## 4 Discussion
Additional study is necessary to further validate these results in clinical applications prior to large-scale adoption, however. Although they did not demonstrate broad statistical significance when compared to crossed screws, shape-memory staples were another construct that showed promise as a novel fixation method. While crossed screws showed greater rigidity and construct stiffness when compared to staples, the staples provided greater contact force and contact surface area. Staples also demonstrated full recovery of the plantar gapping following loading, indicating an ability to respond to and recover from changes that occur at the joint interface during normal physiological activity post-operatively [29]. Interestingly enough, staples were found to be significantly weaker than crossed screws or various plates in a systematic review of the biomechanical properties of contrucks used for first metatarsophalangeal arthrodesis [33]. Further study in biomechanical models is necessary to validate the use of staples in TMT arthrodesis prior to clinical trial. Another key outcome addressed in this review was kinematic and force distribution changes in the foot following TMT arthrodesis. A principal finding was that, while fusion of the medial and middle columns does not significantly alter foot joint kinematics or pressures, whole foot TMT arthrodesis significantly increases calcanecuboid and lateral pressures of the foot [25; 28]. This finding holds true when observing the lateral column alone, given that isolated lateral column fusion also increases calcanecuboid and lateral column pressures [21]. This may occur due to a loss of motion in the lateral column, which has been implicated as the most mobile Lisfrac joint [2; 5]. It is for this reason that [PERSON] and colleagues suggest that every effort be made to preserve the mobility of this joint [2]. The lack of significant change in adjacent joint motion following medial and middle column arthrodesis and isolated fourth or fifth TMT arthrodesis indicates that these fusions do not compromise the structural balance of the foot or offload weightbearing responsibilities on less mobile joints of the foot. Whole foot and isolated lateral column arthrodesis should be avoided, especially if clinical improvement can be obtained with media/middle column or fourth or fifth TMT arthrodesis. Early clinical trials have validated the results of our review, confirming the effectiveness of plantar plating. [PERSON] et al. studied 62 patients that underwent plantar plating as the method of choice for midfoot arthrodesis and reported a 94% union rate [34]. There were also improvements in angular alignment of the talus, metatarsals, and plantar arches. Likewise, [PERSON] et al. reported a 98% union rate and a similar improvement in joint angles following plantar plating in 58 patients [35]. [PERSON] et al. used the intramedullary IO fix device and reported a 94% fusion rate at the first TMT joint, with only one patient complicated by superficial skin infection and non-union [36]. While there is a significant need for further prospective clinical studies assessing fixation constructs, early clinical data validates our findings that plantar plating provides rigid fixation and high degree of resistance to deformity while maintaining better alignment of the foot. As suggested earlier, this is likely due to its ability to stabilize the soft tissue arches of the midfoot. Similarly, intramedullary fixation demonstrated comparable clinical outcomes likely owing to the greater compressive forces afforded by the device while avoiding surrounding soft tissue irritation and interruption of circulation necessary for joint healing and stabilization. The primary limitation of this review and the included articles was the limited clinical applicability of strict, isolated biomechanical analysis in cadaveric or synthetic bone con structs.