Primary Arthrodesis Versus Open Reduction Internal

ORTHOPAEDIC SURGERY

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Primary arthrodesis versus open reduction internal ﬁxation for complete Lisfranc fracture dislocations: a retrospective study comparing functional and radiological outcomes

Nathan Kirzner , Wesley Teoh, Sianne Toemoe, Tim Maher, Rejith Mannambeth, Andrew Hughes, Daniel Goldbloom, Hamish Curry and Harvinder Bedi Alfred Hospital, Melbourne, Victoria, Australia

Key words Abstract anatomical reduction, complete Lisfranc fracture dislocation, functional outcome, open reduction Background: The aims of this retrospective study were to compare the functional and internal fixation, primary arthrodesis. radiological outcomes of primary arthrodesis and open reduction internal fixation (ORIF) for the treatment of complete Lisfranc fracture dislocations. Correspondence Methods: A retrospective cohort study of 39 patients treated for a complete Lisfranc frac- Dr Nathan Kirzner, Alfred Hospital, 55 Commercial ture dislocation, defined as Myerson types A and C2, over a period of 8 years at a level Road, Melbourne, VIC 3004, Australia. 1 trauma centre was performed. Of these, 18 underwent primary arthrodesis, and 21 ORIF. Email: [email protected] The primary outcome measures included the American Orthopaedic Foot and Ankle Society N. Kirzner MBBS, BSc, MSurgSC, MRadTher; score, the validated Manchester Oxford Foot Questionnaire functional tool, and the second- W. Teoh MBBS; S. Toemoe MBBS; T. Maher ary outcome was the radiological Wilppula classification of anatomical reduction. MBBS; R. Mannambeth MBBS, MS (Ortho), DNB Results: Significantly better functional outcomes were seen in the primary arthrodesis (Ortho); A. Hughes FRACS (Ortho); D. Goldbloom group. These patients had a mean Manchester Oxford Foot Questionnaire score of 30.1 MBBS, FRACS (Ortho); H. Curry MBBS, FRACS points, compared with 45.1 for the ORIF group (P = 0.017). Similarly, the mean American (Ortho); H. Bedi MBBS, FRACS (Ortho). Orthopaedic Foot and Ankle Society score was 71.8 points in the fusion group versus 62.5 in the ORIF group (P = 0.14). Functional outcome was dependent on the quality of final Accepted for publication 2 December 2019. reduction (P < 0.001). Primary arthrodesis achieved good initial reduction in 83% cases doi: 10.1111/ans.15627 compared to 62% with ORIF (P = 0.138). There was a loss of reduction quality of 47% in the ORIF group over time. Conclusion: Primary arthrodesis for complete Lisfranc fracture dislocations resulted in improved functional outcomes and quality of reduction compared to open reduction and internal fixation.

8–12 Introduction achieving good functional outcomes, the method of treatment is still controversial. The Lisfranc joint complex describes the tarsometatarsal joints Despite early reduction and appropriate treatment, painful (TMTJ) and the ligamentous attachments that provide structural sup- osteoarthrosis remains problematic,10,13,14 and may necessitate conver- port to the transverse arch of the midfoot.1 Lisfranc fracture disloca- sion to TMTJ arthrodesis in some patients. In recent years there has tions are an uncommon injury accounting for approximately 0.2% of been a trend towards open reduction internal fixation (ORIF) with dor- – all fractures,2 5 the majority a result of high-velocity trauma.6 These sal bridge plating instead of transarticular screws in an attempt to are often serious, unstable injuries requiring surgical intervention and avoid additional iatrogenic articular damage caused by screw penetra- often leading to chronic disability.7,8 Myerson classified these injuries tion.11,15 While the literature shows improved functional outcomes according to direction and degree of displacement and divided them and maintenance of reduction with bridge plating.12,16 Our preceding into type A (homolateral complete), types B1 and B2 (homolateral paper showed that patients with complete Lisfranc injuries, in either a incomplete medially or laterally), and types C1 and C2 (divergent par- homolateral or divergent direction, had considerably worse outcomes tially or completely).17 The goals of treatment are to obtain a painless, independent of the type of treatment.12 This is thought to reflect the plantigrade, and stable foot, with return to premorbid function.4 While severity of the initial injury and the likelihood to subsequently develop it is clear that maintenance of anatomic alignment is a critical factor in post-traumatic arthritis.

