Arthrodesis or Open Reduction Internal Fixation for Lisfranc Injuries: A Meta-analysis

Abstract

The purpose of this study is to determine if arthrodesis, compared with open reduction and internal fixation (ORIF), produces favorable American Orthopaedic Foot and Ankle Society (AOFAS) and visual analogue scale (VAS) scores, and to determine if differences in complication, revision surgery, and secondary arthrodesis rates exist for patients with Lisfranc fracture/dislocation injuries. Searches were performed in PubMed using the keywords “Lisfranc fracture,” “metatarsal fracture,” “ORIF,” “open reduction internal fixation,” “arthrodesis,” and “fusion.” These criteria left 183 articles for review. Exclusions left 21 articles and 2 translations of Chinese abstracts. Data analysis was performed using Student’s 2-sample t test for samples of equal variance, and chi-square test for goodness of fit. The t test revealed a significant difference (P = .03) between the average AOFAS score for patients who underwent primary arthrodesis (84.7 ± 6.14) compared with those who were treated with ORIF (78.9 ± 5.09). There was no significant difference for the average VAS scores (P = .33) of the arthrodesis and ORIF groups. The complication rate of arthrodesis patients was significantly lower than ORIF patients (P = .04), and the rates of revision surgery (P = .22) and secondary arthrodesis (P = .53) were not significant between the groups. The results of this study indicate that arthrodesis may be a better surgical option than ORIF, due to the higher functional scores and the lower complication rate.

Levels of Evidence: Level III: A meta-analysis

Keywords

Lisfranc fracture dislocation metatarsal fracture dislocation open reduction internal fixation arthrodesis

It is estimated that 20% of Lisfranc complex injuries are missed on first examination, leading to long-term complications and disability.”

The tarsometatarsal joint, often referred to as the Lisfranc joint, is located on the plantar aspect of the foot between the midfoot and the forefoot.¹ Unlike with the other metatarsals, no intermetatarsal ligament spans the joint between the first and second metatarsals, leaving support of the joint dependent on the Lisfranc plantar ligament.² This structure stabilizes the arch of the foot when bearing weight, and prevents displacement of the first 2 metatarsals.¹ While injuries to the Lisfranc joint complex are rare (accounting for 0.2% of all fractures),³ the consequences if left untreated can be debilitating.⁴ It is estimated that 20% of Lisfranc complex injuries are missed on first examination, leading to long-term complications and disability.^4,5

Lisfranc injuries may occur through direct or indirect force, with direct injuries being the most common mechanism of injury.⁶ Direct injuries are often seen during high-energy trauma events, such as motor vehicle accidents or falling from a height.^2,6 Indirect injuries usually result from axial load delivered to a plantar-flexed foot, causing a rotational injury.^6,7 There is controversy in the current literature over the best method to treat Lisfranc injuries,² although the best outcomes are associated with anatomical reduction.⁸

Open reduction internal fixation (ORIF) has long been the standard of care for Lisfranc injuries.^7,9 However, even after ORIF intervention, 40% to 94% of patients develop posttraumatic osteoarthritis.² Many of these patients require arthrodesis to fuse the tarsometatarsal joints. Other studies have recommended that arthrodesis be used as a salvage procedure in the event of failed ORIF.¹⁰ The findings of several recent studies indicate that arthrodesis may be an effective primary treatment for Lisfranc injuries.^10-13

Comparison of primary arthrodesis to ORIF is not a new topic. Systemic reviews conducted in 2012 and 2016 examined the current literature to determine if evidence exists that would support one surgical intervention over the other.^13,14 Sheibani-Rad et al¹³ explored the data from 6 articles, comparing the mean American Orthopaedic Foot and Ankle Society (AOFAS) scores between ORIF and primary arthrodesis patients, as well as the proportion of the patients who had anatomic reduction. They concluded that both procedures are viable treatments, but there may be an advantage toward performing primary arthrodesis. The 2016 review found 39 articles eligible but examined only 3 studies for their comparison data and high levels of evidence.¹⁴ They examined the rates of hardware removal, risk of revision surgery, overall patient outcomes, and anatomic reduction of ORIF and arthrodesis for Lisfranc patients; of the 4 groups, only hardware removal showed a significant difference in the treatments. However, these studies utilize relatively small sample sizes or do not focus on standardized scores of foot function, areas that this study will attempt to satisfy.

