SLR - October 2016 - Cherreen Tawancy
Reference: Dubois-Ferriere V, Lubbeke A, Chowdhardy A, Stem R, Dominguez D, Assal M. Clinical Outcomes and Development of Symptomatic Osteoarthritis Two to 24 Years After Surgical Treatment of Tarsometatarsal Joint Complex Injuries. J Bone Joint Surg Am. 2016 May 4;98:713–20.Scientific Literature Review
Reviewed By: Cherreen Tawancy, DPM
Residency Program: MedStar Washington Hospital Center
Podiatric Relevance: Injuries to the tarsometatarsal joint complex are a relatively uncommon injury, comprising 0.2 percent to 7.9 percent of all foot and ankle fractures. However, posttraumatic arthritis that can occur following these injuries is an important complication with which the podiatric surgeon should be familiar. ORIF and primary fusion are still highly debated as the treatment option depending on the injury pattern, but understanding the long-term implications of these treatments is important for the podiatric surgeon to bear in mind when treating these injuries.
Methods: This study was a retrospective review assessing clinical outcomes, occurrence of symptomatic osteoarthritis (OA) and risk factors for symptomatic OA among patients with a Lisfranc injury treated either with ORIF or primary arthrodesis with an average follow-up period of around 10 years (range two to 24 years). The study enrolled all patients who had sustained a Lisfranc injury at the authors’ institution between 1988 and 2009, which amounted to 128 patients, 61 of which were available for long-term follow-up. All patients underwent either ORIF or primary arthrodesis if the comminution present prevented ORIF. Functional outcome measures were determined using the AOFAS score, the Foot Function Index (FFI), VAS for pain and the SF-12 physical component summary (PCS) to assess global health. The authors also assessed the occurrence of symptomatic OA as well as risk factors for developing OA following surgical treatment of a Lisfranc injury.
Results: Sixty-one patients were available for long-term follow-up. At a mean follow-up of 10.9 years, the average AOFAS score was 79, FFI was 16.9, VAS was 2.5 and SF-12 PCS was 49.8. These findings were reported by the authors to be similar to previous studies. Of note, no significant functional differences were noted between patients who underwent ORIF versus those who had primary fusion. Time to return to work was available for 41 out of 61 patients, which, combining both ORIF and fusion patients, was a mean of 4.7 months. Radiographic evidence of OA was noted in 72.1 percent of patients, and radiographic signs of malalignment were noted in 26.2 percent of patients. 54.1 percent of patients experienced symptomatic posttraumatic OA, and of these patients, 85.7 percent had a nonanatomic reduction confirmed on x-ray. Patients were also noted to have an increased risk of symptomatic OA if they were a current or former smoker (63.3 percent) or had a Myerson Type C fracture pattern (55.6 percent).
Conclusions: Based on this retrospective study, patients tend to do well in the long-term after undergoing surgical treatment of Lisfranc injuries based on the functional outcomes and time to return to work reported in this article. However, the occurrence of posttraumatic OA was substantial, and the rate of symptomatic OA, while lower than radiographic evidence of OA, was still present in both treatment groups. The authors also concluded that smoking, nonanatomic reduction and fracture pattern played a role in the risk of developing posttraumatic OA. These risk factors should be considered prior to planning surgical intervention to the Lisfranc joint. In addition, surgical technique is of paramount importance. Out of the three risk factors identified by the authors, nonanatomic reduction had the highest rate of symptomatic OA by far. While this study did not show a significant difference between ORIF and primary fusion with regards to OA development, patients undergoing ORIF had a slightly higher risk of developing OA. While these findings are thought-provoking, a limitation to this study is that it is retrospective in nature, and only roughly half of the initially enrolled patient population was available for follow-up. Despite this limitation, no other study has reported on the long-term outcomes of surgically treated Lisfranc injuries. In any case, it is important for the podiatric surgeon to be familiar with the fixation techniques, the fracture pattern and even being able to recognize a Lisfranc injury in the first place. In this way, the rate of long-term complications most notably posttraumatic OA can be reduced and improve the patient’s quality of life.