n Feature Article Arthrodesis Versus ORIF for Lisfranc Fractures SHAHIN SHEIBANI-RAD, MD, MS; J. CHRISTIAAN COETZEE, MD; M. RUSSELL GIVEANS, PHD; CHRISTOPHER DIGIOVANNI, MD abstract Full article available online at Healio.com/Orthopedics. Search: 20120525-26 The Lisfranc joints make up the bony structural support of the transverse arch in the midfoot and account for approximately 0.2% of all fractures. Early recognition and treatment of this injury are paramount to preserving normal foot biomechanics and function. Controversy exists regarding the optimal treatment of patients with Lisfranc injuries, particularly when the instability is entirely ligamentous. A The authors performed a qualitative, systematic review of the literature to compare the 2 most common procedures for Lisfranc fractures: primary arthrodesis and open reduction and internal fixation (ORIF). Six articles with a total of 193 patients met the inclusion criteria. At 1-year follow-up, the mean American Orthopaedic Foot and Ankle Society score of ORIF patients was 72.5 and of arthrodesis patients was 88.0. Fisher’s exact test revealed no significant effect of treatment group on the percentage on pa- tients who had an anatomic reduction (P5.319). B This study highlights that both procedures yield satisfactory and equivalent results. A slight advantage may exist in performing a primary arthrodesis for Lisfranc joint injuries in terms of clinical outcomes. C Figure: Myerson classification. Total incongruity (A). Partial incongruity (B). Divergent (C). Dr Sheibani-Rad is from the Department of Orthopaedic Surgery, McLaren Regional Medical Center, Michigan State University, Flint, Michigan; Drs Coetzee and Giveans are from Minnesota Sports Medi- cine and Twin Cities Orthopedics, Minneapolis, Minnesota; and Dr DiGiovanni is from the Department of Orthopaedic Surgery, Brown Medical School, Rhode Island Hospital, Providence, Rhode Island. Drs Sheibani-Rad, Coetzee, Giveans, and DiGiovanni have no relevant financial relationships to disclose. Correspondence should be addressed to: Shahin Sheibani-Rad, MD, MS, Department of Orthopae- dic Surgery, McLaren Regional Medical Center, Michigan State University, 401 S Ballenger Hwy, Flint, MI 48532 ([email protected]). doi: 10.3928/01477447-20120525-26 e868 Healio.com The new online home of ORTHOPEDICS | Healio.com/Orthopedics LISFRANC FRACTURES | SHEIBANI-RAD ET AL he Lisfranc joints make up the bony structural support of the transverse Tarch in the midfoot. Lisfranc inju- ries account for approximately 0.2% of all fractures,1 with an incidence of 1/55,000 cases per year.1,2 Early recognition and treatment of this injury are paramount to preserving normal foot biomechanics and function. Approximately 20% of Lisfranc joint injuries are missed on initial antero- posterior and oblique radiographs,3 and 1 persistent malalignment after this injury Figure 1: Graph showing flow of studies retrieved for systematic review. can lead to chronic pain, progressive de- formity, and prolonged disability.4,5 Controversy exists regarding the op- tarsocuneiform joint, talometatarsal an- Quenu and Kuss15 or a modification of timal treatment of patients with Lisfranc gle, and the line tangential to the medial Myerson et al5 or Hardcastle et al,16 (2) injuries, particularly when the instabil- aspect of the navicular and the medial cu- treatment within 48 hours of injury, (3) ity is entirely ligamentous.6 Although neiform intersecting the base of the first the use of 1 of the 2 treatments of interest, the current trend is treating these patients metatarsal. Clinical outcome assessment and (4) publication between January 1985 with open reduction and internal fixation was determined via patient scoring based and September 2011 in English. All injury (ORIF),6-8 those with dislocation in the on the postoperative American Ortho- mechanisms were eligible for the study. absence of significant fracture continue paedic Foot and Ankle Society (AOFAS) Exclusion criteria included studies that to pose a therapeutic challenge. Despite midfoot scale. The purpose of the study focused on a biomechanical model, review appropriate initial treatment, up to 94% was to compare clinical and radiographic articles, articles on the pediatric popula- of these patients develop posttraumatic outcomes between arthrodesis and ORIF tion, isolated case reports, surgical tech- arthritis and require a conversion to an ar- interventions for Lisfranc injuries based nique articles, foreign language reports, throdesis of the tarsometatarsal joints.9-11 on available clinical and radiologic out- studies using either closed reduction or Some studies report primary arthrodesis comes. percutaneous pinning as the primary treat- to be a salvage method,12,13 whereas oth- ment, reports of arthrodesis as a salvage ers recommend it as a primary treatment.14 Literature Search or secondary procedure, and patient as- Because no consensus exists for manag- A comprehensive search was per- sessment that did not include the AOFAS ing Lisfranc fracture-dislocation variants, formed of Medline, Cochrane