Does Open Reduction and Internal Fixation versus Primary Arthrodesis Improve Patient Outcomes for Lisfranc Trauma? A Systematic Review and Meta-analysis

Abstract

Background Although Lisfranc injuries are uncommon, representing approximately 0.2% of all fractures, they are complex and can result in persistent pain, degenerative arthritis, and loss of function. Both open reduction and internal fixation (ORIF) and primary fusion have been proposed as treatment options for these injuries, but debate remains as to which approach is better. Questions/purposes We asked whether ORIF or primary fusion led to (1) fewer reoperations for hardware removal; (2) less frequent revision surgery; (3) higher patient outcome scores; and (4) more frequent anatomic reduction. Methods A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Three trials met the criteria for inclusion within the meta-analysis. Qualifying articles for the meta-analysis had data extracted independently by two authors (NS, AF). The quality of each study was assessed using the Center for Evidence Based Medicine's evaluation strategy; data were extracted from articles rated as good and fair: two and one article, respectively. Results The risk ratio for hardware removal was 0.23 (95% confidence interval [CI], 0.11-0.45; p \ 0.001) indicating more hardware removal for ORIF than fusion. For other revision surgery, the risk ratio for ORIF was 0.36 (95% CI, 0.08-1.59; p = 0.18) favoring neither. Similarly, neither was favored using patient-reported outcomes; the standard mean difference was calculated to be 0.50 (95% CI, À2.13 to 3.12; p = 0.71). When considering the risk of nonanatomic alignment, neither was favored (risk ratio, 1.48; 95% CI, p = 0.60). Conclusions The surgeon should consider the increased risk of hardware removal along with its associated morbidity and discuss this with the patient preoperatively when considering ORIF of Lisfranc injuries. Because no new trials have been performed since 2012, further randomized controlled trials will be needed improve our understanding of these interventions. Level of Evidence Level I, therapeutic study.

Military personnel sustaining Lisfranc injuries have high rates of disability separation

“…This requires surgery in nearly all cases. Failure to restore the normal anatomy promotes early post-traumatic arthritis, although this may occur even with appropriate treatment 9 10…”

Gait analysis and functional outcome in patients after Lisfranc injury treatment

“…Intersegment rang of motion (ROM) during gait was previously found to be related to PROM in patients with foot and ankle trauma [32]. Hence, kinematic gait analysis could provide more insight into kinematic changes in patients after Lisfranc injury and in addition could lead to more information on unsolved issues such as the influence on surgical reduction on functional outcome and the best fixation method [4,[33][34][35][36][37][38][39].…”

Nonoperative, open reduction and internal fixation or primary arthrodesis in the treatment of Lisfranc injuries: a prospective, randomized, multicenter trial – study protocol

“…However, even after appropriate treatment with ORIF, up to 40 to 94% of patients will develop post-traumatic arthritis [ 5 , 13 , 30 , 31 ], necessitating conversion to an arthrodesis to relieve pain [ 14 – 16 ]. To prevent the need for secondary operations and the development of post-traumatic arthritis, primary arthrodesis (PA) is suggested [ 30 , 32 – 34 ]. The treatment of non-dislocated injuries, in turn, is controversial [ 29 , 35 – 38 ].…”

“…Statistically significant differences were not found in physical functioning with regard to SF-36 or SMFA scores at any follow-up time interval. In their systematic review and meta-analysis, Smith et al [ 34 ] concluded that ORIF has a higher risk of implant removal compared with PA (risk ratio 0.23 (0.11–0.45) p < 0.001), although there were no statistically significant differences in revision surgery, PROMs or non-anatomic alignment. Cochran et al [ 32 ] organized a retrospective comparative cohort study on PA versus ORIF in young athletic military personnel with low-energy Lisfranc injury.…”