SLR - December 2016 - Matthew Wilson

Does Open Reduction and Internal Fixation versus Primary Arthrodesis Improve Patient Outcomes for Lisfranc Trauma? A Systematic Review and Meta-Analysis

Reference:
Smith N, Stone C, Furey A. Does Open Reduction and Internal Fixation versus Primary Arthrodesis Improve Patient Outcomes for Lisfranc Trauma? A Systematic Review and Meta-Analysis. Clin Orthop Relat Res. 2016 Jun;474(6):1445–1452.

Scientific Literature Review

Reviewed By: Matthew Wilson, DPM
Residency Program: Grant Medical Center

Podiatric Relevance: Although Lisfranc injuries are relatively rare, they often lead to poor patient outcomes with substantial persistent pain, posttraumatic arthritis, decreased function and decreased quality of life. Both open reduction with internal fixation (ORIF) and primary arthrodesis have been demonstrated to be acceptable methods for treatment of acute Lisfranc injuries. It is widely accepted that patient outcomes are largely related to the success of accurate anatomic reduction, but there is still much discussion as to which procedure yields better results. This systematic review compares ORIF versus primary arthrodesis for treatment of acute osseous or ligamentous Lisfranc injuries with regards to 1) incidence of hardware removal; 2) incidence of operative revision other than hardware removal; 3) patient outcome scores; and 4) risk of nonanatomic reduction.

Methods: The authors searched PubMed, EMBASE and Cochrane databases in October 2014 using combinations of the following terms: “metatarsal bones,” “Lisfranc,” “midfoot,” “tarsal joints” and “tarsal bones” to describe anatomic location; “fracture” and “dislocations” to describe injury type; and “fracture fixation,” “fracture fixation, internal,” “fusion” and “arthrodesis” to describe intervention. After removing duplicate articles from the search, a total of 1192 papers were found. Articles were eliminated for basic science work, nonhuman trials, surgical technique guides, pediatric trials, other injuries, commentaries, meeting summaries, biomechanical studies, textbook chapters, reviews, no comparative data or involving neuropathic joints. After exclusions, nine articles were left to be included in the qualitative synthesis evaluation. Only RCTs and high-quality cohort studies as described by The Center or Evidence-Based Medicine’s quality assessment were included, as well as studies rated as “good” or “fair” according to the the U.S. Preventative Task Force Quality Rating Criteria for evaluating risk of bias. This left three studies to be included in the meta-analysis.  

Results:
The incidence of hardware removal risk ratio was 0.23 (95 percent CI, 0.11 to 0.45; p < 0.001) demonstrating increased incidence of hardware removal for ORIF versus arthrodesis. For operative revision other than hardware removal, the risk ratio was 0.36 (95 percent CI, 0.08 to 1.59; p = 0.18) demonstrating no difference between the two procedures. Patient outcome scores were similar between the two groups with the standard mean difference being 0.50 (95 percent CI, -2.13 to 3.12; p = 0.71). The risk of nonanatomic reduction had a risk ratio of 1.48 (95 percent CI, 0.34 to 6.38; p = 0.60) indicating no difference between the two procedures.

Conclusions: Patient comorbidities, individual patient characteristics, specific fracture patterns and surgeon preferences should always be considered when deciding on treatment for acute Lisfranc injuries. It is recommended that surgeons discuss with patients preoperatively the increased likelihood of hardware removal with ORIF versus primary arthrodesis. The relative rarity of Lisfranc injuries makes comparative trials difficult to obtain. The large expanse of injury patterns categorized as “Lisfranc injuries” may carry excessive heterogeneity to conclude that one procedure is superior to the other. For many articles involving this topic, the quality of data was not acceptable for inclusion in this meta-analysis, although previous studies have found advantages to both ORIF and arthrodesis given their studies’ parameters. This meta-analysis included only two RCTs and one cohort study, making definitive conclusions difficult to obtain. Further prospective randomized controlled trials are required to determine a superior method for treatment of acute Lisfranc injuries.

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