RESULTS OF ARTHRODESIS OF THE TARSOMETATARSAL JOINTS AFTER TRAUMA
June 12th, 1996
Gregory A. Komenda, MD; Mark S. Myerson, MD; and Kent R. Biddinger, MD
Abstract
We retrospectively evaluated the results of thirty-two patients who had undergone tarsometatarsal arthrodesis for intractable pain after midfoot trauma. The arthrodesis was performed at a mean of thirty-five months (range, six to 108 months) postinjury. Rigid internal fixation was used in all patients, and autogenous bone graft in twenty-four patients, when a defect had been created by debreidement of the joints. Nine patients required additional procedures, including a combination of clawtoe procedures (eight), posterior tibial tendon reconstruction (three), neurectomy (three), calcaneocuboid arthrodesis (one), and ankle arthrodesis (one). Complications included neuritis (three), metatarsalgia (two), malunion (two), asymptomatic non-union (one), wound slough (one), superficial infection (one), and reflex sympathetic dystrophy (one).
All patients were evaluated at a mean interval of forty-nine months (range, twenty-four to 105 months) after the arthrodesis by physical examination, radiographs, and the AOFAS rating scale for the midfoot. The mean preoperative foot score of forty-four significantly improved to a mean postoperative score of seventy-eight (p = 0.02). With the numbers available for study, we could not show that the extent of the arthrodesis, involvement of other hindfoot and forefoot joints, the mechanism of injury, or whether or not the injury was work-related affected functional outcome in a significant fashion.
Introduction
Tarsometatarsal fracture-dislocations are uncommon injuries, and the initial injury is frequently missed or misdiagnosed [5,14]. These injuries are associated with motor vehicle accidents, falls, and twisting injuries to the foot and may be caused by both direct and indirect forces [7,9,15]. The goal of the initial treatment for these injuries is to achieve a stable, anatomic reduction, which has been shown to correlate with good functional results [4-6,8,9,12,15,20]. Although treatment for these injuries includes both operative and non-operative techniques, numerous studies have shown that closed reduction and percutaneous pin or screw fixation, or open reduction and internal fixation yields better results [2,4,7,12,14,15]
Despite appropriate initial treatment, however, the prevalence of painful arthrosis associated with these injuries varies [1,5,7,12,20]: 0/9 (0 per cent) [1] to 15/26 (58 per cent) [20], with the largest series showing 21/69 patients (30 per cent) with degenerative joint disease [7]. Posttraumatic arthrosis may be treated initially by conservative measures, including non-steroidal antiinflammatory medications, molded insoles, and rocker bottom soles, but if these methods fail to relieve the pain, arthrodesis of the tarsometatarsal joints has been recommended by various authors [5,7,20].
The purpose of this study was to analyze the results of arthrodesis of the tarsometatarsal joints for painful arthrosis and deformity after midfoot trauma.
Materials and Methods
A retrospective review of office medical records identified forty-one patients who presented to The Union Memorial Hospital (Baltimore, Maryland), a tertiary referral center for foot and ankle disorders, between 1986 and 1992 with pain secondary to arthrosis and deformity after tarsometatarsal joint injury. Of these forty-one patients, one received initial treatment at our institution; forty were referred for evaluation after initial management at other medical facilities. The diagnosis of tarsometatarsal injury was made using previous medical records, history, and physical and radiographic examinations.
Regardless of the time since injury, we initially treated their pain with various nonoperative modalities, including non-steroidal antiinflammatory medication, accommodative or functional orthoses, shoe modifications, polypropylene ankle foot orthoses, and physical therapy techniques. Although each patient was treated non-operatively, arthrodesis was recommended if symptoms persisted after three to six months of nonoperative care. Six patients had subjective improvement from a variety of the above-listed non-operative interventions. Three patients did not improve, but each elected not to undergo operative treatment. These nine had injuries and pain levels similar to those of the other thirty-two; the pattern of arthrosis in seven of the nine involved the second and third metatarsocuneiform joints, whereas that of two involved the first metatarsocuneiform joint. The remaining thirty-two patients whose symptoms persisted and who were treated with arthrodesis formed our study group. The eighteen females and fourteen males ranged in age from twenty to sixty-four years (average age, forty-five years).