The current study was conducted to perform a meta-analysis of the current literature, comparing the functional outcome, pain ratings, complication rate, and rate of revision surgery between ORIF and arthrodesis treatments groups. The objective was to obtain a larger sample size than any in the current literature in order to get a more definitive result. The purpose of this study is to determine if arthrodesis, compared with ORIF, produces favorable AOFAS, visual analogue scale (VAS) scores, and better complication and revision surgery rates for patients with Lisfranc fracture/dislocation injuries.

Materials and Methods

Searches were performed in PubMed using the keywords “Lisfranc fracture” or “metatarsal fracture”, generating 1706 articles. The search terms “ORIF,” “open reduction internal fixation,” “arthrodesis,” and “fusion” were used to filter the results, producing 183 articles which were then screened. Inclusion criteria is clinical comparison study and retrospective clinical case series and random clinical trial. Focus of this article was on the outcome of the Lisfranc fractures treated with either ORIF and or fusion. Exclusion criteria included studies published in a non-English language, studies that were published before 1997, and studies that did not focus on patient data and clinical outcomes. These exclusions left 20 articles and 2 English translations of Chinese abstracts remaining for in-depth exploration and data analysis (Figure 1). All relevant articles had their references manually cross-checked for potential additional studies. Articles were included in all components of the analysis for which they provided applicable data. Three articles^8,24,33 did not list AOFAS scores; 12 articles^{8,11,12,19,21-25,27,28,30} did not include VAS scores; and 2 abstracts did not include complications. Four other articles were not included when assessing complications because the complications could not be identified for the specific surgical treatment.

Figure 1.

Flowchart of inclusion criteria.

AOFAS and VAS scores were examined using Student’s t test with P < .05 significance. Complication rate, revision rate, and secondary arthrodesis rate were examined using chi-square test with P < .05 significance.

Results

A total of 521 Lisfranc patients, from 19 studies, reported AOFAS scores^{8,12,15-23,25-32} (Table 1). A total of 449 (86.2%) of these patients were treated with ORIF, and 72 (14.8%) were treated with primary fusion. The ORIF patients were last seen at an average of 34.18 months for final follow-up (2 outliers were removed), and the arthrodesis patients were seen at an average of 26.25 months for final follow-up (1 outlier was removed).

Table 1.

Overview of Reference and Patient Data in the Articles Included in the Meta-analysis.

Reference no.	Authors	Year	Surgical type	Sample size	Average F/U (mo)	AOFAS score	VAS score	Evaluated for complication rate
8	Teng et al	2002	ORIF	11	41.2	71	n/a	Yes
11	Henning et al	2009	ORIF Arthrodesis	14 18	24 24	n/a n/a	n/a n/a	Yes
12	Ly and Coetzee	2006	ORIF Arthrodesis	20 21	24 24	68.8 88	n/a n/a	Yes
15	Abassian et al	2015	ORIF	58	104.4	84.5	1.65	Yes
16	Chen et al	2011	ORIF	16	12.6	74.6	n/a	No
17	Dubois-Ferriere et al	2016	ORIF Arthrodesis	50 11	130.9 130.9	79.7 77.8	2.5 2.7	Yes
18	Feng et al	2017	ORIF	15	26.4	75.8	3.1	Yes
19	Ghate et al	2012	ORIF	14	30	79	n/a	No
20	Gu et al	2017	ORIF	14	48	74.4	2.2	Yes
21	Hu et al	2014	ORIF	60	31	81.0	n/a	Yes
22	Kosters et al	2014	ORIF	6	30	73.7	n/a	Yes
23	Kuo et al	2000	ORIF	48	52	77	n/a	Yes
24	Mulier et al	2002	ORIF Arthrodesis	16 6	30.0 30.0	n/a n/a	n/a n/a	Yes
25	Nithyanath et al	2011	ORIF	13	57	82	n/a	No
26	Qiao et al	2017	ORIF Arthrodesis	17 8	7.5 15	88.6 94.0	1 0.13	Yes
27	Rajapaske et al	2006	ORIF	15	42.6	78.3	n/a	Yes
28	Rammelt et al	2008	ORIF	22	36	81.4	n/a	Yes
29	Reinhardt et al	2012	Arthrodesis	25	42	80.8	1.8	Yes
30	Saxena et al	1997	Arthrodesis	7	24	86.4	n/a	Yes
31	Zhang et al	2012	ORIF	29	38.4	80.6	2.4	Yes
32	Zhu et al	2011	ORIF	41	36	84.2	2.6	No
33	Cochran et al	2017	ORIF Arthrodesis	18 14	32 32	n/a n/a	1.5 1.6	Yes

Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; F/U, follow-up; n/a, not available; ORIF, open reduction internal fixation; VAS, visual analogue scale.