Our hypothesis was that primary arthrodesis would prevent the Table 1 Patient and trauma characteristics and functional outcome development of a painful, deformed foot and the need for further Variable ORIF Primary P- surgery and disability in this subset of patients with complete (n = 21) arthrodesis (n = 18) value Lisfranc fracture dislocations. This was assessed through a retro- Male gender, n (%) 17 (81) 9 (50) 0.041 spective cohort study that analysed functional and radiologic out- Age at injury (years), mean (SD) comes following primary arthrodesis compared with open reduction Median 37 (14.2) 49.4 (18.9) 0.024 internal fixation. Range 19–67 21–80 Current smoker, 7 (33.3) 3 (16.7) 0.29 n (%) Diabetes, n (%) 1 (4.8) 2 (11.1) 0.59 Methods Trauma mechanism ’ MVA 15 (71.4) 9 (50) 0.17 Using our hospital s electronic database and the orthopaedic unit Fall 5 (23.8) 7 (38.9) 0.31 audit, all patients who had undergone surgery for tarsometatarsal Crush injury 1 (4.8) 2 (11.1) 0.59 fracture dislocations were identified. The search terms ‘open reduc- Open fracture 4 (19) 2 (11.1) 0.67 fi ’ ‘ Removal of metal 15 (71) 9 (50) 0.07 tion of fracture of the TMTJ with internal xation and primary Columns fixed, 0.87 arthrodesis’, along with the Medicare Benefits Schedule codes n (%) 47 624, 47 651 and 47 657, were utilized to identify all patients 2-column 4 (19.1) 8 (44.4) 3-column 17 (80.9) 10 (55.6) who had sustained complete Lisfranc fracture dislocation between 1 Follow-up (months) January 2009 and 1 July 2017. Median 38 52 In the 8-year study period, a total of 55 patients presented with Range 12–76 12–95 Myerson, n (%) complete Lisfranc fracture dislocations. The following inclusion A 16 (76.2) 14 (77.8) 1.00 criteria were used: (i) complete Lisfranc fracture dislocation; C2 5 (23.8) 4 (22.2) (ii) either ORIF or primary arthrodesis; (iii) at least 12 months AOFAS (foot) score, mean (SD) Mean 62.5 (19) 71.8 (19) 0.14 follow-up; (iv) contactable and agreeable to inclusion in the study. Range 18–98 38–100 Patient were excluded from the study if they had concomitant tarsal MOXFQ (foot) score, mean (SD) bone fixation (n = 8), were lost to follow-up or uncontactable Mean 45.1 (16.1) 30.1 (21.5) 0.017 – – fl Range 20 77 0 70 (n = 6), or had Charcot or in ammatory arthropathy (n = 2). After Overall satisfaction, 9 (42.9) 13 (72.2) 0.065 exclusion, a total of 39 complete Lisfranc fracture dislocations were n (%) included in the study (Table 1). Data are presented as n (%). AOFAS, American Orthopaedic Foot and Patient data including gender, age, smoking habits, diabetic status, Ankle Society midfoot score; MOXFQ, Manchester Oxford Foot Question- fi trauma mechanism, open or closed injury, operative characteristics, naire; MVA, motor vehicle accident; ORIF, open reduction internal xation. post-operative complications and follow-up data were retrieved. Post-operative complications were assessed from follow-up outpa- tient clinic notes and divided into soft tissue complications including the joints prior to fixation. The medial two or three rays were fused, superficial and deep wound infections and neurovascular injury; depending on the instability pattern. Surgery was performed by malfixation and loss of fixation including broken screws; severe pain three surgeons (HB, HC and DG), who were all members of a sin- issues; and non-union or malunion. The institution’s human research gle surgical unit. Two of the surgeons (HC and DG) were previous ethics committee provided ethical approval for the study. trainees of HB and thus their techniques were similar. The preoperative X-ray and computed tomography scans were The columns fixed were classified into two columns consisting of reviewed by a fellowship trained orthopaedic surgeon to identify the rigid medial column (first metatarsal and first cuneiform) and mid- associated injuries and the type of injury categorized according to dle column (second and third metatarsals and their respective cunei- the Myerson classification as either homolateral complete (A) or forms), or three-column, which included the relatively mobile lateral divergent complete (C2) (Fig. S1).17 The post-operative imaging column (consisting of fourth and fifth metatarsals articulating with the studies and operative reports were used to group patients according cuboid).1,21,22 Following fixation of the medial two columns, the lat- to the type of surgery performed: (i) dorsal plate fixation of the eral column was assessed under fluoroscopy and if unstable or incom- TMTJ or (ii) primary arthrodesis of the TMTJ. The choice of pletely reduced, fixation was performed with K-wires. This temporary implants used was ultimately at the discretion of the surgeon. All lateral stabilization was performed in both the arthrodesis and ORIF cases included were fixed exclusively with locking plates, of which groups if required as the lateral column was never fused. These were 33 were manufactured by DePuy Synthes (2.7-mm foot plating sys- removed between 6 and 8 weeks later. Post-operative rehabilitation tem; DePuy Synthes, Paoli, PA, USA) and six by Medartis; was the same in all groups and consisted of 6 weeks non-weight bear- 2.8-mm APTUS trilock plating system (Medartis, Basel, ing, followed by protected weight-bearing in a controlled ankle motion Switzerland). boot for further 6 weeks. Arch supports were employed between The exposure and techniques were the same between the two 3 and 6 months and implant removal when performed, occurred at a groups. In the primary arthrodesis group, the cartilage and fibrous minimum of 6 months post initial fixation or fusion surgery. tissue was resected, and the joints were decorticated. Additionally, Functional outcomes were measured by the American Orthopae- an incision was made on the lateral aspect of the heel and autolo- dic Foot and Ankle Society (AOFAS) midfoot score23 and the vali- gous bone graft was collected. This was subsequently packed into dated Manchester Oxford Foot Questionnaire (MOXFQ).24 The

