Fusion of the Tarsal Joints: Outcome, Diagnostics, and Management of patient expectations

Controversies exist in the field of diagnostics and operative treatment of foot problems that are treated through fusion of tarsal joints. This thesis aims to clarify existing controversies in tarsal fusion by evaluating diagnostic strategies and outcome measurement of different surgical procedures, contributing to a better and more patient centered quality of care for this patient group as well as a better understanding of success and failure of the different procedures. Diagnostic strategies Literature shows consensus in X-ray examination being inaccurate to measure postoperative consolidation. It is therefore recommended to use CT scanning postoperatively instead of X-ray examination especially if union after arthrodesis is to be determined (Chapter 4). Diagnostic injections in various joints are considered a specific and sensitive test. Although the patients had good results after arthrodesis, a control group made clear that the pain relief after injection was not predictive of a good result of the operation. No positive recommendation for intra-articular injections can be given (Chapter 5). Treatment In this thesis the treatment is focussed on operative tarsal fusion. The literature shows good results after tarsal arthrodesis in general (chapter 2), but unfortunately there is little evidence on which technique should be used for which specific diagnosis. A review of the literature according to the Newcastle Ottawa Score showed three favourable combinations, found through best evidence synthesis (chapter 6). In rheumatoid arthritis talonavicular and triple arthrodesis show good results. In posttraumatic arthritis, subtalar arthrodesis is a good solution, and there are indications in the literature that arthroscopic arthrodesis has better outcome than open arthrodesis. Although OA of the ankle joint is generally considered to be a late effect of tarsal arthrodesis, this had not increased at the follow-up study after 7.5 years. A correlation was found between good alignment and a stable minor degree of OA (chapter 3). Outcome measurements In order to improve the care for patients in need of tarsal fusion, it is imperative to measure outcome continuously. Unfortunately, most of the outcome scores and PROMS are being questioned for validity and have raised concern. Many of these scores are not used consistantly, are not validated or have low sensitivity. The present interest in Patient Reported Outcome Measurement (PROM) is promising because research has long been researcher or doctor oriented and to a lesser extent patient oriented. In this thesis, the Quote method was used to incorporate patient views into outcome instruments for tarsal fusion. The fact that a Quote instrument is always specific concerning the diagnosis, the intervention and the location, makes it a great tool to improve care in a continuous process. A QUOTE score can be updated by repeating a focus group meeting after analysis. It should be clear that a QUOTE score is to be used in addition to more objective outcome scores and has the purpose to improve care (chapter 7).