Level III, retrospective comparative series.

Category: Midfoot/Forefoot, Sports, Trauma Introduction/Purpose: Traumatic injuries to the tarsometatarsal or Lisfranc joints can be complex problems associated with long-term pain, disability, and deformity. Most current literature advises early open reduction and internal fixation (ORIF) for acute Lisfranc injuries and reserves arthrodesis for chronic injuries, isolated ligamentous injuries, or salvage procedures. There is also a reported association between delayed diagnosis or missed injuries and poor outcomes. The purpose of this study was to evaluate the association between time from injury to treatment and method of fixation with outcome. Methods: A retrospective review of 171 non-battle related closed tarsometatarsal dislocations and fracture dislocations was conducted of patients identified using the Department of Defense Trauma Registry and Military Health System Mart from 2009- 2014 searching by CPT codes. Demographic information, injury characteristics, treatment course, and physical evaluation board results were examined. Return to duty was defined as a patient returning to full duty and passing their service specific physical fitness test. We excluded polytrauma patients, battle injuries, deep infections requiring surgical debridement, those with pre- existing duty limiting conditions, those who separated from the military for unrelated reasons prior to completing their rehabilitation and those with incomplete data. Results: Overall of 107 patients 69% returned to full active duty, 4% returned to limited duty with permanent duty restrictions and 27% underwent a medical evaluation board and were ultimately discharged from service. The ORIF group consisted of 80 patients; the average time from injury to fixation was 2.5 weeks and 63% returned to full duty, 6% returned on permanent profile. Of the arthrodesis group 20 underwent primary arthrodesis with an average time from injury of 15.4 weeks and a return to duty rate of 80%. Seventy-one percent of patients who underwent arthrodesis as a salvage procedure for failed ORIF or post-traumatic osteoarthritis (PTOA) underwent a medical evaluation board and were discharged from service. Conclusion: This represents one of the largest cohorts in the literature and redemonstrates that tarsometatarsal dislocations and fracture-dislocations are serious injuries that can lead to permanent disability. The data also demonstrates very low return to duty rates in those who underwent salvage arthrodesis reinforcing the importance of initial anatomic reduction and the poor outcomes of PTOA. Most notably it demonstrates higher return to duty rates among patients who underwent primary arthrodesis despite the inclusion of more missed/chronic injuries when compared to ORIF. This suggests that primary arthrodesis may be a viable option in a young and active population despite later treatment.

Background A battlefield-related injury results in increased local and systemic innate immune inflammatory responses, resulting in wound-specific complications and an increased incidence of osteoarthritis. However, little is known about whether severe injuries affect long-term systemic homeostasis, for example, immune function. Moreover, it also remains unknown whether battlefield-acquired metal fragments retained over the long term result in residual systemic effects such as altered immune reactivity to metals. Questions/purposes Does a retained metal fragment from a battlefield injury contribute to increased (1) adaptive metal-specific immune responses, (2) systemically elevated metal ion serum levels, and (3) serum immunoglobulin levels compared with combat injuries that did not result in a retained metal fragment? Methods In this pilot study, we analyzed metal-immunogenicity in injured military personnel and noninjured control participants using lymphocyte transformation testing (LTT, lymphocyte proliferation responses to cobalt, chromium and nickel challenge at 0.001, 0.01 and 0.1-mM concentrations in triplicate for each participant), serum metal ion analysis (ICP-mass spectroscopy), and serum immunoglobulin analysis (IgE, IgG, IgA, and IgM ). Military personnel with a battlefield-sustained injury self-recruited without any exclusion for sex, age, degree of injury. Those with battlefield injury resulting in retained metal fragments (INJ-FRAG, n = 20 male, mean time since injury ± SD was 12 ± 10 years) were compared with those with a battlefield injury but without retained metal fragments (INJ-NO-FRAG, n = 12 male, mean time since injury ± SD was 13 ± 12 years). A control group comprised of male noninjured participants was used to compare measured immunogenicity metrics (n = 11, males were selected to match battlefield injury group demographics). Results Military participants with sustained metal fragments had increased levels of metal-induced lymphocyte responses. The lymphocyte stimulation index among military participants with metal fragments was higher than in those with nonretained metal fragments (stimulation index = 4.2 ± 6.0 versus stimulation index = 2.1 ± 1.2 (mean difference 2.1 ± 1.4 [95% confidence interval 5.1 to 0.8]; p = 0.07) and an average stimulation index = 2 ± 1 in noninjured controls. Four of 20 participants injured with retained fragments had a lymphocyte proliferation index greater than 2 to cobalt compared with 0 in the group without a retained metal fragment or 0 in the control participants. However, with the numbers available, military personnel with retained metal fragments did not have higher serum metal ion levels than military participants without retained metal fragment-related injuries or control participants. Military personnel with retained metal fragments had lower serum immunoglobulin levels (IgG, IgA, and IgM) than military personnel without retained metal fragments and noninjured controls, except for IgE. Individuals who were metal-reactive positive (that is, a stimulation index > 2) with retained metal fragments had higher median IgE serum levels than participants who metal-reactive with nonmetal injuries (1198 ± 383 IU/mL versus 171 ± 67 IU/mL, mean difference 1027 ± 477 IU/mL [95% CI 2029 to 25]; p = 0.02). Conclusions We found that males with retained metal fragments after a battlefield-related injury had altered adaptive immune responses compared with battlefield-injured military personnel without indwelling metal fragments. Military participants with a retained metal fragment had an increased proportion of group members and increased average lymphocyte reactivity to common implant metals such as nickel and cobalt. Further studies are needed to determine a causal association between exposure to amounts of retained metal fragments, type of injury, personnel demographics and general immune function/reactivity that may affect personal health or future metal implant performance. Level of Evidence Level IV, therapeutic study.

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