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FAIXXX10.1177/1071100717711483Foot & Ankle InternationalCochran et al research-article7114832017

Article

Foot & Ankle International® 2017, Vol. 38(9) 957­–963 Primary versus Open Reduction © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav and Internal Fixation for Low-Energy Lisfranc DOI:https://doi.org/10.1177/1071100717711483 10.1177/1071100717711483 Injuries in a Young Athletic Population journals.sagepub.com/home/fai

Grant Cochran, MD1, Christopher Renninger, MD1, Trevor Tompane, MD1, Joseph Bellamy, MD2, and Kevin Kuhn, MD1

Abstract Background: There are 2 Level I studies comparing open reduction and internal fixation (ORIF) and primary arthrodesis (PA) in high-energy Lisfranc injuries. There are no studies comparing ORIF and PA in young athletic patients with low- energy injuries. Methods: All operatively managed low-energy Lisfranc injuries sustained by active duty military personnel at a single institution were identified from 2010 to 2015. The injury pattern, method of treatment, and complications were reviewed. removal rates, fitness test scores, return to military duty rates, and Foot and Ankle Ability Measure (FAAM) scores were compared. Thirty-two patients were identified with the average age of 28 years. PA was performed in 14 patients with ORIF in 18. Results: The PA group returned to full duty at an average of 4.5 months whereas the ORIF group returned at an average of 6.7 months (P = .0066). The PA group ran their fitness test an average of 9 seconds per mile slower than their preoperative average whereas the ORIF group ran it an average of 39 seconds slower per mile (P = .032). There were no differences between the 2 groups in the FAAM scores at an average of 35 months. Implant removal was performed in 15 (83%) in the ORIF group and 2 (14%) in the PA group (P = .005). Conclusions: Low-energy Lisfranc injuries treated with primary arthrodesis had a lower implant removal rate, an earlier return to full military activity, and better fitness test scores after 1 year, but there was no difference in FAAM scores after 3 years. Level of Evidence: Level III, comparative cohort study.

Keywords: Lisfranc, ORIF, arthrodesis, midfoot

Introduction area.1,5,6,7,12,13,16,17 Several studies investigated the treatment outcomes for Lisfranc injuries in athletes but they largely Lisfranc injuries affect the tarsometatarsal (TMT), intercu- consisted of nonoperative management, closed reduction neiform, and the naviculocuneiform . They include any and internal fixation, or ORIF. In many cases, they also combination of bony and ligamentous injury to this complex. describe a more subtle variety of the injury and frequently Historically they have been associated with high-energy involve a relatively small number of patients without a mechanisms such as motor vehicle crash, falls, or crush inju- comparative group.5,13,17 ries.10 The treatment of these high-energy injuries has evolved

over time with authors now agreeing that an anatomic reduc- 1 1,2,8,19,25 Naval Medical Center San Diego, San Diego, CA, USA tion through open means is of critical importance. 2Sports & Orthopaedic Specialists, Minneapolis, MN, USA Well-designed, prospective studies comparing open reduc- tion and internal fixation (ORIF) with primary arthrodesis Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of (PA) demonstrate comparable outcomes in combined bony the Navy, Department of Defense, or the United States Government. and ligamentous injuries and improved outcomes with PA in injuries that are primarily ligamentous.9,11 Corresponding Author: Grant Cochran, MD, Naval Medical Center San Diego, Department of Recently, there has been a greater appreciation of Orthopedic , 34800 Bob Wilson Drive, San Diego, CA 92134, Lisfranc injuries in association with low-energy mecha- USA. nisms, and there is a growing body of literature in this Email: [email protected] 958 Foot & Ankle International 38(9)

The role of PA is unclear in young, athletic patients who sustain low-energy injuries. The purpose of this study was to compare the outcomes of low-energy Lisfranc injuries treated with PA or ORIF in a young military population.

