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Orthopaedics & Traumatology: Surgery & Research 100 (2014) S231–S237

Available online at

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orkshops of the SOO (2013, Tours). Original article

isk of osteoarthritis secondary to partial or total arthrodesis of theubtalar and midtarsal joints after a minimum follow-up of 10 years�

. Ebalarda, G. Le Henaffb, G. Sigonneyc, R. Lopesd, G. Kerhoussee,. Brilhault f, D. Hutena,∗

Orthopaedic and Trauma Surgery Department, CHU Rennes, hôpital Pontchaillou, 2, rue Henri-Le-Guilloux, 35000 Rennes, FranceOrthopaedic and Trauma Surgery Department, CHU Brest, hôpital La-Cavale-Blanche, boulevard Tanguy-Prigent, 29609 Brest, FranceOrthopaedic and Trauma Surgery Department, CHU Rouen, hôpital Charles-Nicolle, pavillon Dève, 1, rue de Germont, 29000 Brest, FranceOrthopaedic and Trauma Surgery Department, CHU Hôtel-Dieu, place Alexis-Ricordeau, 44093 Nantes, FranceCHP Saint-Grégoire, Orthopaedic Surgery Department, 36, boulevard de la Boutière, 35760 St-Grégoire, FranceOrthopaedic and Trauma Surgery Department, CHU de Tours, hôpital Trousseau, 37044 Tours, cedex 09, France

a r t i c l e i n f o

eywords:riple arthrodesisubtalaralonavicular arthrodesisegenerative ankle osteoarthritisegenerative tarsal osteoarthritis

a b s t r a c t

Introduction: The goal of this retrospective, multicentre study was to evaluate the long-term outcomesin patients who have undergone partial or total arthrodesis of the subtalar and midtarsal joints.Hypothesis: Secondary osteoarthritis of the adjacent joints can negatively affect the outcomes more than10 years after these fusion procedures.Material and Methods: The outcomes of 72 fusions (total: 22; partial: 50) performed between 1981 and2002 were evaluated using the Maryland Foot Score (MFS), self-evaluation questionnaire and threeweight-bearing X-ray views (Meary’s with cerclage wire around heel, lateral and dorsoplantar). Theaverage follow-up was 15 ± 5 years (range 10–31).Results: There were two deep infections that resolved after lavage and antibiotics therapy. There were21 early complications (10 complex regional pain syndrome, 7 delayed wound healing, 2 superficialinfections, 2 venous thrombosis) that all resolved. There were five cases of non-union (6.9%) that healedafter being re-operated. After five years, secondary osteoarthritis led to the fusion being extended to thetibotalar joint (1 case) and midtarsal joint (1 case). At the last follow-up, the average MFS was 71.5 (range25–100). Patient deemed the result as either excellent (10%), very good (9%), good (55%), poor (19%) orbad (7%). Pain at the last follow-up was present in 84% of cases. The rear-foot was normally aligned in45% of cases, varus aligned in 22% and valgus aligned in 33%. The MFS was significantly better in patientswith normal alignment. Patients with neurological foot disorders had significantly more preoperative(80% cavovarus) and postoperative foot deformity (P<0.05). At the last follow-up, the rate of secondaryosteoarthritis in the surrounding joints was elevated: 73% tibiotalar, 58.3% subtalar, 65.8% talonavicular,53.5% calaneocuboid. The presence of osteoarthritis was not correlated with pain or lower MFS. Howeverthere was significantly more pain at last follow-up than at 12 months postoperative and two fusions were

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required in patients with secondary osteoarthritis.Conclusion: Although partial or total arthrodesis of the subtalar and midtarsal joints is a reliable proce-dure, it induces secondary osteoarthritis. Even though it seems to be well tolerated more than 10 yearsafter the initial procedure, this possibility must be discussed with young, active patients.Level of evidence: IV, retrospective study.

