-tide boot. |
| Kuik et al. 2021 | Prospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | Medartis® six-hole titanium locking plate, with a 2.8 mm interfragmentary compression screw (Medartis AG, Basel, Switzerland) | Non-weight bearing in Barouk post op boot for 6–8 weeks |
| Kumar et al. 2010 | Retrospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | Precontoured titanium alloy low profile plate with an interfragmentary compression screw (MTP arthrodesis Hallu-Fix System, Integra Extremity Reconstruction, Plainsboro, NJ, USA) | Immediate full weight bearing in rigid flat-soled postoperative shoe |
| Latif et al. 2019 | Retrospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | Anchorage metatarsophalangeal cross plate system with interfragmentary lag screw (Stryker®, Selzach, Switzerland) | Immediate full weight bearing in rigid flat-soled postoperative shoe for 6 weeks |
| Lombardi et al. 2001 | Retrospective Case Series (Level IV) | Crossed Screw Fixation | Type of screw and manufacturer details not stated | Non-weight bearing in short leg cast for 3 weeks, then limited weight bearing in surgical shoe for 3 weeks. |
| Marudanayagam et al. 2014 | Retrospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation |
Fyxis plate is a low-profile (1.3-mm
thick) plate, made of titanium alloy (Fyxis Biotech, Salon de Provence, France) |
Immediate heel weight bearing in rigid flat-soled postoperative shoe for 6 weeks |
| Migues et al. 2013 | Retrospective Case Series (Level IV) | Single Screw Fixation | Single 6.5 mm Endomedullary screw (No manufacturer details stated) | Immediate full weight bearing in rigid soled postoperative shoe for 6 weeks |
| Mohammed et al. 2012 | Retrospective Case Series (Level IV) | Crossed Screw Fixation | Crossed 3.2 mm cannulated BOLD® Fixation self-drilling, self-tapping screws (Integra™ LifeSciences, Hampshire, UK) | Immediate heel weight bearing in heel wedge postoperative shoe for 6 weeks providing satisfactory fusion progress on radiographs |
| Patel et al. 2019 | Retrospective Case Series (Level IV) | Interosseus Post and Lag Screw Implant (IOFix) | IOFix (Extremity Medical, Parsippany, NJ, USA) | Immediate full weight bearing in rigid soled postoperative shoe |
| Ravenell et al. 2024 | Retrospective Case Series (Level IV) | Staple Fixation | Two nickel-titanium alloy (NITINOL) staples inserted at 90 degrees to one another, ranging in size between 15 and 25 mm (No manufacturer details stated) | Immediate full weight bearing in rigid soled postoperative shoe |
| Roukis et al. 2012 (1) | Retrospective Case Series (Level IV) | Parallel Flexible Titanium Intramedullary Nail with Dorsal Staple Fixation |
Parallel Ti-Fuse flexible titanium intramedullary nails lengths of 35, 40, 45, and 50 mm (Memometal, Inc., Memphis, TN, USA)
Metallic staple added dorsally across the first metatarsal–phalangeal joint to limit rotation potential (No manufacturer details stated) |
Immediate heel and lateral forefoot weight bearing in rigid soled postoperative shoe |
| Roukis et al. 2012 (2) | Retrospective Case Series (Level IV) | Parallel Flexible Titanium Intramedullary Nail with Dorsal Staple Fixation |
Parallel Ti-Fuse flexible titanium intramedullary nails lengths of 35, 40, 45, and 50 mm (Memometal, Inc., Memphis, TN, USA)
Metallic staple added dorsally across the first metatarsal–phalangeal joint to limit rotation potential (No manufacturer details stated) |
Immediate heel and lateral forefoot weight bearing in rigid soled postoperative shoe |
| Roukis et al. 2012 (3) | Retrospective Case Series (Level IV) | Crossed Flexible Titanium Intramedullary Nail with Dorsal Staple Fixation |
Parallel Ti-Fuse flexible titanium intramedullary nails lengths of 35, 40, 45, and 50 mm (Memometal, Inc., Memphis, TN, USA)
Metallic staple added dorsally across the first metatarsal–phalangeal joint to limit rotation potential (No manufacturer details stated) |
Immediate heel and lateral forefoot weight bearing in rigid soled postoperative shoe |
| Segal et al. 2020 | Retrospective Case Series (Level IV) | Interosseus Post and Lag Screw Implant (IOFix) | IOFix (Extremity Medical, Parsippany, NJ, USA) | Immediate heel weight bearing in rigid soled postoperative shoe |