Original Injury and Treatment
The original injury had been sustained between six months and nine years (mean, three years) before arthrodesis. The mechanism of injury included a fall (thirteen patients), a motor vehicle accident (ten patients), a crush injury (five patients), and a minor twisting accident (four patients). Four patients (#2, 6, 13, and 15) had multiple associated injuries, including fractures of the femur, tibia, ankle, hip, and spine. Seven patients (#2, 5, 6, 10, 13, 19,and 24) had associated injuries to the cuneiforms, cuboid, and metatarsals [15].
The initial injury in nine patients had been treated operatively. Four (#14, 19, 29, and 32) of the nine had undergone closed reduction and percutaneous fixation with Kirschner wires; in three (#19, 29, and 32), the fracture or dislocation was malreduced [more than 15 degrees of abduction of the first metatarsal or two millimeters of shift of the metatarsal(s), or both] [15]. Five of the nine operatively managed patients underwent open reduction and internal fixation, four with Kirschner wires (#2, 7, 15, and 28) and one (#1, the only one whose initial injury was managed at this institution) with screws. In three (#2, 7, and 28), deformity of more than two millimeters displacement of the metatarsals was still present after fixation. One patient (#28) had comminuted fractures of the metatarsals and cuneiforms secured with Kirschner wires through a large open wound.
In twenty-three of the thirty-two patients, the initial fracture or dislocation had been treated non-operatively. We examined radiographs of the initial injury for seventeen of these twenty-three patients. For ten of those seventeen patients, the tarsometatarsal joint injury was either misdiagnosed or missed completely: five patients (#8, 20, 23, 30, and 31) in whom the tarsometatarsal joint injury was not diagnosed were treated for a sprain of the foot; the other five patients (#5, 10, 16, 22, and 25) were treated for a fracture of either the metatarsal, cuneiform, or cuboid; the dislocation of the tarsometatarsal joint was not identified.
Of the twenty-three patients, eleven were treated with cast immobilization with no attempt to reduce the displaced fracture or dislocation; seven of these were allowed to bear weight as tolerated in the cast, and four were instructed to remain on crutches for an average of three weeks. Twelve patients were treated with cast immobilization after attempted reduction of the fracture-dislocation. In ten of these twelve patients, some degree of malalignment was present (two to six millimeters of displacement of the metatarsal or lateral angulation of more than 15 degrees, or both. In two patients, no discernible radiographic malalignment was present.
Evaluation
The decision as to the preferred extent of the arthrodesis was made based on the location of pain and the radiographic appearance of the joints. We classified the tarsometatarsal articulation by dividing it into three columns designated as medial (first metatarsocuneiform joint), middle (second and third metatarsocuneiform joints), and lateral (fourth and fifth metarsocuboid joints). We used passive manipulation of the midfoot, which involves simultaneous pronation and abduction of the forefoot (Fig. 1), to determine the location of maximum pain. We did not use local anesthetic injections to determine which joints were painful as these joints are small and selective anesthesia into one or more joints was not felt to be sufficiently accurate. Although technetium bone scans may be useful in localizing the involved joints, this was not found to be clinically useful since increased uptake was often noted to be present in joints that were not painful. This was particularly relevant with respect to the lateral column, where arthrodesis was rarely performed, but in those patients for whom a bone scan had been obtained, increased uptake was often present. It has been our experience that these additional diagnostic modalities are unnecessary in determining which joints are painful.
Pre- and postoperative weight-bearing anteroposterior and lateral radiographs of both feet were obtained. The talus-first metatarsal angles on the radiographs and the height of the medial cuneiform from the floor for each injured foot were compared to those of the paired uninjured foot.
Arthrodesis: Operative Technique
Two methods of arthrodesis were used: 1) in the presence of minimal deformity, in-situ arthrodesis was performed with no attempt at realignment (eight patients), or 2) in the presence of forefoot deformity, realignment in both the sagittal and transverse planes was attempted before arthrodesis (twenty-four patients).