� Round Table on “Partial or total arthrodesis of the torsion couple”.∗ Corresponding author. Tel.: +33 2 99 26 71 67.

E-mail address: Denis.huten@CHU-rennes.fr (D. Huten).

http://dx.doi.org/10.1016/j.otsr.2014.03.003877-0568/© 2014 Elsevier Masson SAS. All rights reserved.

© 2014 Elsevier Masson SAS. All rights reserved.

1. Introduction

Although the outcomes of partial or total arthrodesis of the sub-talar and midtarsal joints are now well validated [1–7], overload of

the adjacent joints brings about the risk of secondary osteoarthri-tis (OA) [8–10]. Very few long-term studies have been publishedthat would allow us to evaluate this risk [1,2,6,11–13]. As a conse-quence, it is difficult for surgeons to provide complete information

S232 M. Ebalard et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S231–S237

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n the possibility of secondary osteoarthritis to patients who areandidates for this procedure and want to know about their futureunction.

The Round Table at the Société d’Orthopédie de l’Ouest (Westernrance Orthopaedic Society) meeting in 2013 sought to evaluate theutcomes at least 10 years after the fusion procedure. The hypoth-sis was that secondary osteoarthritis in the adjacent joints mightegatively affect the long-term functional outcomes of fusion of thehree main joints in the midfoot.

. Material and methods

This was a multicentre retrospective study of 320 cases of par-ial or full arthrodesis cases performed at five university hospitalentres in Western France (Brest, Nantes, Rennes, Rouen and Tours)etween 1981 and 2002. Partial arthrodesis was defined as fusionf one or more of the following joints: subtalar (ST), talonavicu-ar (TN) and calcaneocuboid (CC). In complete or triple arthrodesis,ll three joints were fused. Patients with a previous tibiotalar (TT)usion or joint implant were excluded. The main outcome measureas osteoarthritis in joints near the fusion site. The secondary out-

omes were complications, functional results, fusion rate and footrchitecture.

Sixty-five patients (72 fusions) or 22.5% of the initial cohortgreed to participate in the study. The other patients were eitherost to follow-up (59.2%), had died (9.9%) or declined to participate8.4%). This group of 72 fusion cases formed the basis for the cur-ent study. The age, body mass index (BMI), diagnosis, preoperativelinical data available in the patient file (pain, TT mobility labelleds either <15◦, 15◦-30◦, >30◦), type of fusion, surgical technique andomplications were recorded.

.1. Functional outcomes

The follow-up for each patient was performed either by tele-hone (52 cases) or in the surgeon’s clinic (20 cases). Functionalutcomes were evaluated using the Maryland Foot Score (MFS),

hich is specific to foot and ankle function [14]. In the 100-pointFS, >89 points is an excellent result, 75–89 points is a good

esult, 50–74 is an average result, and <50 points a bad result. Theatients were also asked to complete a self-evaluation question-aire relative to the result (excellent, very good, good, poor, orad).

he last follow-up (FU).

2.2. Radiology outcomes

Three weight-bearing views taken before surgery, immediatelyafter surgery and six months postoperative were evaluated: Mearyview with cerclage wire around the heel [15], lateral view and dor-soplantar view. For the last follow-up, the patients sent these samethree views to us.

Three parameters were evaluated: foot architecture before andafter the fusion procedure; fusion rate; osteoarthritis at the adja-cent joints.

2.2.1. Foot architectureMeary view:

• the TT angle was measured. If the angle deviated from 180◦, thefoot was characterized as having valgus or varus misalignment;

• the frontal alignment was evaluated using the Djian-Annonierangle: normal alignment (4-8◦ valgus), valgus misalignment (>8◦

valgus) or varus misalignment (<4◦ valgus) [16,17].• Lateral view: any disruption in the Meary-Toméno line, no matter

its magnitude, suggested a cavus or planus foot.