Table 2 Myerson classification, Wilppula anatomic reduction and columns fixed stratified by functional outcome measures

Variables AOFAS foot score P-value MOXFQ foot score P-value

Myerson A(n = 30) 68.1 (18.8) 0.46 38.3 (19.8) 0.92 C2 (n = 9) 62.6 (21.5) 37.6 (22.0) Wilppula Good (n = 20) 74.2 (16.0) 0.012 29.8 (18.8) 0.006 Fair/poor (n = 19) 59.1 (19.9) 46.9 (17.7) Columns 2-column (n = 12) 72.7 (18.3) 0.21 31.8 (17.3) 0.19 3-column (n = 27) 64.2 (19.5) 41.0 (20.7)

AOFAS, American Orthopaedic Foot and Ankle Society midfoot score; MOXFQ, Manchester Oxford Foot Questionnaire.

latter is scored inversely with a lower score representing a better Lisfranc fracture dislocations. The mean MOXFQ score was 30 in outcome. Finally, patient responses were recorded for overall satis- the fusion group, compared to 45 in the ORIF group (P = 0.017). faction as either satisfied or not satisfied. The AOFAS scores showed a non-significant difference also in The anatomic reduction (alignment, length and Lisfranc inter- favour of the fusion cohort. The mean scores were 72 in the pri- val diastasis) was assessed on post-operative images using the mary arthrodesis group versus 62.5 in the ORIF group, but did not Wilppula classification of good, fair or poor anatomic reduction. reach statistical significance (P = 0.14). Overall, six patients had A good anatomic reduction was described as a good total shape excellent outcomes (score ≥90); five patients had good outcomes of the foot, with the diastasis between the first and second meta- (90 > score ≥ 75); 19 patients had fair outcomes (75 > score ≥ 50) tarsal bases <5 mm. Fair anatomic reduction was described as a and eight patients had poor outcomes (score <49). first and second metatarsal base diastasis of 6–9 mm. Finally, In terms of secondary outcomes, good or anatomic reduction was poor anatomic reduction was defined as marked deformity achieved in 15 of 18 (83%) cases in which primary arthrodesis was (e.g. cavus, abduction or adduction, shortening, or first metatar- performed, compared to 13 of 21 (62%) with ORIF (P = 0.14) sal dislocation), with a diastasis between the first and second (Table S1). There was a loss of reduction quality in the ORIF group metatarsal bases of >10 mm.25 over time of 53%. At final follow-up there was a significantly Statistical analysis was performed using the SAS software ver- greater proportion of patients in the primary arthrodesis group sion 9.4 (SAS Institute, Cary, NC, USA). Comparisons between maintaining a good anatomic reduction compared with the ORIF groups were made using Student’s t-tests or Mann–Whitney U-tests group (78% versus 29%, P = 0.002). The rate of intra-articular as appropriate for continuous variables and chi-squared or Fisher’s comminution between the first two TMTJs showed no significant exact test as appropriate for categorical variables. Immediate and difference between groups (55% in the ORIF group versus 57% in latest Wilppula anatomic reduction within each surgical group were the primary arthrodesis group). assessed using McNemar’s test. No adjustment was made for multi- Subgroup analyses directly comparing functional outcome ple comparisons. A two-sided P-value less than 0.05 indicated sta- scores with the Myerson classification, the number of columns tistical significance. fixed and anatomical reduction scores are presented in Table 2. An association was found between the radiological and func- Results tional outcome measures. Comparing good Wilppula anatomic reduction with fair/poor reductions, resulted in significantly bet- The patient characteristics and mechanism of injury, along with ter mean AOFAS and MOXFQ scores (AOFAS 74, MOXFQ 30; Myerson classification26 of injury type and the number of columns P < 0.001). There was no difference between Myerson types A requiring fixation are given in Table 1. The mean follow-up period and C2 in functional outcomes using both the AOFAS (68.1 and was 46 months. There were 26 men and 13 women with a mean 62.6; P = 0.46) and the MOXFQ (38.3 and 37.6; P = 0.92). age of 42.74 years (19–80). The injury was in the right foot in Finally, there was no significant association between the number 26 patients and the left in 13. ORIF with bridge plating was used in of columns fixed and functional outcome. 3-column fixation 21 patients (54%) and primary arthrodesis in 18 patients (46%). showed a mean AOFAS of 64.2 and MOXFQ of 41.0, compared There was a high proportion of high energy injuries (69%), smokers to AOFAS of 71.7 and MOXFQ of 31.8 for 2-column fixation. (26%) and diabetics (8%). The proportion of smokers, diabetics Reoperation for removal of metal was at the surgeons’ discre- and open fractures were comparable between both groups, although tion, occurring 71% of the time in the ORIF group compared the primary arthrodesis group had more women (50% versus 19%) with 50% in the arthrodesis cohort. and higher mean age (49 years versus 37 years), along with shorter In terms of complications, the ORIF group had two patients with mean follow-up. superficial wound infections treated solely with oral antibiotics Primary functional outcomes are also presented in Table 1. There (Table S2). Two patients had ongoing deep peroneal nerve paraes- was a statistically significant improvement with primary arthrode- thesia and broken screws were detected in three patients. In the pri- sis, compared to open reduction internal fixation alone for complete mary arthrodesis group, there was one case of superficial wound