The arthrodesis was performed under general anesthesia in twenty-two and with local ankle block in ten patients. Bone graft was used in twenty-four patients; it was obtained from the ipsilateral calcaneus in thirteen and from the ipsilateral iliac crest in eleven patients. Bone graft was necessary when the joints could not be aligned with bony contact; the type of graft selected was based on the size of the defect created by debridement of the joints. Intraoperative radiographs were obtained when any realignment of the forefoot was performed, and fluoroscopy was used routinely to determine the position of the internal fixation.
Arthrodesis was performed using screws in all cases; however, the type of screws used varied. Initially, 4.0-mm cancellous and 3.5-mm cortical screws were used. The decision to use cortical versus cancellous screws was based on the size of the metatarsals and, more recently, 3.5-mm cortical and 4.5-mm cannulated cancellous screws were used because of ease and accuracy of screw placement. If the lateral column was in a position of malreduction, these joints were mobilized by resection of scar tissue, realigned, and secured either with Kirschner wires or screw fixation. This fixation of the lateral column was temporary and was removed once weight-bearing was commenced at approximately eight weeks after the operation. Arthrodesis of the lateral column was performed in only two patients. We performed arthrodesis of the following columns: medial column alone, five patients (#18, 26, 27, 30, and 31); middle column alone, five patients (#5, 11, 16, 20, and 21); all three columns, two patients (#3 and 19); and medial and middle columns, twenty patients. Although the middle column in some patients may have included only the second metatarsal-middle cuneiform joint, we have applied this designation, for practical purposes, to both the second and third metatarsals. Isolated arthrodesis of the third metatarsocuneiform joint was not done. In four patients the arthrodesis also included the naviculocuneiform joint (#2, 10, 24, and 31).
An additional procedure or procedures were performed concomitantly in nine patients; posterior tibial tendon reconstruction, three patients (#2, 14, and 26); ankle arthrodesis, one patient (#13); claw toe procedures, eight patients (#3, 5, 6, 13, 14, 21, 26, and 28); excision of an interdigital neuroma, three patients (#3, 5, and 13); and arthrodesis of the calcaneocuboid joint, one patient (#6).
In-situ arthrodesis. This procedure is indicated for minimal deformity with arthrosis limited to the medial or middle column, or both (Fig. 2). As local bone graft is used preferentially, if any is required, local anesthesia is often sufficient. One incision, centered over the second tarsometatarsal joint, is used. If the medial column only is to be arthrodesed, the incision is placed dorsal to the shaft of the first metatarsal. The dorsocentral incision is made with care to identify and protect the superficial and deep peroneal nerves, dorsalis pedis artery, and the vertical descending arterial branch in the first web space. The joints to be arthrodesed are exposed, the capsules are opened, and all fibrous tissue that blocks reduction is removed. Digital traction and plantar flexion of the forefoot allows distraction of the joints. The cartilage and subchondral bone are then removed with a bevelled chisel. It is important to remove the plantar aspect of the joint to prevent dorsal angulation and malunion. The reduction is held temporarily with guide pins or Kirschner wires, and radiographs are obtained to confirm the anatomical reduction. A high-speed burr is then used to debride the joint edges and, if a gap is created, it is filled with local bone graft, occasionally obtained from the calcaneus. Additional bone graft is usually unnecessary with these in-situ procedures. The screw size is selected according to the size of the metatarsal. We use 4.5- and 3.5-mm screws for the medial and middle columns, respectively. To avoid splitting the dorsal cortex of the metatarsal, the hole must be carefully countersunk, or the screw must be inserted from a proximal dorsal to a distal plantar direction.