Methods After local institutional review board approval, operatively managed Lisfranc injuries were identified at a single mili- tary tertiary referral center from July 2010 to June 2015. Inclusion criteria included being on active duty in the mili- tary, sustaining a low-energy mechanism of injury, and treat- ment with either ORIF or PA. Exclusion criteria included any hindfoot or ankle injury, high-energy mechanism, initial surgery at another facility, and less than 1 year’s follow-up. Injuries were classified as low-energy if they occurred dur- ing athletic activity, ground-level twisting, or a fall from less than 3 feet. Operative database search yielded 80 traumatic Lisfranc injuries. Forty-eight were due to low-energy mech- Figure 1. Weightbearing radiographs demonstrating a ligamentous of the first and second rays. anisms. Ten patients were excluded for not being active duty military, 2 had concomitant hindfoot or ankle injuries, 3 had their initial surgery at an outside hospital, and 1 was lost to Table 1. Injury Characteristics of the Open Reduction follow-up after his 6-month appointment. This left 32 cases Internal Fixation (ORIF) Group Compared With the Primary (18 ORIF, 14 PA) for inclusion. The patient cohort was com- Arthrodesis (PA) Group. posed of 31 males and 1 female with a mean age at surgery of 28 (range, 19-39) years, and a mean follow-up time of 32 ORIF, % PA, % (range, 13-70) months. Thirty-four percent reported some (n=18) (n = 14) P Value tobacco use. Mechanisms of injury included athletic activity Primarily ligamentous 72 64 .71 (n=23), fall from less than 3 feet (n=6), and ground-level Myerson type B1 pattern 22 14 .67 twisting (n=3). There were no significant differences in sex, Displaced articular fracture 0 0 1 age, follow-up time, tobacco use, or mechanism of injury Lateral column instability 0 0 1 between the 2 groups. A trauma fellowship-trained orthopedic surgeon reviewed all plain films and computed tomographic (CT) scans. According to the Hardcastle (modified by Myerson) classifi- Radiographic parameters used to assess injury patterns and cation system, there were 7 type B1 and 25 type B2 inju- quality of reduction included any step off or incongruity of ries.15 No comminuted intra-articular fractures were seen. the TMT joints; diastasis greater than 2 mm between the There was no lateral column instability that required fixa- medial cuneiform and the base of the second metatarsal; the tion. There were no statistically significant differences in alignment of the medial border of the second metatarsal with injury patterns between the 2 groups (Table 1). the medial border of the intermediate cuneiform on the The indication for operative management was any anteroposterior radiograph; the alignment of the medial bor- demonstrable instability in the Lisfranc complex. der of the fourth metatarsal with the medial border of the ORIF was the surgery of choice for most patients who pre- cuboid on the oblique radiograph; and alignment of the talus sented in the acute period. PA was selected for any patients with the first ray on the lateral radiograph. Weightbearing who presented greater than 6 weeks after injury. There were radiographs were obtained in 27 (84.4%) patients to assess 3 patients with primarily ligamentous injuries who under- the instability pattern (Figure 1).22 The remaining patients went PA in the acute period after a shared decision-making were unable to bear weight and had diagnostic nonweight- process in which the findings of Ly and Coetzee were bearing films. The indication for CT scan was to accurately discussed.11 identify all bony injuries for preoperative planning. A primar- Instability patterns were confirmed using intraoperative ily ligamentous pattern was identified as having no struc- stress fluoroscopy. Operative techniques mirrored those tural fractures at the unstable joints. Twenty-two patients previously described.3,4 All procedures were performed by (69%) had primarily ligamentous patterns. All injuries with foot and ankle or trauma fellowship-trained orthopedic sur- isolated instability of the first or second rays were classified geons. An open approach to the unstable segments was per- as grade II according to the Nunley classification system.17 formed in all cases. The first and second TMT joints as well Cochran et al 959

