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Lisfranc Fracture-Dislocations Lisfranc Injuries Keith D. Cook, DPM Director, Podiatric Medical Education University Hospital Newark, New Jersey JULY 13, 2019 Disclosures DePuy Synthes: Consultant, Lecturer Osteomed: Consultant, Lecturer, Royalties UMDNJ OFFICE OF ADVANCEMENT AND COMMUNICATIONS 2 Objectives Maintain a high clinical suspicion for Lisfranc fracture-dislocations Decide between Open Reduction Internal Fixation versus Primary Arthrodesis Utilize latest fixation techniques UMDNJ OFFICE OF ADVANCEMENT AND COMMUNICATIONS 3 Lisfranc Fracture-Dislocation Overall frequency: • Lisfranc = 14% of all foot and ankle injuries • 20% Misdiagnosed 4 Obvious Subtle 5 Clinical Suspicion Edema Ecchymosis Erythema Pain Unable to walk Fracture blisters Compartment syndrome? 6 Diagnosis X-rays Contralateral x-rays Stress radiographs CT Scan MRI for ligament rupture 7 “Outcome After Open Reduction & Internal Fixation of Lisfranc Joint Injuries” Kuo, Hansen, et al. JBJS 82-A(11), Nov. 2000 Review of 48 patients with Lisfranc ORIF Pts. with non-anatomic reduction had a significantly higher prevalence of post- traumatic osteoarthritis than did those with anatomic reduction Anatomic reduction resulted in better AOFAS & MFA scores “Anatomic reduction & stable internal fixation has become a standard principle governing treatment of tarsometatarsal fracture-dislocations” 8 Treatment “It is well accepted that patients are likely to develop late joint deformity at the tarsometatarsal junction, joint separation, and radiographic and clinical evidence of post- traumatic arthritis when anatomic reduction is not obtained.” • Teng, Pinzur, et al. Foot ankle Int. 23:922-926, 2002. 9 Treatment Fusion vs ORIF 3.5 or 4.0mm screws K-wires Ex-Fix Bridge Plating 10 “Treatment of Primary Ligamentous Lisfranc Joint Injuries: Primary Arthrodesis Compared with Open Reduction and Internal Fixation” Ly, Coetzee. JBJS 88-A (3) March 2006 20 pts. w/ ORIF, 21pts. w/ primary arthrodesis 2 years post-op AOFAS score: – ORIF = 86.6 – Arthrodesis = 88 5 ORIF pts went on to arthrodesis Post-injury activity level: – ORIF= 65% – Arthrodesis = 92% 11 “Arthrodesis vs ORIF for Lisfranc Fractures” Sheibani-Rad S, Coetzee JC, et al Orthopedics 2012 Systematic Review 6 articles Fisher’s exact test revealed no significant effect of treatment group on the AOFAS score percentage on patients who had an anatomic reduction This study highlights that both procedures yield satisfactory and equivalent results 12 “Does Open Reduction and Internal Fixation versus Primary Arthrodesis Improve Patient Outcomes for Lisfranc Trauma? A Systematic Review and Meta-analysis.” Clinical Orthopedics & Related Research, 2016 3 studies Risk of hardware removal higher for ORIF group No risk difference for revisional surgeries or non-anatomic reduction between groups Patient recorded outcomes did not favor either group 13 A Systematic Review and Meta-analysis of the Treatment of Acute Lisfranc Injuries: Open Reduction and Internal Fixation versus Primary Arthrodesis Foot Ankle Surgery, April 2019 8 studies (2 RCT, 6 non-RCT studies) 547 patients No statistically significant difference between ORIF versus PA in return to work or activity and satisfaction rates ORIF group higher risk of hardware removal Overall complication rates equivalent in both groups UMDNJ OFFICE OF ADVANCEMENT AND COMMUNICATIONS 14 Reoperation Rate Differences Between Open Reduction Internal Fixation and Primary Arthrodesis of Lisfranc Injuries Buda, et al. Foot Ankle Int, September 2018 217 patients ORIF = 163, PA = 54 Mean f/u = 62.5 months Excluding planned hardware removal, reoperation rate: ORIF = 29.5%, PA = 29.6% p = 1 Highest rate for return to OR included deep infection, delayed wound healing and high-energy trauma UMDNJ OFFICE OF ADVANCEMENT AND COMMUNICATIONS 15 Cost Comparison and Complication Rate of Lisfranc Injuries Treated with Open Reduction Internal Fixation versus Primary Arthrodesis Barnds, et al. Injury, December 2018 Review of national insurance database of 23.5 million orthopedic patients 2130 patients Non-operative = 1248, ORIF = 670, PA = 212 Average Cost PA = $5,005.82, ORIF = $3,691.97, p=0.045 Complication Rate PA = 30.2% (64/212), ORIF = 23.1% (155/670) Hardware Removal Rate PA = 18.4% (39/212), ORIF = 43.6% (292/670) Primary arthrodesis is both more expensive and has a higher complication rate than ORIF UMDNJ OFFICE OF ADVANCEMENT AND COMMUNICATIONS 16 Lisfranc Screw Orientation? 17 “Determining the Strongest Orientation for “Lisfrancs Screw” in Transverse Plane Tarsometatarsal Injurues: A Cadaveric Study” Cook, KD, Jeffries LC, O’Connor JP, Svach D JFAS. 48(4): 427-431, 2009. Purpose: To determine the strongest orientation of Lisfranc’s screw when performing ORIF of Lisfranc fracture-dislocation injuries. 18 Alternative Lisfranc’s Screw: A Cadaver Study 6 pairs of fresh-frozen human cadavers 2 screw orientations of 3.5mm cannulated partially threaded screws, AO technique Alternative screw: placed from 2nd met base to medial cuneiform Tradition screw: placed from nd medial cuneiform to 2 met base 19 Alternative Lisfranc’s Screw: A Cadaver Study Pulled to failure with MTS Results: • Alternative screw mean force to failure=165.1 + 58.6N • Traditional screw mean force to failure=149.0 + 54.9N • p=0.247 20 Alternative Lisfranc’s Screw: A Cadaver Study Conclusion: The Lisfranc’s screw from the 2nd metatarsal to the medial cuneiform provides stability to the tarsometatarsal joint complex equal to or stronger than the traditional orientation. Technically easier Orientation of the “Lisfranc Screw” J Orthop Trauma 2012, Vinod K. Panchbhavi, MD 21 KJ 22 23 Morbidly obese F, s/p MVA 24 25 5 months post-op 26 27 26 yo M s/p forklift injury no pmh 28 29 30 2 months post-op 31 Summary High degree of clinical suspicion ORIF as effective or more effective than PA with less cost Alternative fixation techniques UMDNJ OFFICE OF ADVANCEMENT AND COMMUNICATIONS 32 Thank you! 33 .
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