Realignment arthrodesis. For patients who have residual displacement and deformity of the forefoot, we believe that realignment of the forefoot is preferable to an in-situ arthrodesis [18]. Although no previous reports discuss the amount of displacement requiring realignment and arthrodesis, the morbidity after tarsometatarsal injury has been demonstrated to worsen with more than two millimeters displacement and 15 degrees of malalignment.[15] In this study, any patient with three or more millimeters displacement or 15 or more degrees of malalignment in the transverse or sagittal plane was treated with realignment and arthrodesis (Fig. 3). Typically, a flatfoot deformity is present associated with forefoot abduction and with lateral translation and dorsiflexion of the metatarsals. The medial soft tissues may be attenuated and occasionally the lateral soft tissues may be contracted. Our goal in reducing the deformity was to restore alignment of the medial base of the first metatarsal with the medial edge of the cuneiform, restore alignment of the medial base of the second metatarsal with the medial edge of the second cuneiform in the transverse plane, and align the long axis of the talus with the long axis of the first metatarsal in both the sagittal and transverse planes [3,18] (Fig. 4). The incisions are planned according to the deformity. For severe deformity, three incisions are used, one dorsomedial to the first metatarsal, one between the second and third metatarsals, and one dorsal to the fifth metatarsal, occasionally extending proximally to the calcaneus.
In patients who have severe forefoot abduction, the peroneus brevis tendon and other lateral soft tissues are contracted and require lengthening. If the contracture is severe, we use a small external fixation device intraoperatively to assist with the reduction, as described by Sangeorzan et al [17,18]. A pin is inserted laterally into the fifth metatarsal and a second pin into the calcaneus. If the pin inserted into the fifth metatarsal does nor obtain secure fixation, it is inserted into the fourth metatarsal. The pins are inserted to converge slightly as an aid in the realignment. Before distraction, all the joints to be arthrodesed are mobilized by resecting the scar tissue, debris, and cartilage. A bevelled chisel is used to denude the joint surfaces, but no bone is resected.
We find that the realignment is facilitated by initially correcting the position of the first metatarsal. This is performed by grasping the hallux by the hand and forcing it into varus, while the base of the first metatarsal is pushed laterally with the thumb (Fig. 4). The first metatarsal is temporarily secured with a cannulated guide pin inserted from the dorsal surface of the metatarsal proximally into the medial cuneiform. A large bone reduction clamp is placed obliquely to close the gap between the base of the second metatarsal and medial cuneiform. Both the second and the third metatarsals are secured with Kirschner wires into their respective cuneiforms, and a cannulated guide pin is inserted from the medial cuneiform distally toward the second metatarsal base. Anteroposterior and lateral radiographs are obtained to confirm the corrected alignment.
The arthrodesis is performed with 3.5-mm cortical screws introduced in a lag fashion, or with partially threaded cannulated 4.5-mm screws. It has been our experience that despite substantial arthrofibrosis and deformity, the joints between the fourth and fifth metatarsals and the tarsal bones usually remain painless postoperatively, provided alignment is corrected [18]. If the fourth and fifth metatarsals are displaced more than two millimeters, they are anatomically reduced and this position is maintained with smooth Kirschner wires [4,5,12,20] that are removed at approximately eight weeks with resumption of weight-bearing. The wounds are closed with 4-0 subcuticular sutures and 5-0 chromic simple interrupted sutures used for the skin.
The patient is then placed in a bulky compression dressing, which is changed to a cast at two weeks. Weight-bearing is begun in a below-the-knee weight-bearing cast or commercially available weight-bearing boot at approximately eight weeks and may be used for an additional four to eight weeks, depending on the healing of the arthrodesis as determined by the radiographs.
Analysis
The results of arthrodesis were evaluated objectively by clinical and radiographic examination and by comparison of pre- and postoperative scores on the AOFAS 100-point clinical rating scale for the midfoot [11]. The preoperative scores were obtained retrospectively using a patient questionnaire and review of the medical records.
Weight-bearing anteroposterior and lateral radiographs were used to evaluate alignment and the presence of fusion. Measurements of the talus-first metatarsal angle in both the lateral and anteroposterior planes and the height of the medial cuneiform to the floor were used to assess alignment.
The statistical tests used to evaluate the data included Student's t-test, one-way ANOVA (analysis of variance with a Scheffe comparison), and Pearson's correlations. The statistical software program used was SPSS/PC (SPSS Inc., Chicago, IL).
Results
The thirty-two patients were examined at a mean of forty-nine months (range, twenty-four to 105 months) after the arthrodesis and fusion was determined to be present in thirty-one feet. One patient (#14, treated with arthrodesis of the medial and middle columns) had a healed fusion of the middle column but developed a painless non-union of the first metatarsocuneiform joint. In addition to the tarsometatarsal arthrodesis, this patient had been treated concomitantly for posterior tibial tendon dysfunction and an acquired flarfoot deformity with a flexor tendon reconstruction. Although this patient experienced intermittent swelling and aching after surgery, she had no pain in the midfoot after nine months.
