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What challenges do you feel surgeons face when it comes to midfoot fusions?
 
I think the biggest risk is obtaining the alignment you need and being able to mitigate complications using the appropriate hardware and achieving good bone apposition at the time of surgery. Other challenges are limiting the stress associated with issues related to not having enough end-to-end bone contact and/or the inability to have the appropriate alignment you had intended.
 
I also think another challenge is ultimately simulating what appropriate weight-bearing would look like in the operating room as compared to what the reality is when the patient does eventually start weight-bearing.
 
What role can/should a jig play in overcoming these challenges?
 
As someone who doesn't really use a ton of jigs and has adopted techniques, I think the alignment jig provides reproducibility and accuracy compared to free handing and relying on solely fluoroscopic imaging. The alignment jig functions as an addition to what a surgeon already uses inherently to that end. If the goal is not appropriately designed preoperatively, then I do not think that the alignment jig is the appropriate crutch that's necessary to achieve a successful outcome.
 
Do you have any technique pearls to share?
 
Technique pearls involve use of a bone tenaculum and I would say even an invasive distractor, like a Hintermann or a Weinraub, (which) can be perceived as an alignment jig that does allow for the rotation. In addition, some of these newer basic attractors can also impart compression. One can also implement fixators, assisted plating, and other modalities as well, as a means of providing a pseudo jig–type device that can also be helpful for the surgeon. I do believe sometimes another consideration is whether you have enough soft tissue, and whether you're willing to make some of the dissection required for placing alignment jigs.
 
As far as a technical perspective, ensuring you have the appropriate goals in mind, achieving your deformity parameters, maintaining your bone apposition while also mitigating any technical aspects, using a tenaculum, and providing some provisional fixation with use of wires, can be just as good as doing an alignment jig without the necessary precision. However, sometimes the alignment jigs may ultimately pigeonhole a provider unless they're patient-specific.
 
What is the literature demonstrating when it comes to using a jig in midfoot fusions?
 
Most of the literature consists of case studies and reports on specific alignment devices. They've certainly gained a lot of recent popularity. Even with the advent of the metatarsus adductus alignment jig, there's very little data (at this time) to support improved alignment and/or improved clinical outcomes.
 
The reality is that the patients don't necessarily care about the X-rays. They're more interested in their overall pain relief, and their patient-reported outcome measures as well.
 
I don't think that alignment jigs are a bad thing. I think that certainly they're an opportunity for a surgeon to get greater precision, accuracy, and reproducibility. However, I also emphasize the importance of actual surgeon experience, expertise, and a true understanding of what you're trying to achieve.
 
Dr. Wynes is a fellow of the American College of Foot and Ankle Surgeons, and is an Associate Professor in the Department of Orthopedic Surgery at the University of Maryland Medical Center.