seen was contracture of the extensor hallucis longus, and this required operative management. Late midfoot collapse or was seen in 3 patients, and these were categorized as treatment failures. Predictably, implant removal rates were higher in the ORIF group (P < .001). Patients returned to military activity when they were able to perform their primary job duties, and participate in mandatory physical training. Overall return to duty rate was 88% and occurred at a mean of 6.0 (range, 4.3-20.7) months. A timed distance running test is performed bi-annually and annually in the United States Navy and Marine Corps, respectively. Postinjury run times were available in 21 of the 27 (78%) who returned to duty. One patient opted to perform an alternate cardiovascular event, and the other 5 patients returned to full duty but separated from the military for unrelated reasons prior to the next fitness test. The aver- age preinjury run times were calculated and compared to the first postinjury run time. To allow for direct comparison between the Navy and Marine Corps patients, the run times Figure 2. The patient from Figure 1 underwent open reduction were converted to seconds per mile. internal fixation with transarticular screws. Twenty-seven of 32 (84%) patients completed a phone interview at an average of 35 (range 12-70) months. Each as the Lisfranc interval were fixed in each case. The medial patient was asked about additional , if they were intercuneiform joint was typically fixed as well. In the PA currently under the care of a surgeon, and if they were still group, the joints were prepared and the subchondral in the military. The Foot and Ankle Ability Measure was perforated. Autograft was used in most cases. The (FAAM) was also completed over the phone if it had not joints were then reduced and provisionally held with clamps been done in clinic. or Kirschner wires. Direct visualization and fluoroscopy All continuous variables were compared with a 2-tailed was used to ensure an anatomic reduction prior to final fixa- Student t test. All categorical variables were compared with tion. Fixation followed with transarticular screws and/or Fisher exact test. Significance was set for all analyses at locked compression plates. In the ORIF group, the joints P <.05. Excel (Microsoft, Seattle, WA) was utilized for all were inspected for debris and then reduced. A mixture of statistical analysis. bridge plates and transarticular position screw constructs were used (Figure 2). A medial column plate was used for instability of the naviculocuneiform joints in 3 patients. Results Following fixation of the unstable medial column, the lat- Open Reduction Internal Fixation Group eral column was assessed and found to be stable in all cases; thus, no fixation or fusion was performed. Postoperative Of the 18 patients in the ORIF group, 3 (16%) injuries were plain radiographs were reviewed using the parameters initially missed but then diagnosed within the first week. described above and an anatomic reduction was achieved in Thirteen (72%) were primarily ligamentous. Mean time to 30 of 32 (94%) patients. No postoperative CT scans were surgery was 18 (range, 11-33) days. Isolated instability of obtained to assess for persistent occult subluxation. the first and second rays was uniform across this group, and A standardized postoperative course was utilized. A pos- no patients required fixation of the third, fourth, or fifth ray. terior slab splint was used in all patients until 2 weeks. A TMT fixation constructs included screws alone in 10 (56%), removable boot or cast was then used in the ORIF and PA screws and plates in 1 (5%), and plate only in 7 (39%). groups, respectively. The cast was removed at the 6-week Minor complications included 4 with permanent deep pero- visit and patients in the PA group were made to wear a neal nerve sensory changes and 2 superficial that removable boot. Graduated weightbearing was allowed at occurred after implant removal, both were successfully 10 weeks in the ORIF group. Weightbearing was restricted treated with oral antibiotics. The only major complication in the PA group until there was clinical and radiographic evi- was contracture of the extensor hallucis longus, and this dence of fusion, which was typically at the 10-week visit. required operative management. Three treatment failures Minor complications included sensory changes in the deep were seen. One had midfoot collapse and required conver- peroneal distribution (n=6), superficial (n=2), and sion to arthrodesis at 43 months (Figure 3). The other 2 symptomatic implants (n=2). The only major complication developed midfoot arthritis, and fusion was recommended 960 Foot & Ankle International 38(9)