It was not possible to determine accurately when arthrodesis occurred, as all the patients were examined at four-week intervals. It was our impression, however, that arthrodesis, as determined by the absence of warmth and swelling and by the presence of radiographic signs of trabeculation, occurred at eight weeks in sixteen patients, by ten weeks in ten patients, and by twelve weeks in five patients.
AOFAS Scores
The postoperative AOFAS 100-point midfoot rating scale scores were computed and compared to the preoperative scores (determined retrospectively). Overall, there was a difference between the mean preoperative score of forty-four (range, twenty-two to sixty-four) and the mean postoperative score of seventy-eight (range, forty-seven to ninety-eight) (p = 0.02, Student's t-test). With the numbers available for study, comparison of the mean pre- and postoperative AOFAS scores according to the mechanism of injury and the extent and location of arthrodesis did not demonstrate a significant difference with respect to outcome (one-way ANOVA).
Six patients had sustained work-related injuries (crushing injury, five; fall, one); their mean pre- and postoperative scores were forty-one (range, twenty-six to fifty-eight) and seventy-one (range, fifty-one to eighty-eight), respectively. For the twenty-six patients with non-work-related injuries, the mean pre- and postoperative scores were forty-five (range, twenty-two to sixty-four) and eighty (range, forty-seven to ninety-eight), respectively. With the numbers available for study, Student's t-test analysis did not show a statistically significant difference between these two groups (p = 0.81).
Nine patients had additional procedures at the time of arthrodesis, as described in Materials and Methods. With the numbers available for study, we could not show a significant difference between the postoperative scores of this subgroup and those of the other twenty-three patients (p = 0.085, Student's t-test).
The five patients who underwent revision procedures after arthrodesis (see complications) had a mean preoperative score of forty-one (range, twenty-eight to fifty-two) and a mean postoperative score of sixty-six (range, forty-seven to eight-three). For the three patients who experienced neuritis or nerve injury, the mean score was forty-three preoperatively (range twenty-seven to fifty) and sixty postoperatively (range, fifty-four to sixty-six). The pre- and postoperative scores of the one patient who developed a non-union of the medial column were fifty-eight and seventy-seven, respectively. We could not show a significant difference between the postoperative scores of this subgroup of five patients and those of the other twenty-seven patients (p = 0.14, Student's t-test).
We could not show a correlation between age and outcome (r = 0.029, p < 0.05, Pearson's correlation).
Radiographic Analysis
Radiographic analysis was performed only for those patients treated with realignment, reduction and arthrodesis. Abduction of the metatarsals, or lateral angulation, as measured on anteroposterior radiographs and expressed as the talus-first metatarsal angle (normal approximates 0o), improved from a mean of 13o abduction (range, 0 to 28o) preoperatively to a mean of 4o adduction (range, 0 to 8o) postoperatively. The height of the first metatarsal, as measured on the lateral radiographs and expressed as the lateral talus-first metatarsal angle (normal approximates 0o), improved from a mean of 16o dorsiflexion (range, 0 to 24o) preoperatively to a mean of 6o (range, 0 to 10o) postoperatively. The height of the medial cuneiform to the floor improved from a mean of twenty-four millimeters (range, seventeen to forty-two millimeters) preoperatively to a mean of thirty-six millimeters postoperatively (range, twenty-four to forty-two millimeters). The postoperative mean height of the medial cuneiform compared favorably with that of the uninjured foot: thirty-nine millimeters (range, thirty-four to forty-five millimeters).
