Jeannie Huh, MD Christopher Gross, MD Alex Lampley, MD Samuel B. Adams, MD James K. DeOrio, MD James A. Nunley II, MD Mark E.

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1 Jeannie Huh, MD Christopher Gross, MD Alex Lampley, MD Samuel B. Adams, MD James K. DeOrio, MD James A. Nunley II, MD Mark E. Easley, MD Duke University Medical Center Durham, NC

2 Disclosures Predictors of Nonunion in Midfoot Arthrodesis Presenter: Jeannie Huh, MD My disclosures are in the Final AOFAS Mobile App. I have no potential conflicts with this presentation.

3 Background Midfoot arthrodesis salvage procedure for: Painful arthritis multiple etiologies Instability Deformity Lack of evidence available indicating optimal surgical technique: Fusion construct Fixation type Bone graft/osteobiologics

4 Historical union rate: 90-98% 1-6 Background Based on studies with selective populations/etiologies Before introduction of modern midfoot-specific plating systems Paucity of literature regarding predictors of outcomes Mostly post-traumatic Quality of reduction 1-4 Time interval between injury and arthrodesis 1 Primary arthritis: Realignment of midfoot 2 Body mass index (BMI) associated with higher complication rate 3

5 Study Purposes To determine our midfoot arthrodesis union rate and compare it to that reported in the literature. To determine the patient and surgical factors that influence the union rate in midfoot arthrodesis.

6 Retrospective chart review All midfoot arthrodeses, regardless of etiology From Jan 2005 to Dec 2013 Single academic institution Methods 4 fellowship-trained foot & ankle surgeons

7 Methods Variables collected: Patient factors: Demographics Prior surgery Indication for arthrodesis Surgical factors: Mode of fixation Number joints arthrodesed Specific joints arthrodesed Concomitant procedures Postoperative outcomes: Union rate Complications Reoperations Statistical analysis performed to determine factors associated with nonunion

8 Results 312 consecutive midfoot arthrodeses 181 arthrodeses had >12 mo followup (mean 29.1 (12-100) mo) 161 adults Indication for Arthrodesis N (%) 33 men; 133 women Primary Osteoarthritis Mean age: 58 (18-84) yrs Mean BMI: 29.1 ( ) 1 st ray instability Diabetes: 29 (16%) Post-traumatic arthritis Tobacco use: 63 (34.8%) Inflammatory arthritis Prior surgery: 64 (35.4%) Charcot neuropathic arthritis Primary arthrodesis: 162 (89.5%) Revision arthrodesis: 19 (10.5%)

9 Results Mode of fixation: Transarticular screw(s): 61 Plate(s): 21 Transarticular screw(s) + Plate(s): 99 Bone graft/osteobiologics: 135 (74.6%) Concomitant procedure: 130 (71.8%) Forefoot: 66 (36.5%) Hindfoot: 52 (28.7%) Tendo-Achilles lengthening (TAL): 54 (29.8%) Number joints arthrodesed: Single joint: 81 Multiple joints: 100 Columns: Isolated Medial: 78 Isolated Middle: 11 Both: 91 Lateral: 3 Rows: Isolated tarsometatarsal (TMT): 135 Isolated naviculocuneiform (NC): 15 Both: 31 Extension to talonavicular (TN): 15

10 Results Overall union rate: 84% (152/181) Factors associated with nonunion: Variable Nonunion Rate p-value Revision 31.6% (6/19) (p=0.05) Tobacco use 30.2% (19/63) (p=0.0001) Multiple joints 24% (24/100) (p=0.001) NC joint arthrodesis 30.4% (14/46) (p=0.002) Extension to TN joint 46.7% (7/15) (p=0.049) Plate fixation 20.3% (25/123) (p=0.02) Allograft bone 25.7% (19/74) (p=0.003)

11 Results No difference in union rate: Age, gender, BMI, diabetes Indication for arthrodesis Autograft bone or osteobiologic agent Concomitant procedure Decreased nonunion rate: TAL: 7.4% (4/54) vs 19.6% (25/127) (p=0.045) Complications other than nonunion: 34.3% (62/181) Complication N (%) Hardware irritation Metatarsalgia Adjacent joint arthritis Deep infection Superficial infection Malunion 4 2.2

12 Discussion This investigation was a preliminary review of our midfoot arthrodesis experience Lower union rate and higher complication rate, compared to prior studies, may be related to: Inclusion of all etiologies of midfoot arthritis and all deformities Greater number of revision cases Greater number of multiple joint and extended joint arthrodeses Study limitations: Heterogenous study population Large number of patients excluded due to <12 mo followup Functional outcomes not reported A follow-on study with prospective clinical and radiographic outcome measures is currently underway

13 Factors predictive of nonunion after midfoot arthrodesis: Conclusions Revision arthrodesis Tobacco use Multiple joint fusion Arthrodesis at level of NC joints Extended constructs that include TN joint Plate fixation Use of supplemental bone allograft BMI, diabetes, indication for arthrodesis, and concomitant procedures were not associated with higher nonunion rate. TAL demonstrated a protective effect against nonunion.

14 References 1. Sangeorzan, BJ;Veith, RG;Hansen, ST, Jr. Salvage of Lisfranc's tarsometatarsal joint by arthrodesis. Foot Ankle. 1990;10(4): Mann, RA;Prieskorn, D;Sobel, M. Mid-tarsal and tarsometatarsal arthrodesis for primary degenerative osteoarthrosis or osteoarthrosis after trauma. J Bone Joint Surg Am. 1996;78(9): Myerson MS, Fisher RT, Burgess AR, Kenzora JE: Fracture dislocations of the tarsometatarsal joints: End results correlated with pathology and treatment. Foot Ankle 1986;6(5): Arntz CT, Veith RG, Hansen ST Jr: Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am 1988;70(2): Nemec, SA;Habbu, RA;Anderson, JG;Bohay, DR. Outcomes following midfoot arthrodesis for primary arthritis. Foot Ankle Int. 2011;32(4): Komenda, GA;Myerson, MS;Biddinger, KR. Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg Am. 1996;78(11):