Risk of osteoarthritis secondary to partial or total arthrodesis of the subtalar and midtarsal joints after a minimum follow-up of 10 years.

INTRODUCTION: The goal of this retrospective, multicentre study was to evaluate the long-term outcomes in 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 than 10 years after these fusion procedures. MATERIAL AND METHODS: The outcomes of 72 fusions (total: 22; partial: 50) performed between 1981 and 2002 were evaluated using the Maryland Foot Score (MFS), self-evaluation questionnaire and three weight-bearing X-ray views (Meary's with cerclage wire around heel, lateral and dorsoplantar). The average follow-up was 15 ± 5 years (range 10-31). RESULTS: There were two deep infections that resolved after lavage and antibiotics therapy. There were 21 early complications (10 complex regional pain syndrome, 7 delayed wound healing, 2 superficial infections, 2 venous thrombosis) that all resolved. There were five cases of non-union (6.9%) that healed after being re-operated. After five years, secondary osteoarthritis led to the fusion being extended to the tibotalar joint (1 case) and midtarsal joint (1 case). At the last follow-up, the average MFS was 71.5 (range 25-100). Patient deemed the result as either excellent (10%), very good (9%), good (55%), poor (19%) or bad (7%). Pain at the last follow-up was present in 84% of cases. The rear-foot was normally aligned in 45% of cases, varus aligned in 22% and valgus aligned in 33%. The MFS was significantly better in patients with 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 secondary osteoarthritis 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. However there was significantly more pain at last follow-up than at 12 months postoperative and two fusions were required in patients with secondary osteoarthritis. CONCLUSION: Although partial or total arthrodesis of the subtalar and midtarsal joints is a reliable procedure, it induces secondary osteoarthritis. Even though it seems to be well tolerated more than 10 years after the initial procedure, this possibility must be discussed with young, active patients. LEVEL OF EVIDENCE: IV, retrospective study.

Is it worth fixing proximal humeral fractures at increased vascular risk?

OBJECTIVE: To evaluate fixation of proximal humeral fractures by anterograde nailing, in terms of fracture reduction, bone healing; osteonecrosis; functional consequences of osteonecrosis and malunion. DESIGN: Prospective, consecutive, multicenter based. SETTING: Academic Trauma Centers; approval was received from the ethics committee of the institutions involved in the study. METHODS: Fifty-one patients were enrolled prospectively, with 31 3-part and 20 4-part displaced fractures (head displacement greater than 45°, tuberosity-head gap greater than 10mm, diaphyseal gap greater than 10mm). A Telegraph™ nail (FH Orthopedics, Heimsbrunn, France) was the fixation device used, introduced through a superolateral transdeltoid approach under fluoroscopic guidance. The assessment included Simple Shoulder Test, absolute Constant score, X-rays every 3 months and CT-scan at final evaluation. Twelve patients died and one was lost to follow-up. Immediate complications included secondary displacement in four patients. RESULTS: There were no infections, no deltoid muscle or axillary nerve damage, and all the fractures united. After a mean follow-up of 24.1 months, malunion was observed in 29% of the remaining 38 patients and osteonecrosis in 32%. Both complications were more frequent and extensive in patients with 4-part fractures. The osteonecrosis area influenced the Constant score, which was 55.8 points when the area was less than 30%, 50.6 points between 30 and 50%, and 38 points when larger than 50%. Head malunion affected the Simple Shoulder Test and the Constant score. CONCLUSION: Nailing may thus be recommended for 3-part fractures, because osteonecrosis is less frequent, more focused, and better tolerated in this sub-group. In contrast, antegrade nailing was not more beneficial than other internal fixation techniques for preventing osteonecrosis or head malunion in patients with 4-part fractures. LEVEL OF EVIDENCE: Level IV: prospective study.