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Primary Arthrodesis Versus Open Reduction Internal ORTHOPAEDIC SURGERY ANZJSurg.com 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. © 2019 Royal Australasian College of Surgeons ANZ J Surg 90 (2020) 585–590 586 Kirzner et al. 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.
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