© 2019 Royal Australasian College of Surgeons 588 Kirzner et al. infection, which resolved with oral antibiotics, and one case of bro- 28.6; P = 0.002). We postulate that this considerable loss of reduc- ken screw. Of note, severe post-operative pain was reported in tion in the ORIF group is due to the severity of the initial injury seven of 21 patients in the ORIF group and two patients required required to obtain a complete Lisfranc fracture dislocation. It is arthrodesis within the study period. suspected that the improved functional outcomes in the primary fusion group may be related to improved maintenance of anatomi- fi Discussion cal reduction, with all but one patient achieving fusion by nal follow-up. The management of acute Lisfranc injuries has been constantly Another potential and important consideration is that by fusing evolving in recent times. Anatomic reduction has been shown to the TMTJs, primary arthrodesis avoids post-traumatic arthrosis that significantly reduce the rate of developing osteoarthritis and results likely occurs in the ORIF group. In 2016, Lau et al.16 reported that in better functional outcomes.12,16,27 However, our preceding paper a good anatomical reduction had an 18.2 times decreased risk of demonstrated that patients with complete Lisfranc injuries had con- severe osteoarthritis compared with a fair or poor reduction. Simi- siderably worse outcomes, independent of the treatment modality.12 larly, Adib et al.27 found that in patients with an anatomical reduc- We speculated that this group of patients would be better treated tion, 35% developed osteoarthritis, compared with 80% of those with primary arthrodesis of the involved TMTJs. who had a non-anatomical reduction. While these studies show a Historically, fusion of the TMTJs for Lisfranc injuries has been a reduced rate of post-traumatic arthrosis with good anatomic reduc- well-accepted salvage procedure,28–30 which could be performed tion, our study demonstrates that in complete fracture dislocations without a devastating effect on function. This has generally been maintenance of this reduction is difficult with ORIF. We further performed on patients whose symptoms fail to resolve following found that functional outcome improved significantly with the qual- initial treatment and rehabilitation. In recent times, however, ity of the reduction at final follow-up. arthrodesis has been considered as a primary option for certain sub- In our study, the Myerson classification was used. In 2014, a ret- sets of patients with Lisfranc injuries.18–20 It has been observed that rospective study by Yu et al.33 of 80 patients with Lisfranc injuries pure dislocations without fracture may be associated with a poorer and a mean follow-up of 24 months, showed a statistically signifi- outcome despite ORIF.28 A prospective randomized study by Ly cant difference in functional outcome between Myerson type B and Coetzee19 comparing primary arthrodesis and ORIF for purely (homolateral incomplete medially or laterally) compared to those of ligamentous Lisfranc injuries showed significantly improved mean Myerson types A (homolateral complete) and C (divergent partially AOFAS scores (88 versus 68.6; P < 0.005) at short- and medium- or completely). The results of our preceding study concurred with term follow-up. Henning et al.18 showed a reduction in the need for these findings, showing significantly worse functional outcomes in subsequent surgeries with primary fusion and ORIF for purely liga- the types A and C2 compared to types B1, B2 and C1.12 Subgroup mentous injuries, although no difference in outcomes was seen. analysis in our current study showed no difference in functional To date there is a scarcity of literature comparing primary outcomes when comparing Myerson types A and C2, suggesting arthrodesis with ORIF for Lisfranc fracture dislocations,18–20 and the direction of complete displacement does not impact outcome. none looking specifically at complete injuries. In our study primary When comparing the number of columns fixed, there was no signif- arthrodesis was associated with statistically significant functional icant difference between 2- and 3-column fixations. This is likely improvements compared to ORIF alone. Reported AOFAS midfoot due to a similar amount of soft-tissue dissection between the two scores for functional outcomes have ranged from 70 to 86.4 for pri- groups. Furthermore, it supports the decision-making process in mary arthrodesis.18,19,31,32 These are consistent with our findings. deciding upon temporary lateral column fixation with K-wires or A recent retrospective study by Reinhardt et al.31 reviewed immobilization only. Complications were similar between the two 25 patients treated with primary arthrodesis for either primarily lig- groups; however, the ORIF group had a significantly greater pro- amentous or combined osseous and ligamentous Lisfranc fracture portion of patients with post-operative pain issues. dislocations. Both produced good clinical and patient-based out- This study has a number of potential limitations. It was primarily comes with mean AOFAS scores of 83.3 and 78.5, respectively. In limited by its retrospective nature and the possibility to introduce bias 2017, Wang et al.32 described a retrospective comparative study of into the allocation of patients into differing treatment groups. Despite 34 patients comparing functional outcomes in patients with Lisfranc this potential drawback, there were similar high proportion of smokers, fracture dislocations treated with primary arthrodesis or ORIF. At diabetics and open injuries among the three groups. This is likely due medium-term follow-up, mean AOFAS scores were comparable to the severity of the injury at our level 1 trauma centre and the fact between groups (85 versus 84.3). However, no differentiation was that we were specifically looking at complete Lisfranc fracture disloca- made based on severity of initial injury and only five complete inju- tions. This finding of better outcomes in the arthrodesis group may be ries were included in the study. Furthermore, quality of anatomical areflection of this cohort and may not be as applicable to low-energy reduction and functional outcomes were not correlated nor follow- injuries. There was a slightly greater proportion females with an older up imaging to assess maintenance of reduction reported. In our mean age in the primary arthrodesis group, which could be a source of study, primary arthrodesis achieved improved anatomical reduction bias due to lower expectations. Furthermore, younger patients within a and was better at maintaining that reduction compared to ORIF. At major trauma centre population may be less compliant with post- final follow-up there was a significantly greater proportion of operative instructions due to social/psychological factors. Another con- patients in the primary arthrodesis group maintaining a good ana- sideration, although likely less of a factor could be the added stress tomic reduction compared with the ORIF group (77.8% versus placed on the implants in a younger, more active cohort.