Central midfoot score. All study designs were the authors of the current study performed Register of Controlled Trials, and Ovid eligible, including randomized, controlled a qualitative, systematic review of the lit- using the key words Lisfranc, Lisfranc trials and prospectively or retrospectively erature to compare the 2 most common fracture, Lisfranc dislocation, metatarsal nonrandomized, controlled trials. procedures for Lisfranc fractures: primary fracture, metatarsal dislocation, Lisfranc arthrodesis and ORIF. Review of radio- arthrodesis, Lisfranc ORIF, and Lisfranc Statistical Methods graphic reduction and patient outcomes open reduction internal fixation. The data- Statistical analysis was performed was peformed. base review also included a search of any using SPSS version 16.0 for Windows published report in the American Associa- software (SPSS, Inc, Chicago, Illinois). MATERIALS AND METHODS tion of Orthopaedic Surgeons (AAOS) an- Fisher’s exact test was performed to com- A formal review was performed of all nual meeting proceedings between 2006 pare the reduction rate between the ORIF available reports in the English literature and 2010. To ensure that all possible ar- group and the arthrodesis group. Statisti- pertaining to ORIF and primary arthrod- ticles were considered, the references of cal significance was set at P,.05. esis (complete and partial) of the Lisfranc all relevant articles were manually cross- joints. Radiographic outcome assessment referenced to identify potential additional RESULTS included final or postoperative anatomic studies. The database search resulted in 1743 ar- reduction based on >1 of the following For a study to satisfy the inclusion ticles (Figure 1). After limiting the search radiological findings: diastasis between criteria, it required (1) inclusion of a Lis- to clinical trials in English and excluding the first and second metatarsals or meta- franc classification system according to biomechanical and surgical techniques, JUNE 2012 | Volume 35 • Number 6 e869 n Feature Article This left a total of 6 studies for the Table 1 current review (Table 1). The studies in- Selected Articles From Systematic Review cluded 8 treatment arms and a total of 193 eligible patients. Of the 6 studies, 4 Author Study Design Fixation Type No. of Patients True Na focused on ORIF alone. Two studies di- Arntz et al6 PCS ORIF 40 40 rectly compared ORIF and arthrodesis. Mulier et al12 PCS ORIF vs primary 28 28 The ORIF group comprised a total 160 arthrodesis eligible patients, with 152 patients under- Kuo et al17 RR ORIF 48 42 going the procedure and returning for fol- Ly & Coetzee18 PRC ORIF vs primary 41 41 low-up. The arthrodesis group comprised arthrodesis 33 patients. Rajapakse et al19 RR ORIF 25 17 Six articles included data on post- Teng et al20 RR ORIF 11 11 operative anatomic reduction,6,12,17-20 Abbreviations: ORIF, open reduction and internal fixation; PCS, prospective consecutive and 4 articles provided AOFAS midfoot series; PRS, prospective randomized comparison; RR, retrospective review. scores.17-20 Of 3 prospective studies, 2 in- aOnly patients who were available for follow-up and/or met inclusion/exclusion criteria, not total patient population. cluded direct comparisons of ORIF and arthrodesis. One study used a randomized design, and in the remaining prospective Table 2 studies, it was unclear whether the pa- tients were randomized. Mean follow-up Comparison of AOFAS Scores Between Selected Studies was 39.8 months. Kuo Ly & Rajapakse Teng Mean Of the 6 articles that met the inclusion Procedure et al17 Coetzee18 et al19 et al20 AOFAS Significance criteria, 6,12,17-20 4 reported AOFAS scores 17-20 ORIF 80.2 68.6 70.3 71.0 72.5 NA at 1-year follow-up. Each of these arti- Arthrodesis NA 88.0 NA NA 88.0 NA cles included patients treated with ORIF, with 1 of the 4 also reporting AOFAS Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; NA, not applicable; ORIF, open reduction and internal fixation. scores for an arthrodesis group (Table 2).18 The total number of patients evaluat- ed was 90 in the ORIF group and 21 in the Table 3 arthrodesis group. At 1-year follow-up, Comparison of Anatomic Reduction the mean AOFAS score of ORIF patients was 72.5 and of arthrodesis patients was Patients ORIF Arthrodesis P 88.0. By not having access to the origi- Total No. 146 33 nal data sets, the authors were unable to perform a statistical analysis on AOFAS No. with reduction 134 28 scores at 1 year between patients under- % 91.8 84.8 .319 going ORIF and arthrodesis. However, al- Abbreviation: ORIF, open reduction and internal fixation. though the sample size is somewhat small for the arthrodesis group, a clinical differ- ence between the 2 groups is evident at case reports, imaging studies, studies not this could not be determined from the ab- 1-year follow-up, with the AOFAS score involving ORIF or arthrodesis, studies not stract. From this group, 16 articles were for the arthrodesis group higher than that involving the Lisfranc joint, nonoperative determined to fulfill the inclusion criteria.