Lisfranc injuries: fix or fuse?

Abstract

Aims This systematic review and meta-analysis was conducted to compare open reduction and internal fixation (ORIF) with primary arthrodesis (PA) in the treatment of Lisfranc injuries, regarding patient-reported outcome measures (PROMs), and risk of secondary surgery. The aim was to conclusively determine the best available treatment based on the most complete and recent evidence available. Methods A systematic search was conducted in PubMed, Cochrane Controlled Register of Trials (CENTRAL), EMBASE, CINAHL, PEDro, and SPORTDiscus. Additionally, ongoing trial registers and reference lists of included articles were screened. Risk of bias (RoB) and level of evidence were assessed using the Cochrane risk of bias tools and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool. The random and fixed-effect models were used for the statistical analysis. Results A total of 20 studies were selected for this review, of which 12 were comparative studies fit for meta-analysis, including three randomized controlled trials (RCTs). This resulted in a total analyzed population of 392 patients treated with ORIF and 249 patients treated with PA. The mean differences between the two groups in American Orthopedic Foot and Ankle Society (AOFAS), VAS, and SF-36 scores were -7.41 (95% confidence interval (CI) -13.31 to -1.51), 0.77 (95% CI -0.85 to 2.39), and -1.20 (95% CI -3.86 to 1.46), respectively. Conclusion This is the first study to find a statistically significant difference in PROMs, as measured by the AOFAS score, in favour of PA for the treatment of Lisfranc injuries. However, this difference may not be clinically relevant, and therefore drawing a definitive conclusion requires confirmation by a large prospective high-quality RCT. Such a study should also assess cost-effectiveness, as cost considerations might be decisive in decision-making. Level of Evidence: I Cite this article: Bone Jt Open 2021;2(10):842–849.

Management of Lisfranc Injuries

“…However, there is some evidence that PA may provide superior results to IF in select patient groups, including injuries that are purely ligamentous, high-energy, and/or in the presence of severe articular damage at the time of injury. There are currently 6 published meta-analyses on this topic 78-83 (Table I). However, the heterogenous nature of the described surgical techniques and injuries included, make it challenging to draw firm conclusions.…”

“…The reoperation rate was significantly higher in the fixation group (78% vs. 20%), but when hardware removal cases were excluded, the reoperation rates were comparable, as were the overall complication rates. van den Boom et al performed a recent comprehensive systematic review on the topic 79 . Twenty studies (12 suitable for meta-analysis) were included, with 392 patients treated with IF and 249 patients with PA.…”

A Systematic Review of Outcomes Following Lisfranc Injury Fixation: Removal vs Retention of Metalwork

“…A number of reviews have compared primary arthrodesis vs open reduction and internal fixation-all limited by wide study heterogeneity with as yet no evidence of clinically relevant difference between the two. 36,42,47 The potential but unproven purported benefits of metalwork removal include optimization of midfoot biomechanics and function, reduced pain, lower risk of broken metalwork, and easier secondary surgery in the event of developing painful posttraumatic osteoarthritis. The disadvantages of routine metalwork removal include risks of surgery such as deep peroneal nerve injury, 21 a second anaesthesia, further time off work, rehabilitation delays, increased health care costs, and potentially no subjective benefit to the patient.…”