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30. Thompson IM, Bohay DR, Anderson JG. Fusion rate of first tar- Supporting information sometatarsal arthrodesis in the modified Lapidus procedure and flatfoot reconstruction. Foot Ankle Int. 2005; 26: 698–703. Additional Supporting Information may be found in the online ver- 31. Reinhardt KR, Oh LS, Schottel P, Roberts MM, Levine D. Treatment sion of this article at the publisher’s web-site: of Lisfranc fracture-dislocations with primary partial arthrodesis. Foot Table S1. Myerson classification, Wilppula anatomic reduction Ankle Int. 2012; 33:50–6. fi fi 32. Wang L, Yang C, Huang J, Shen J, He C, Tong p. Open reduction and and columns xed strati ed by functional outcome measures. internal fixation versus primary partial arthrodesis for Lisfranc injuries Table S2. Complications by type of surgery. accompanied by comminution of the second metatarsal base. Acta Figure S1. 3D CT reconstructions of Myerson types A (homo- Orthop. Belg. 2017; 83: 396–404. lateral) and C2 (divergent) complete Lisfranc fracture disloca- 33. Yu X, Pang QJ, Yang CC. Functional outcome of tarsometatarsal joint tions. fracture dislocation managed according to Myerson classification. Pak. Figure S2. Algorithm demonstrating surgeons’ decision for J. Med. Sci. 2014; 30: 773–7. ORIF versus primary arthrodesis.