2.2.2. Fusion of the arthrodesisFusion was evaluated six months after the procedure and at

the last follow-up. Fusion was achieved if the subchondral bonehad disappeared and bone trabeculae bridged the joint space. Thefusion percentage was categorized as either 0%, <50%, >50%, 100%.An arbitrary threshold of <50% was used to classify a case as havinga non-union.

2.2.3. Osteoarthritis of the adjacent jointsThe presence of osteoarthritis was evaluated using the Graves

classification system [4]: 0: normal joint space; 1: isolated narrow-ing of the joint space; 2: narrowing with osteophytes and sclerosis;3: osteoarthritis with joint space no longer present.

2.3. Statistical methods

The statistical analysis was performed by the Department ofPublic Health and Medical Information at CHU Rennes:

• with qualitative data, the Fisher’s exact, Pearson’s chi-square,Welch Two Sample T-test and Wilcoxon rank sum tests wereused;

M. Ebalard et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S231–S237 S233

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3.1.1. Early complicationsThere were early complications in 23 of the arthrodesis cases

(32%):

Table 1Diagnosis.

%

Post-traumatic changes 58.3Calcaneus 33.3Talus 22.2Navicular bone 2.8

Work-related injury 28.6

Fig. 2. Fo

with quantitative data, the Kruskal-Wallis rank sum test and anal-ysis of variance (Anova) were used.

Bilateral cases were considered to be independent samples. Theisk of Type 1 error was set at 5% when determining if a differenceas statistically significant.

. Results

The 72 fusion cases were performed in 38 men and 27 women;he average patient age was 39.8 years (range 13–74). The averageMI was 25.3 kg/m2 (range 14.0–44.1).

In most cases (58.3%), the diagnosis was due to trauma (Table 1).T fusion was mainly performed after calcaneus fracture and triplerthrodesis performed in patients with deformity due to neurolog-cal disorder (Table 2). Patients reported having preoperative ankleain in 41.6% of cases. The range of motion was normal (>30◦) in8.7% of cases, limited (15◦ to 30◦) in 21.8% of cases and restricted<15◦) in 8.5% of cases.

A lateral sub-malleolar horizontal approach was used in 64% ofases, a dual medial-lateral approach in 27% and medial approach

n 7% (TN fusion only). Fixation was performed with staples (28%f cases), screws (29%) or both (31%). In patients where an addi-ional procedure was required (Table 2), bone grafts were requiredn 56 cases (77.8%) with most grafts taken from the iliac crest (90%),

itecture.

tenotomy and plantar aponeurotomy were performed in 12 cases,and tarsectomy in five cases. The operated limb was immobilizedfor six to eight weeks.

The average follow-up was 15 ± 5 years (range 10–31 years). Itwas more than 15 years in 45 cases (62.5%).

3.1. Complications

Neurologic 25.0Inflammatory 11.1Congenital 4.2Others 1.4

S234 M. Ebalard et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S231–S237

Table 2Diagnosis and surgery features for the various types of arthrodesis procedures.

Arthrodesis type Diagnosis Approach Associated procedures

Post -trauma(%)

Neuro(%)

Infla(%)

Cong(%)

Others(%)

Lateral(%)

Lateral + medial(%)

Medial(%)

Others(%)

Bonegrafting (%)

Tenotomy(%)

Tarsectomy(%)

Triple (22) 22.8 59 13.7 4.5 68 27 4.5 68 30 9ST (37) 81.1 10.8 5.4 2.7 84 26 84 14 8TN (9) 44.4 55.6 89 11 88.8 11TN + CC (3) 66.7 33.3 100 66 0 0

0 100 0 0

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(73%) was higher than preoperatively (Fig. 4). There was no corre-lation between TT osteoarthritis and the type of fusion procedure(triple arthrodesis: 73.6%, ST fusion: 73%, TN fusion: 72.5%), pain,the MFS and foot architecture at the review.

