Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Bruce J. Sangeorzan, MD*,
Harborview Medical Center, Seattle, Washington
Thuan and Coetzee report on a prospective trial comparing two methods of treatment for patients with injuries primarily to the ligaments of the tarsometatarsal joint. While it is known that patients with ligamentous injury do less well than patients who have a substantial osseous component to the injury when both are treated with anatomic reduction1, no previous author, to my knowledge, has compared the arthrodesis to open reduction and internal fixation in a prospective trial. Because bone healing is more durable than ligament healing, some authors have suggested that primary arthrodesis should have a role in the treatment of midfoot injuries1. Some literature recommends against primary arthrodesis2,3, but it is based on retrospective data in unmatched groups. The study by Mulier et al.4 addresses the same question but comes to a different conclusion. However, authors in that study reported retrospective comparisons with very small groups treated by different surgeons and included patients who underwent fusion of all five rays. This study, although small in scope, randomized patients prospectively and compared patients within a single location treated by a single surgeon. Comparisons were made with use of the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale, a visual analog pain scale, and a clinical questionnaire that addressed patient satisfaction.
The group that was managed with open reduction and internal fixation had a failure rate of 25% and a pain score of 4.1 on a visual analog pain scale of 0 to 10. The group treated by primary arthrodesis had one failure and a pain score of 1.2. Both groups had secondary operations and primarily hardware removal. The AOFAS midfoot scale demonstrated a substantially higher level of function in the primary arthrodesis group. If implant removal is considered a complication, both groups had higher than expected levels of complication. This could be explained by the relatively early removal of hardware at an average time of six months.
No study is perfect. The randomization method in this study does not meet the standards of 2006. The AOFAS midfoot score can be difficult to apply and understand. With small numbers of patients, a difference in patient satisfaction can be influenced by a few outliers. Finally, this study reflects outcomes in the hands of a surgeon who is expert not only in the treatment of injuries but who also has expertise in midfoot arthrodesis. Nonetheless, this is the best study to date. There is no widely accepted valid foot-specific measure, and the randomization method appears to have created two comparable groups. The study provides strong support for the treatment of primarily ligamentous injuries with a primary arthrodesis of the medial tarsometatarsal joints, particularly in the hands of those who are comfortable with this procedure. A multicenter trial would be useful to determine whether the same outcomes could be achieved by the general orthopaedic community. The authors should be congratulated for successful completion of a prospective clinical trial for the treatment of this uncommon injury. The study provides scientific evidence to support primary arthrodesis in this setting.
*The author did not receive grants or outside funding in support of his research for or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.
References
1. Kuo RS, Tejwni NC, DiGiovanni CW, Holt SK, Benirschke SK, Hansen ST Jr, Sangeorzan BJ. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000:82:1609-18.
2. Lenczner EM, Waddell JP, Graham JD. Tarsal-metarsal (Lisfranc) dislocation. J Trauma. 1974;14:1012-20.
3. Arntz CT, Veith RG, Hansen ST Jr. Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am. 1988;70:173-81.
4. Mulier T, Reynders P, Dereymaeker G, Broos P. Severe Lisfrancs injuries: primary arthrodesis or ORIF? Foot Ankle Int. 2002:23:902-5.
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