SLR - September 2016 - Jacqueline Prevete

Clinical Outcomes and Development of Symptomatic Osteoarthritis Two to 24 Years After Surgical Treatment of Tarsometatarsal Joint Complex Injuries

Reference: Dubois-Ferriere V, Lubbeke 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. 2016 May 4; 98(9): 713–20.

Scientific Literature Review

Reviewed By: Jacqueline Prevete, DPM
Residency Program: New York Presbyterian – Queens, NY

Podiatric Relevance: The relevance of this article is to provide clinical support as to whether primary fusion and/or open reduction and internal fixation leads to long-term osteoarthritis after a Lisfranc injury. The results and findings of this study may provide additional factors to consider when operatively treating a Lisfranc injury and provides long-term follow-up information that assesses the actual incidence of osteoarthritis in relation to the subjects’ initial surgical intervention. This article also helps evaluate how successful both surgical options are and gives long-term follow-up information regarding patients’ functionality and pain level after surgical intervention. It also helps distinguish between symptomatic versus nonsymptomatic osteoarthritis and correlate it to radiographic findings after surgical intervention.

Methods: This was a retrospective study that reviewed a total of 61 patients who underwent either open reduction and internal fixation or primary arthrodesis for treatment of a Lisfranc injury at a specific institution between 1988 and 2009. The 61 patients were identified from a hospital database, and the indications for surgery were based on instability and displacement both clinically and radiographically. The surgical intervention for both arthrodesis and open reduction and internal fixation was also standardized for all patients; for ORIF, screws were used to fixate tarsometatarsal joints 1, 2 and 3 while Kirschner wires were used for joints 4 and 5. The decision as to what procedure was to be performed was made by the surgeon. A primary arthrodesis was performed of tarsometatarsal joints 1, 2 and 3 in the setting of comminution. For the 4th and 5th tarsometatarsal joints, primary arthrodesis was not performed.

All patients underwent an identical postoperative course. These patients were followed up two to 24 years postoperatively and were evaluated to assess pain, function, general health, symptomatic osteoarthritis and also assessed for risk factors to affect osteoarthritis. Functional assessments were made using the AOFAS score, FFI and VAS. Heath was evaluated using the SF-12 Health Survey Physical Component Summary (PCS).

Other considerations noted in these postoperative patients include smoking status, the presence or absence of polytrauma and postoperative weightbearing radiographs. Radiographs were evaluated for anatomic alignment, which was based on certain criteria on three radiographic views. If the patient had pain along with evidence of radiographic osteoarthritis, s/he was considered to have symptomatic osteoarthritis. All radiographs were evaluated by two blinded examiners, and follow-up examination of all patients was correlated with the data obtained by the blinded radiographic reviewers.

Sixty-one patients were included in follow-up data. Fifty underwent ORIF, and 11 underwent primary arthrodesis. Only two patients had postoperative complications; one was a postoperative infection treated with antibiotics, and the second was failure of internal fixation that required a subsequent surgery. The time between surgical intervention and follow-up time was an average of 10.9 years (range: 2.9–23.9 years).

Results: The clinical outcomes that were assessed at postoperative follow-up were based on the AOFAS, FFI, VAS pain and SF-12 PCS scores as reported by each subject. The follow-up period ranged from 2 to 24 years postoperatively. Forty-one of the subjects all returned to work, with the time between work and surgery averaging around 4.7 months.

In regards to polytrauma, the data collected in this study showed no difference between those patients who had sustained polytrauma versus those who had not, with no significant difference between AOFAS score and the VAS scores.

In the comparison of primary arthrodesis versus open reduction and internal fixation, the AOFAS score, the FFI score and the mean VAS pain score did not differ significantly. In the radiographic evaluation of these postoperative subjects, posttraumatic osteoarthritis was seen in approximately 72 percent of the patients evaluated. Malalignment was also seen in approximately 26 percent of patients. When correlating these radiographic findings with the clinical findings (i.e., subjects scores on the AOFAS and VAS pain scale), it was also found that those subjects with symptomatic osteoarthritis had worse clinical outcome scores; this was seen in approximately 54 percent of the patients studied.

Finally, the study also provided a correlation between certain risk factors and symptomatic osteoarthritis. The risk factors that showed the highest incidence of symptomatic osteoarthritis included the presence of radiographic malalignment, Myerson type-C fracture classification and the status as a former or current smoker at the time of surgery.

Conclusions: This article brings up several conclusions in regards to patients with Lisfranc injuries who undergo surgical treatment. At an average follow-up time of approximately 10 years, the functionality of these patients was determined to be very good and similar to preoperative pain levels and functionality. The article makes the point that symptomatic osteoarthritis was more common with Myerson type-C fracture patterns, which makes sense given that these types of injuries typically show more displacement and disruption to the Lisfranc joint with increased severity.

Previous studies mentioned in this article have correlated the extent of initial injury with increased risk of osteoarthritis, as well as increased risk of osteoarthritis in the setting of malalignment or poor anatomic reduction. This article provides additional evidence to support previous literature; however, it also had about half of the patients included with symptomatic osteoarthritis even in the presence of anatomic reduction. Another additional risk factor delineated in this article was a history of smoking, which also makes sense given that smoking can affect microvascular circulation, bone density and healing potential during the postoperative period.

One shortcoming I found with this article was the limited information on the patients during the operative period in regards to their comorbidities and other medical issues. Other systemic conditions, such as diabetes, degenerative or inflammatory arthritis as well as osteoporosis, may affect bone healing and the progression of symptomatic osteoarthritis. The article addresses this shortcoming by noting that most of the subjects who underwent surgical intervention were less than 40 years of age at the time of surgery, which lessens the likelihood of primary osteoarthritis. Another factor that was not mentioned in the methods section of this study was whether or not all surgeries were performed by the same surgeon; this may affect long-term results in terms of technical ability to adequately reduce and/or primarily fuse the affected joints. With different surgeons performing the operative intervention, this could add additional variables that may contribute to long term outcomes.

My interpretation of this article is that deciding between primary arthrodesis versus open reduction and internal fixation is really the surgeon’s preference and does not have a significant effect on the patient’s long-term postoperative functionality and pain level. What this article demonstrated is that anatomic reduction is imperative when operatively treating these injuries; the more severe and displaced the initial injury is, the more significant the symptomatic osteoarthritis may be. In terms of how it would change my management of patients, I may consider a primary fusion instead of open reduction/internal fixation for patients who have Myerson type-C injuries given the severity of their injury and the high incidence of posttraumatic osteoarthritis to avoid further surgery later because of significant symptomatic osteoarthritis. 

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