Complications
Three patients (#5 ,7 and 28) developed neuritis of the deep peroneal nerve postoperatively. One (#7) of these three patients had undergone initial open reduction and fixation with percutaneous Kirschner wires for a crush injury. In addition to a malunion, he developed severe deep peroneal nerve neuritis, which was subsequently surgically treated before our evaluation and treatment. Although the deep peroneal neuroma was identified and resected, it required a repeat procedure with resection of the deep peroneal nerve and proximal transposition. The second patient (#5) developed a deep peroneal nerve neuroma requiring a subsequent resection. Both these patients continue to experience symptoms of hyperesthesias and dysesthesias postoperatively. The third patient (#28) had neuritis of the deep peroneal nerve; however, he was treated conservatively with amitriptyline (twenty-five milligrams taken at night for one month) and his painful symptoms have resolved.
Two patients (#3 and 19) developed metatarsalgia as a result of malunion of one or more metatarsals. In one patient (#3), this was thought to be due to malunion of the second metatarsal, which was plantarflexed, and was treated successfully with a dorsal wedge osteotomy of this second metatarsal. In the second patient (#19), arthrodesis of all three columns was performed (Fig. 5). He developed postoperative pain under the second and third metatarsals and was treated with dorsal wedge osteotomies of both these metatarsals. He then experienced pain under the fourth and fifth metatarsal heads, which were in turn treated with dorsal wedge osteotomies. The multiple osteotomies were successful in alleviating his discomfort and he has been able to return to construction work with minimal pain.
There were three other complications. One patient (#28) who sustained a crush injury associated with soft-tissue loss and severe fracture comminution developed a wound slough that was successfully treated with a split-thickness skin graft in the immediate postoperative period. One patient (#5) developed a superficial wound infection effectively treated with oral cephalexin (500 milligrams four times daily for ten days). There were no deep infections. One patient (#7) who experienced severe recurrent postoperative deep peroneal neuritis also manifested signs and symptoms of reflex sympathetic dystrophy. Although the sympathetically mediated pain resolved with lumbar sympathetic blocks, physical therapy, and the use of amitriptyline (twenty-five milligrams at night for two months), he continued to experience symptoms of neuritis.
Subsequent additional procedures were performed in five patients (#3, 5, 6, 7, and 19) for metatarsalgia (#3 and 19), resection of a neuroma (#5 and 7), and additional arthrodesis (#5 and 6). The additional arthrodesis procedures were performed to the first metatarsocuneiform joint (#5) and to the fourth and fifth metatarsocuboid joints (#6) due to painful arthrosis not previously diagnosed in both patients.
Discussion
There is a high prevalence of post-traumatic arthrosis after tarsometatarsal fractures and dislocations with or without adequate initial treatment [1,5,7,9,12,20], ranging from 0/9 (0 per cent) [1] to 15/26 (58 per cent) [20], with the largest series showing 21/69 patients (30 per cent) with degenerative joint disease [7]. When conservative treatment fails to relieve these patients' symptoms to an acceptable level, arthrodesis of the painful tarsometatarsal joints is the treatment of choice [5,10,18].
Johnson and Johnson [10] reported a series of fifteen patients who underwent tarsometatarsal arthrodesis using a dowel graft technique to treat post-traumatic arthrosis. There was no attempt at reduction of the deformity, and the arthrodeses were performed in situ. These authors reported two cases of painful non-unions that required repeat arthrodesis with inlay bone graft. They also reported fair and poor results in five of their fifteen patients (30 per cent), based on activity, pain, and radiographic union. Although there was a suggestion that a decline in the quality of the result after fusion was associated with increasing age, the study group was too small for statistical significance. The dowel technique was not our preferred method to obtain arthrodesis because the removal of a dowel(s) creates additional instability of the metatarsocuneiform articulation and because this technique was not associated with an acceptable success rate, as originally reported.
Sangeorzan et al. [18] reviewed the results of sixteen patients who developed arthrosis after tarsometatarsal injury and who underwent arthrodesis using rigid internal fixation. They identified a correlation between the outcome and time between injury and arthrodesis, alignment of the arthrodesis, quality of reduction, and whether the injury was work related. Using a stepwise multiple regression analysis, they determined, however, that the only factor in predicting outcome was the alignment of the arthrodesis. Sangeorzan et al. [18] recommended that the lateral column not be arthrodesed and showed that arthrodesis of the lateral column was not necessary to obtain a good result.