| Singhal et al. 2018 | Retrospective Case Series (Level IV) | Interosseus Post and Lag Screw Implant (IOFix) | IOFix (Extremity Medical, Parsippany, NJ, USA) | Immediate heel weight bearing in rigid soled postoperative shoe with the aid of crutches |
| Spacek et al. 2023 | Retrospective Case Series (Level IV) | Crossed Screw Fixation | Crossed 4.0 mm bevelled-head crossed compression screws (No manufacturer details stated) | Immediate full weight bearing in rigid soled postoperative shoe, with instructions to avoid propelling off the hallux for 4 weeks |
| Tewillinger et al. 2022 | Retrospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation |
Low-profile dorsal locking plate (Airlock, NovaStep, Rennes, France)
chamfered compression screw (PECA-C, Novastep, Rennes, France) |
Non-weight bearing in posterior splint for 1 week, then transitioned into CAM walking boot and non-weight bearing for 4 weeks |
| Wassink et al. 2009 | Retrospective Case Series (Level IV) | Single Screw Fixation | Single 3.5-mm intramedullary lag screw, 32–38 mm (No manufacturer details stated) | Immediate heel weight bearing in a cast with support of crutches for 2 weeks, then full weight bearing in a below-knee walking cast or a removable stiff-soled surgical shoe (Darco shoe, Darco International Inc., Huntington, WV, USA) |
| Weber et al. 2021 | Retrospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | Dorsal locking plate with interfragmentary lag screw (No manufacturer details stated) | Immediate full weight bearing in either flat forefoot off-load postoperative shoe or high fore-foot off-load shoe for 6 weeks |
| Weigelt et al. 2021 | Retrospective Case Series (Level IV) | Plate with Interfragmentary Compression Screw Fixation | Dorsal locking plate with an integrated compression screw (Anchorage CP plate, Stryker, Mahwah, NJ, USA) or a dorsal locking plate (Anchorage V2 plate, Stryker, Mahwah, NJ, USA) with a separate compression screw 4 mm cannulated screw | Immediate heel weight bearing in rigid soled postoperative sandal for 6 weeks |
| Anderson et al. 2018 | Expert Opinion (Level V) | Plate with Interfragmentary Compression Screw Fixation | Single cannulated lag screw and anatomic dorsal plate (No Manufacturer details stated) | N/A |
| Coughlin et al. 2004 | Expert Opinion (Level V) | Plate Fixation | Six-hole dorsal mini-compression plate fixed with six bicortical screws (No Manufacturer details stated) | N/A |
| Ho et al. 2017 | Expert Opinion (Level V) | Plate with Interfragmentary Compression Screw Fixation | Dorsal plate with an interfragmentary lag screw (No Manufacturer details stated) | N/A |
| Kouesouradis et al. 2021 | Expert Opinion (Level V) | Plate with Interfragmentary Compression Screw Fixation | Dorsal plate in combination with a lag screw across the fusion site (No Manufacturer details stated) | N/A |
| Lam et al. 2017 | Expert Opinion (Level V) | Crossed Screw Fixation | Two crossed screws represented a simple and less costly technique (No Manufacturer details stated) | N/A |
| Rico et al. 2022 | Expert Opinion (Level V) | Crossed Screw Fixation, and Staple Fixation |
nickel and titanium staples popular, with or without shape memory
Crossed cannulated screws (No Manufacturer details stated) |
immediate partial weight bearing with rigid postoperative shoe during the first 6 weeks and for their subsequent removal and progressive weight bearing with conventional shoes |
| Roukis et al. 2011 | Expert Opinion (Level V) | Parallel Flexible Titanium Intramedullary Nail with Dorsal Staple Fixation |
Parallel Ti-Fuse flexible titanium intramedullary nails lengths of 35, 40, 45, and 50 mm (Memometal, Inc., Memphis, TN, USA)
Metallic staple added dorsally across the first metatarsal–phalangeal joint to limit rotation potential (No manufacturer details stated) |
N/A |
| Shaffer et al. 2023 | Expert Opinion (Level V) | Plate with Interfragmentary Compression Screw Fixation | Dorsal locking plate and a lag screw, followed by non-locking plate and lag screw (No Manufacturer details stated) | N/A |
| Trnka et al. 2006 | Expert Opinion (Level V) | Plate Fixation | Dorsal plate (No Manufacturer details stated) | N/A |
| Turan et al. 1987 | Expert Opinion (Level V) | Crossed Screw Fixation | Crossed Compression Screws (No Manufacturer details stated) | N/A |
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