ST + CC (1) 100 10

ost-trauma: post-traumatic; Neuro: neurological; Infla: inflammatory; Cong: cong

four infections occurred: two superficial (antibiotics therapyonly) and two deep (one after wound dehiscence) which resolvedafter lavage and antibiotics therapy;seven cases of delayed wound healing, which resolved with localwound care;ten cases of complex regional pain syndrome, which were morecommon in patients who had suffered a work-related injury(P = 0.029);two cases of deep vein thrombosis.

Every skin complication case occurred in patients operatedhrough the lateral approach (P<0.05) for triple arthrodesis.

.1.2. Non-unionThere were five non-unions (6.9%): two after triple arthrodesis,

wo after ST and one after TN + CC. Bone grafting was performed in6 cases, included three of the five non-union cases. There was noorrelation between the non-union rate and BMI, the type of fix-tion used or the addition of a bone graft. All of these non-unionases, the initial fusion was repeated (freshening, fixation and auto-raft) within one year and in two cases, the ST fusion was extendedo the midtarsal joint.

.1.3. Fusion in patients with secondary osteoarthritisAt five years, premature secondary osteoarthritis in two patients

ed to extension of the fusion (one TT fusion after triple arthrodesisnd one midtarsal fusion after ST fusion).

.2. Functional results

At the last follow-up, the MFS was 71.5/100 on average (range5–100) (excellent: 22%; good: 23%, average: 40% poor: 15%).ighty-four percent of patients claimed to have rear-foot and/ornkle pain (slight: 29%; fair: 20%; moderate: 23%; marked: 10%;ignificant: 2%) versus only 38% one year after surgery (P < 0.05).atients either wore normal shoes (38%), flat or fitted shoes (43.5%)r orthopaedics shoes (17.4%). Walking distance was limited in6.5% of patients. Walking on irregular terrain was difficult or

mpossible in 62.3% because their foot was unable to adapt to thenevenness of the ground (Fig. 1). There were no significant dif-erences between the MFS or any of its components and the BMI,iagnosis or type of fusion procedure. Patients self-evaluated theirutcome as excellent in 10% of cases, very good in 9%, good in 55%,oor in 19% and bad in 7%; the initial diagnosis did not affect thisvaluation.

.3. Radiography results

.3.1. Foot architecture

At the last review, only 45% of cases had normal rear-foot

lignment (Fig. 2). The MFS score was higher when the foot wasormally aligned (average MFS of 80) than when it was misalignedaverage MFS of 68) (P < 0.05), with no differences between varus

Fig. 3. Graves 2 TT osteoarthritis 17 years after triple arthrodesis.

and valgus. The TT angle was normal in 27% of cases. The footappeared normal on lateral views in only 33% of cases (Fig. 3).Note that these latter two results only take the direction of themisalignment into account, not its magnitude. Patients withneurological foot disorders had significantly more preoperative(80% cavovarus) and postoperative deformity (P < 0.05).

3.3.2. Fusion of the arthrodesisFive of the non-union cases have been described above. In the

seven other cases, less than 50% of at least one joint space hadfused after six months, but the patients were asymptomatic. Atthe last follow-up, it was greater than 50%, which suggests thatunion occurred at six months and continued to progress. Overall,the fusion rate was 93.6%: 90.9% in triple arthrodesis cases, 94.6%in ST fusion cases and 100% in TN fusion cases.

3.3.3. Osteoarthritis of the adjacent joints3.3.3.1. TT joint. The TT osteoarthritis rate at the last follow-up

Fig. 4. TT osteoarthritis.

M. Ebalard et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S231–S237 S235

Fig. 5. ST osteoarthritis.

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Fig. 6. TN osteoarthritis.

.3.3.2. ST, TN and CC joints. By performing partial arthrodesis, 96oints were spared:

12 ST joints (9 isolated TN fusions and 3 TN + CC);38 TN joints (37 ST fusions and 1 ST + CC);46 CC joints (37 ST fusions and 9 TN).