The experience of Sangeorzan et al. [18] was similar to ours in that many of our patients had radiographic evidence of arthrosis of the fourth and fifth metatarsocuboid joints but had no pain in this location both pre- and postoperatively. Why this is the case is not well understood. Various authors have quantified the motion of the lateral column of the midfoot [13,16]. Interestingly, the lateral column, which has the greatest sagittal plane motion (averaging 10 degrees) was the least painful in our experience. However, the second metatarsocuneiform articulation, which has the least motion (averaging 0.6 degrees) [16], was the most painful in our study.
Only two patients in our study required arthrodesis of the lateral column. Interestingly, both of the patients who underwent extended arthrodesis of all three columns required a subsequent revision procedure for metatarsalgia with metatarsal osteotomies (#3 and 19). A third patient (#6) sustained an injury associated with forefoot abduction and compression of the metatarsocuboid and calcaneocuboid joints. The metatarsocuboid joints were not painful, and realignment of the forefoot was achieved with an interposition bone block arthrodesis of the calcaneocuboid joint. Two years later, he began to experience intractable lateral pain and required an arthrodesis of the metatarsocuboid joints. Minimal lateral motion was present before this second arthrodesis, and we concluded that the pain was in some way aggravated by the decreased lateral column motion. Although these numbers are small, one may infer that the motion of the lateral column is important for optimal function. Therefore, wherever possible, we recommend that the lateral column not be treated by arthrodesis, particularly as most of these joints are asymptomatic despite radiographic evidence of arthrosis.
This leads to the question of which columns to arthrodese. We used clinical examination and plain radiographs to determine which joints required arthrodesis. When we obtained a bone scan, diffuse uptake throughout the midfoot was present, often in locations that were painless. These scans are very sensitive to bone turnover or increased blood flow secondary to inflammation from arthrosis, but they do not always coincide with the painful joints. Although the bone scan has been used by others, we do not recommend it nor other imaging modalities to determine the extent of the arthrodesis [19].
Radiographic analysis demonstrated satisfactory postoperative alignment as compared to the contralateral, uninjured foot. Because our study did not include a group in which an in situ fusion was performed in the presence of obvious malalignment, we cannot compare the two techniques. However, it is our belief that realignment of the midfoot contributes to the overall good results, as demonstrated by the foot scores.
We believe that tarsometatarsal arthrodesis to treat symptomatic arthrosis after a traumatic injury should be accomplished through realignment of the midfoot deformity (when present), rigid fixation, and bone grafting as necessary. The patients in this study had a marked improvement with respect to pain and function after arthrodesis, as determined by the AOFAS midfoot score.
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20. Wilppula, E. Tarsometatarsal fracture-dislocation. Late results in 26 patients. Acta Orthop. Scand. 44:335-345, 1973.
Figure Legends
Fig. 1. An artist's rendition of manipulation of the midfoot, involving simultaneous pronation and abduction of the forefoot.
Fig. 2. This patient (#8) had minimal deformity as shown in the preoperative anteroposterior (A) and lateral (B) radiographs. Management included in situ arthrodesis, as seen in the postoperative anteroposterior (C) and lateral (D) radiographs taken twenty-four months after arthrodesis.
Fig. 3. This patient (#31) experienced pain in the medial and middle columns. Preoperative anteroposterior (A) and lateral (B) radiographs showed abduction deformity of the forefoot. Management included reduction, realignment, and arthrodesis of the involved articulations, as indicated by the postoperative anteroposterior (C) and lateral (D) radiographs taken thirty months after arthrodesis.
Fig. 4. An artist's rendition of the intraoperative manipulative maneuver for reduction of the medial column.
Fig. 5. This patient (#19) presented with pain in all three columns. Preoperative anteroposterior (A) and lateral (B) radiographs showed arthrosis of all htree columns and mild deformity. Management included arthrodesis of the entire tarsometatarsal articulation, as shown by the postoperative anteroposterior (C) and lateral (D) radiographs taken seventy-one months after arthrodesis. He developed postoperative metatarsalgia that required osteotomy of the second and third metatarsals and a change in the screw configuration. He underwent subsequent revision with osteotomies of the fourth and fifth metatarsals for lateral metatarsalgia.
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