Figure 3. Chronic loss of reduction and midfoot arthritis developed in the patient from Figure 1. Salvage arthrodesis was recommended. but the patients declined. Implant removal was performed in 15 (83%). All transarticular screws were removed, whereas some bridge plates were allowed to be left in place. Time to implant removal averaged 120 days. Sixteen (89%) in the ORIF group were able to return to military duty at an average of 209 (range, 79-343) days. Visual analog scale (VAS) pain score at final clinical fol- Figure 4. Primary arthrodesis with proximal tibia bone graft low-up averaged 1.5 (range 0-7), with 7 (39%) being pain that went on to uneventful union at 3 months. free. Average postinjury run time was 39 seconds slower (range 16 seconds faster to 92 seconds slower) per mile than The first timed run was performed at an average of 320 the preinjury average. The first timed run was performed at (range, 129-621) days after surgery. an average of 369 (range 188-589) days after surgery. Primary Arthrodesis vs. ORIF Outcome Primary Arthrodesis Group Comparison Of the 14 patients in the PA group, 8 (57%) were initially There was no difference in return to duty rates, VAS missed, resulting in delayed diagnosis and presentation pain score at final follow-up, and days to fitness testing beyond 6 weeks, thus indicating fusion. Three patients had between the 2 groups. The average time to return to full delayed surgery secondary to inappropriate management military activity was 2 months sooner in the PA group (P = from their primary doctor or being lost to follow-up. The .0066). Other than undergoing ORIF, there were no other final 3 were indicated for primary arthrodesis in the acute risk factors for a delay in return to military activity. The period as part of a shared decision-making process. Nine average pre- to postinjury run time was 29 seconds faster (64%) were primarily ligamentous. Ten underwent arthrod- per mile in the PA group (P = .032) (Table 2). The FAAM esis of the first and second TMT as well as the medial inter- Activities of Daily Living (ADL) score was 84.7 and 83.3 cuneiform joint, and the Lisfranc interval. Four required the for the ORIF and PA groups, respectively. The FAAM ADL inclusion of the third TMT and lateral intercuneiform joint. Single Assessment Numerical Evaluation (SANE) was Fixation constructs included screws alone in 8 (57%) and 77.5 and 82.1 for the ORIF and PA groups, respectively. combined screws and plates in 6 (43%). Minor complica- The FAAM Sports Subscale score was 70.4 and 69.2 for tions included 2 permanent deep peroneal nerve sensory the ORIF and PA groups, respectively. The FAAM Sports changes and 2 symptomatic medial screws. The 2 symp- Subscale SANE score was 67.9 and 70.7 for the ORIF and tomatic screws were removed at an average of 13 months. PA groups, respectively. There were no differences in any There were no infections in this group. Union occurred of the FAAM subscale scores at an average of 35 months’ uneventfully in all patients at an average of 81 (range, follow-up (Table 3). 58-96) days (Figure 4). Twelve (86%) in the PA group were able to return to military activity at an average of 138 (range, 78-228) days. Discussion VAS pain score at final clinical follow-up averaged 1.6 The management of acute Lisfranc injuries has evolved over (range, 0-8), with 8 (57%) being pain free. Average postin- time. Nonoperative management was replaced by closed jury run time was 9 seconds slower (range 31 seconds faster reduction and Kirschner wire fixation, and now open reduc- to 61 seconds slower) per mile than the preinjury average. tion with rigid fixation is recommended for all displaced Cochran et al 961