Figs. 5–7 show that the arthritis rate in these joints was highert the last follow-up than before the procedure. There was no cor-elation between osteoarthritis (Fig. 8) and pain, the MFS and footrchitecture at the review.

. Discussion

In the current patient cohort, several observations were consis-ent with published findings:

the fusion provided significant pain relief; our satisfaction ratewas in line with the 81–100% rate reported in various studies[4–6,12,18–20];

the functional results were not as good, as in several studies thatreport “fair or reasonable” functional outcomes [3,5,12,18,19];pain upon review was very common, which suggests that theresults degrade over time [6].

Fig. 7. CC osteoarthritis.

Fig. 8. Graves 2 TN + CC osteoarthritis 22 years after ST arthrodesis.

The fusion rate in the current study (90.9% for triple arthrode-sis, 94.6% for ST fusion and 100% for TN fusion) is comparable tothe one reported in other studies. For triple arthrodesis cases, thefusion rate was 77.5% for Angus et al. [1], 83% for Graves et al. [4],94% for Sammarco et al. [21] and 100% for Smith et al. [12] andBrilhault [22]. For ST fusion, the fusion rate ranged from 84% [3]to 100% [23]. For TN fusion, several studies have reported a 100%fusion rate [24,25], contrary to popular belief. These differences canbe explained by the challenges of determining whether fusion hasoccurred [26,27], although this is easier with a CT scan [27]. Wefound no positive effect of bone grafting, which some studies havestated is indispensable [28,29] and others useless [30,31]. In theEasley et al. Study [3], non-union occurred because a thick layerof avascular subchondral bone (more than 2 mm) existed. Smokingis also a known risk factor that increases the non-union rate by afactor of 2.7 [3,32].

As with most other studies, we found no effect of the diagno-sis on the outcomes [1,5,6]. Conversely, Smith et al. [12], reportedlower functional scores in patients with inflammatory diseases.The correlation between good rear-foot positioning and good func-tional results is well known [1,3,9]. Studies other than ours havealso reported a high number of technical deficits: 56% rate of nor-mal rear-foot alignment after TN + CC fusion [33] and incompletedeformity correction after triple arthrodesis [9].

The primary goal of the current study was to determine therisk of the outcomes worsening beyond 10 years due to secondaryosteoarthritis. Only a few other studies have such a long follow-up[1,2,6,11–13]. Nevertheless, our study has its limitations:

A very large number of patients were lost to follow-up. This canbe explained by many patients having moved during a 10+ yearperiod [12].

The multicentre nature of this study involved multiple sur-geons, and the inter-observer reliability during data collection isunknown.

Because several types of fusion procedures and diagnoses werepresent, the study cohort was inhomogeneous.

The strongest features of current study were that 72 cases werefollowed for more than 10 years, and that clinical and radiologicalassessments were used to determine the frequency of secondaryosteoarthritis and its functional impact (Table 3).

The development of osteoarthritis can be attributed to the non-fused joints being overloaded [2,9,10]. It is most common at theankle [8,10]. After triple arthrodesis, the rate of TT osteoarthritisranges from 39 to 77% [1,5–7,13,20,29]. The OA rate in the currentstudy (73%) is similar to the one reported by Wetmore et al. [13],

after 21 years of follow-up in patients with Charcot-Marie-Toothdisease. De Heus et al. [2] have reported an OA rate of only 34%after an average follow-up of 10 years. We are unable to explainthese differences. After ST fusion, the rate of TT osteoarthritis was

S236 M. Ebalard et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S231–S237

Table 3Secondary osteoarthritis in adjacents joints – Review of published studies.

