SLR - August 2016 - Adam Falivene
Reference: Dubois-Ferrière V, Lübbeke A, Chowdhary A, Stern R, Dominguez D, Assal M. Clinical Outcomes and Development of Symptomatic Osteoarthritis 2 to 24 Years After Surgical Treatment of Tarsometatarsal Joint Complex Injuries. J Bone Joint Surg Am May 2016, 98 (9) 713–720.Scientific Literature Review
Reviewed By: Adam Falivene, DPM
Residency Program: SUNY Downstate Medical Center
Podiatric Relevance: Treatment of injuries to the tarsometatarsal joint complex (Lisfranc joint injuries) have yielded good outcomes with short- to medium-term follow-up results. Long-term results with respect to clinical outcome and the presence of symptomatic osteoarthritis is limited in the literature. The authors present a study to assess clinical outcomes, the occurrence of symptomatic osteoarthritis and risk factors for symptomatic arthritis at 2 to 24 years in patients with a tarsometatarsal joint complex injury that was treated surgically with ORIF or with primary arthrodesis.
Methods: The authors performed a retrospective study of all patients who sustained an injury to the tarsometatarsal joint complex who were treated surgically at their institution between 1988 and 2009. A consistent protocol was used during this time, and the indication for surgery was clinical evaluation and radiographic signs of instability and/or displacement of greater than 1 millimeter as seen on radiographic studies. The surgical plan for all patients was ORIF with screws from joints 1, 2 and 3 and Kirschner wires for joints 4 and 5. For tarsometatarsal joints 1 to 3, primary arthrodesis was performed at the surgeon's discretion when tarsometatarsal joint comminution prevented ORIF. Primary arthrodesis of cuboid metatarsal joints 4 and 5 was not performed.
The outcome measures utilized were clinical scores indicating pain, function and general health, the development of symptomatic osteoarthritis and risk factors for symptomatic osteoarthritis. Data was also collected regarding the presence or absence of polytrauma and smoking status at surgery. Pre- and postoperative radiographs (when available) were reviewed for anatomic alignment and evidence of degenerative changes. Radiographic degenerative changes with the presence of any pain was considered as symptomatic posttraumatic osteoarthritis.
The patients were seen for a clinical evaluation that included the use of questionnaires and radiographic assessment 2 to 24 years postoperatively. Functional outcomes were assessed using the AOFAS score and the Foot Function Index. Pain was assessed using the Visual Analog Score. General health was evaluated using the Short Form-12 Health Survey physical component summary.
Results: One hundred twenty-eight patients were surgically treated at the authors' institution between 1988 and 2009. Fifty-five moved away from the area and were lost to follow-up, 10 died and 2 were unwilling to participate in the study. Sixty-one patients participated in the study, and they did not differ significantly from those who were not participants with respect to base-line characteristics of age, sex, type of injury, fracture classification and fixation method. Nine of the patients sustained polytrauma. Fifty-four patients had fracture or fracture-dislocation, and 7 had dislocation only.
Fifty of the patients underwent ORIF, and 11 underwent primary arthrodesis. Postoperative radiograph analysis revealed anatomic reduction was achieved in 54 of the 61 patients. Two patients had postoperative complications: postoperative loss of fixation requiring ORIF with arthrodesis and superficial infection, respectively. Thirteen of 61 patients had to change their physical activity because of pain. Thirty-nine patients could wear normal shoe gear, 19 had inserts in their shoes and 3 had modified shoe gear. Information regarding time to returning to work was available for 41 of the patients, and it showed that all 41 returned to their previous work with the mean time being 4.7 months between surgery and work return. All patients were able to walk > 6 blocks. The mean SF-12 PCS score was 49.8, which is similar to the mean for the general population.
Patients who had experienced polytrauma (9 patients) displayed similar clinical results compared to those who had not (52 patients). The mean AOFAS total score was 76.2+/-15.0 compared with 79.5+/-16.0, and the mean FFI was 17.1+/- 6.6 compared with 16.9 +/- 7.3 for those with polytrauma and those without, respectively. The VAS scores for pain did not differ between those who sustained polytrauma and those who did not.
The outcomes of patients who received primary arthrodesis compared with those who received ORIF also did not differ significantly. The mean AOFAS midfoot score was 77.8 +/- 14.8 and 79.7 +/-16, respectively. The mean VAS pain score was 2.7 +/- 1.1 and 2.5 +/- 1.6, respectively. The FFI was 17.1 +/- 4.3 compared with 16.9 +/- 7.6, respectively.
Radiographic analysis revealed posttraumatic arthritis in 44 (72.1 percent) of the patients and malalignment in 16 (26.2 percent). Of the 46 patients with good alignment, degenerative OA was observed in 28 (60.9 percent). Symptomatic osteoarthritis was frequent and was noted in 33 (54.1 percent) of the patients.
The difference in those with and without symptomatic osteoarthritis reached significance for the main measures of the AOFAS, the FFI total score and the VAS for pain. The risk factors for symptomatic OA that were identified were failure to obtain anatomic reduction, Myerson type-C compared with type-A fracture pattern and smoking status as a former or current smoker at the time of surgery. Four of the patients required secondary arthrodesis because of symptomatic posttraumatic osteoarthritis at an average of 84 months
Conclusions: The authors state that their study includes the largest number of patients with the longest follow-up after surgical treatment of a tarsometatarsal joint injury. Their main findings were: A mean AOFAS score of 79.0, a mean FFI of 16.9 and a mean VAS for pain of 2.5, with about half of the patients having no pain; Osteoarthritis was shown on radiographs for about two-thirds of the patients and symptomatic osteoarthritis was noted for about half of the patients with the later reporting worse outcomes; Risk factors for osteoarthritis were failure to achieve anatomic reduction, Myerson type-C fracture pattern and a history of smoking.
The authors found that their results were consistent with most of the studies present in the literature. They conclude that 2 to 24 years following surgical treatment of tarsometatarsal joint complex injuries, satisfactory clinical outcomes were reached with a large number of patients having returned to their previous level of functioning and employment, with little need for secondary procedures. They show with their study that there is a significant amount of posttraumatic osteoarthritis development evident on radiographs; however, the occurrence of symptomatic osteoarthritis is lower.
The authors appear to have successfully identified the risk factors for symptomatic osteoarthritis following surgical reduction of tarsometatarsal joint complex injuries and have shown that satisfactory clinical outcomes following these procedures is often achievable. One can expect symptomatic osteoarthritis to occur following these procedure types a little more than half the time; however, the need for further surgery and secondary arthrodesis is relatively rare.