Table 2. Military Specific Outcomes of the Open Reduction of the potential for a rapid return to activity, believing that Internal Fixation (ORIF) Group Compared With the Primary primary arthrodesis may prevent the restoration of normal Arthrodesis (PA) Group. foot function.16 However, there are no clinical data regard- ORIF (n = 18) PA (n = 14) P Value ing the long-term consequences of midfoot fusion in the athletic or general population. RTD Rate 89% 86% 1 The literature describing ORIF after sports-related inju- Days to RTD 209 138 .0066 ries consists of multiple case series without any compara- Days to first run test 369 320 .4 tive groups. Curtis et al reported a case series of 19 patients First run time minus 39 s slower/ 9 s slower/ .032 in which 14 were managed nonoperatively and 5 underwent preinjury average time mile mile ORIF.5 They recognized the severity of even subtle injuries Abbreviation: RTD, return to duty. and recommended fixation of all unstable joints. Nunley et al reported a case series of 15 patients in which 7 were managed nonoperatively, 6 were treated with closed reduc- Table 3. Foot and Ankle Ability Measure (FAAM) scores of the tion and internal fixation, and 2 received ORIF.17 Fourteen open reduction internal fixation (ORIF) group compared with the primary arthrodesis (PA) group. were reported to have excellent outcomes. More recently, Deol et al examined the return to training and competition ORIF PA P Value of 17 elite soccer and rugby players after mostly ORIF.6 FAAM ADL Score 84.7 83.3 .84 Sixteen were able to return to training and then full compe- FAAM ADL SANE 77.5 82.1 .54 tition at an average of 20 and 25 weeks, respectively. Return FAAM Sports Score 70.4 69.2 .91 to full military activity averaged 6 months in the current FAAM Sports SANE 67.9 70.7 .79 study. This is at the high end of the 14 to 25 weeks required to return to competitive sport seen within the litera- Abbreviations: ADL, activities of daily living; SANE, single-assessment ture.5,6,17,22 Returning to full duty requires the patient to do numerical evaluation. their daily work, any assigned athletic activity, and possibly be assigned to remote locations. It is therefore not surpris- injuries.1-3,8,10,19,25 Primary arthrodesis was initially used as ing that this cohort was on the longer end of the reported a salvage procedure for midfoot arthritis or collapse after range. Despite the relatively good return to sport data, there failed ORIF.20 Following a study showing high failure is a growing body of literature showing the short- and rates of ORIF in primarily ligamentous injuries and a sur- medium-term failure rates of ORIF.1,2,5-7,16,17 It is important geon-stratified cohort study showing comparable out- to remember that these failure rates are in high-energy inju- comes between ORIF and PA, a randomized trial was ries and there are no clinical data regarding the long-term performed.10,11,14,23 The landmark study by Ly and Coetzee failure rates of ORIF in low-energy injuries. found better short- and medium-term outcomes with PA in The current study was the first to compare PA and ORIF high-energy ligamentous injuries.11 An additional Level I in low-energy injuries. In addition, it assessed return to ath- study in mixed bony and ligamentous high-energy injuries letic activity in a young population. This study found that found comparable results between ORIF and PA, with high those treated with primary arthrodesis were able to return to rates of secondary procedures for HWR in the ORIF group.9 full military activity an average of 2 months earlier. A pos- It is important to note that none of these comparative studies sible confounding factor is that the ORIF group underwent involved any significant number of low-energy injuries or planned implant removal in 83% of cases and this second athletes. surgery may have slowed down the rehab process. The cur- The subsequent indications for acute primary arthrodesis rent study also found that those who underwent primary suggested by Coetzee and Ly are as follows: major ligamen- arthrodesis scored closer to their preinjury time in a 1.5- or tous disruptions and multidirectional instability of the 3-mile timed run. This is likely secondary to bony healing Lisfranc joints; a comminuted intra-articular fracture at the being faster and more durable than soft tissue healing. Once base of the first or second metatarsal; and crush injuries of a solid fusion is seen, pain should be minimal and all activ- the midfoot with an intra-articular fracture dislocation.4 ity limitations are removed from the patient, allowing for a Another suggested indication for primary arthrodesis is a rapid return to training. At an average of 35 months’ follow- significant delay to surgery, although the cut-off time for up, the FAAM scores were equal between the 2 groups. definitive fixation is not agreed upon.16,18,21,24 We used 6 Unfortunately, the current study does not contain multiple weeks as the upper limit for fixation as this is the most con- data points for run times and FAAM scores, so it is not pos- servative time frame in line with expert opinion. sible to follow functional recovery over time as tested by The indications for primary arthrodesis in low-energy these modalities. The functional differences seen at differ- athletic injuries are not established. Myerson has recom- ent time points in this study can be explained in one of 2 mended against primary arthrodesis in athletes, regardless ways. 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