Study Avg. follow-up(years) and %LTFU

Type ofarthrodesis

Rate of TTosteoarthritis

Rate ofrear-footosteoarthritis

Symptoms

Angus PD et al. [1] 13 (80% LTFU) Triple: 80 39% Unknown

Wetmore RS et al. [13] 21 (46% LTFU)(CMT)

Triple: 30 76% Unknown

Haritidis JH et al. [11] 25(poliomyelitis)

Triple: 42 28.6% No correlation

Clain MR et al. [33] 7 TN + CC: 16 37.5% ST: “a fewcases”

None

Fogel GR & al. [36] 9.5 TN: 11 Unknown ST: 28% Unknown

Saltzman CL et al. [6] 25 and 44 (69%LTFU)

Triple: 184 25 years: 69%44 years: 100%

Unknown No correlation

De Heus JA et al. [2] 10 (22% LTFU) Triple: 37ST: 17

35%/Triple29%/ST

Unknown No correlation

Smith RW et al. [12] 14 (48% LTFU) Triple: 31 27%Secondaryarthrodesis ofankle: 4%

NC: 27% No correlation

Munoz MA et al. [20] 7(inflammatorydisease)

TN: 54ST: 14Triple: 39

Secondarysurgery:11%/TN22.5%/Triple

Unknown Unknown

Sammarco VJ et al. [21] 1.5 to 7 ST + TN: 16 37.5% CC: 37.5% Unknown

Current study 15 (77.5% LTFU) Triple: 22ST: 37; ST + CC:1TN: 9

74%Secondaryarthrodesis:1.4%

ST: 58.3%TN: 65.8%CC: 53.5%

No correlation

L ; CC: c

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vier SAS; 2006. p. 44–904.[11] Haritidis JH, Kirkos JM, Provollegios SM, Zachos AD. Long-term results of triple

arthrodesis: 42 cases followed for 25 years. Foot Ankle Int 1994;15:548–51.

Chopart: 3

TFU: lost to follow-up; CMT: Charcot-Marie-Tooth disease; TN: talonavicular joint

eported as 14% after four years [3] and 36% after five years [34]. Ourate was higher (73%), likely because of the longer follow-up. Thereas no relationship between TT osteoarthritis and pain or the MFS

t the last follow-up. Other studies found no correlation betweensteoarthritis and pain in the TT joint [5,28,35]. As with other stud-es, we did not find any correlation between TT osteoarthritis andiagnosis or residual architectural defects [2,4,5,18,19,36].

We were able to determine the rate of secondary OA in non-used joints after partial arthrodesis, information rarely reportedn previously published studies (Table 3). The rate of secondaryA was very high in all of the joints that had been spared. Never-

heless, secondary ST, TN and CC osteoarthritis was not correlatedo pain or lower MFS scores at review. After ST fusion, it is easy tomagine that the spared midtarsal joint (CC + TN) would deteriorateue to excessive mechanical loading. But it is harder to under-tand why secondary ST or CC osteoarthritis occurs after TN fusion,hich theoretically restricts ST and CC motion. This suggests that

he restriction is functional but not complete.There was no statistical relationship between secondary

steoarthritis (no matter its location) and symptoms. But we foundignificantly more pain at the last follow-up than at 12 months post-perative. This can likely be explained by secondary osteoarthritisn the TT joint or rear-foot.

. Conclusion

Partial or complete fusion of the subtalar and midtarsal jointsring about satisfactory functional results, but the morbidity isy no means insignificant. Correct rear-foot positioning must bechieved. The arthritic degradation of the non-fused tibiotarsal,ubtalar and midtarsal joints cannot be ignored. Although few

atients are symptomatic after more than 10 years of follow-up,he high percentage of patients with pain upon review sug-ests that the OA will eventually bring out pain. We found noffect of residual architectural deformity on the occurrence of

[

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alcaneocuboid joint; ST: subtalar joint; NC: naviculocuneiform joint.

secondary osteoarthritis. As a consequence, other studies areneeded.

Disclosure of interest

The authors declare that they have no conflicts of interest con-cerning this article.

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