SLR - December 2020 - Mohammad Qureshi

The Surgical Outcome of Lisfranc Injuries Accompanied by Multiple Metatarsal Fractures: A Multicenter Retrospective Study

Reference: Fan MQ, Li XS, Jiang XJ, Shen JJ, Tong PJ, and Huang JF. The Surgical Outcome of Lisfranc Injuries Accompanied by Multiple Metatarsal Fractures: A Multicenter Retrospective Study. Injury. 2019 Feb;50(2):571-578.

Level of Evidence: Level 3

Scientific Literature Review

Reviewed By: Mohammad Qureshi, DPM
Residency Program: McLaren Oakland Hospital – Pontiac, MI

Podiatric Relevance: There is a debate on whether to treat Lisfranc factures by open reduction internal fixation (ORIF) or primary arthrodesis. Previous studies have shown a higher level of post-traumatic osteoarthritis in patients undergoing ORIF compared to primary arthrodesis. This retrospective article investigates the outcome differences of Lisfranc fractures involving multiple metatarsals when treated with ORIF or primary arthrodesis. This article also investigated the differences between the two groups based on fixation types (e.g. plates, screws, and K-wires). 

Methods:  The investigators retrospectively reviewed 176 patients between 2002 and 2015 who sustained Lisfranc fractures with multiple metatarsals (head, neck, shaft, or mixed).  Fractures displaced more than 2 millimeters via imaging were included in the study.  Outcomes were measured by clinical examination, radiographic findings, visual analog pain score (VAS), AOFAS score, FAOS score, and survey questionnaires.  Treatment groups were divided into subgroups ORIF (K-wires, screws and K-wires, plates and K-wires, and plates, screws, and K-wires); primary arthrodesis group (screws and K-wires, plates and K-wires, and plates, screws, and K-wires).

Results: Anatomical reduction was achieved in 161 patients. VAS scores at final follow-up for the ORIF group was 1.93 and 1.21 in the arthrodesis group. Mean AOFAS scores were 74.67 at the final follow-up for the ORIF group and 82.79 for the arthrodesis group (p = 0.003). Significant differences were noted in the primary arthrodesis group in comparison to ORIF: VAS pain score (1.93 versus 1.21), SF-36 physical (75.87 versus 80.90) and mental (75.76 versus 81.33) components, FAOS pain (72.74 versus 84.06), symptoms (71.87 versus 82.49), activities of daily living (73.12 versus 81.54), sport/recreation (57.99 versus 73.23), and quality of life (79.95 versus 86.67). Patients undergoing primary arthrodesis via screws, dorsal plates, and K-wires had better outcomes than the other modes of fixation. Patient treated with dorsal plates and K-wires for ORIF had better outcomes in this group.

Conclusions: The goal of the study was to assess the surgical outcomes between ORIF and arthrodesis in the treatment of Lisfranc fractures that involved multiple metatarsals. Anatomic reduction is of utmost priority when reducing these injuries. When anatomical reduction was not successful, higher levels of refracture and post-traumatic arthritis were noted. At final follow-up, the arthrodesis group had statistically significant better outcome scores in comparison to the ORIF group. Those treated with fusion with screws, dorsal plates, and K-wires had the lowest pain level scores when compared to the other groups. Limitations of this study included the retrospective nature and variability in surgical techniques as different surgeons performed the procedures. Even though ORIF and primary arthrodesis both showed generally good outcomes, the primary arthrodesis had lower pain levels and rates of post-traumatic arthritis.

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