There were 300 Lisfranc patients, from 9 studies, that reported VAS scores.^{15,17,18,20,26,28,31-33} (Table 1). A total of 242 (80.7%) of the patients were treated with ORIF, and 58 (19.3%) were treated with primary fusion. In the ORIF group, patients had their final follow-up an average of 31.38 months after surgery (2 outliers were removed), and the arthrodesis patients had their final follow-up at a mean of 29.67 months after surgery (1 outlier was removed).

In total, 462 Lisfranc patients, from 17 studies, were included in the analysis of complication rate, rate of revision surgery, and rate of secondary arthrodesis^{8,11,12,15,18,20-24,26-31,33} (Table 1). A total of 363 (78.6%) of these patients were treated with ORIF, and 99 (21.4%) were treated with primary fusion. ORIF patients were seen at an average follow-up of 33.51 months (1 outlier was removed), and arthrodesis patients were seen at an average follow-up of 27.29 months.

The t test revealed a significant difference (P = .03) between the average AOFAS score for patients who underwent primary arthrodesis (84.7 ± 6.14) compared with those who were treated with ORIF (78.9 ± 5.09) (Table 2).

Table 2.

Lisfranc Fracture—Arthrodesis or ORIF: Comparison of AOFAS and VAS Scores for the Surgical Interventions.

Surgical intervention	AOFAS	VAS
ORIF	78.9	2.04
Arthrodesis	84.7	1.61
	P = .03	P = .33

Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; ORIF, open reduction internal fixation; VAS, visual analogue scale.

There was no significant difference for the average VAS scores (P = .33) of the arthrodesis and ORIF groups (1.61 ± 0.929 and 2.04 ± 0.677, respectively) (Table 2).

The chi-square test showed that the arthrodesis patients were significantly less likely to have complications develop (P = .04). The rate of revision surgery (P = .46) and the rate of secondary arthrodesis (P = .18) were not significantly different for the 2 surgical treatments (Table 3).

Table 3.

Complication, Revision Surgery, and Secondary Arthrodesis Rates.

	Total patients	Complications	Revision	Secondary
ORIF	363	177	54	35
Arthrodesis	99	30	18	5
		P = .04	P = .46	P = .18

Abbreviation: ORIG, open reduction internal fixation.

Discussion

Lisfranc injuries, when left untreated or undiagnosed, can lead to extreme impairment and long-term disability.⁴ The ligaments at the Lisfranc joint, including the Lisfranc ligament, are vital to maintaining the arch formed as the metatarsals articulate with the cuneiforms and cuboid.^2,5 It is recommended that, on diagnosis, Lisfranc injuries be treated as soon as possible to decrease the risk of future chronic pain, physical limitations, or osteoarthritis.^7,34 Most of the literature recommends that Lisfranc injuries be repaired with open reduction and internal fixation,^1,24,35 although several recent studies seem to indicate that primary arthrodesis may be the better option.^26,29 Recent meta-analysis, which compare relatively fewer studies support our conclusion that primary arthrodesis may result in better AOFAS scores and less pain although these articles lack definitive conclusions on complication rates and are not included as comprehensive breadth of information.^36-38 No consensus has emerged regarding the treatment of Lisfranc injuries, though it is generally agreed upon that closed reduction and casting is unsuccessful for most cases.^23,28,34

The current debate over which surgical method is a better treatment option explained the necessity of this review, and previous reviews in 2012 and 2016 did not utilize as large a sample size, demonstrating a gap in the literature.^1,10,13,14 Additionally, only 1 of the 2 studies examined the rate of follow-up surgery, and neither examined the rate of complications. It was decided to explore foot function score and overall pain scale, as well as complication rate, revision rate, and secondary arthrodesis rate to assess the 2 surgical interventions. AOFAS and VAS scores were assessed from 19 and 9 studies, respectively, and complication rate and rate of follow-up surgery were assessed from 17 studies. It was found that arthrodesis patients, on average, had significantly higher AOFAS scores than ORIF patients and were less likely to develop complications. They had no difference in VAS scores, rate of revision surgery, or rate of secondary arthrodesis.

The scarcity of randomized controlled trials and comparative studies in the literature was one of the major limitations to this meta-analysis. Only 2 randomized controlled trials were found during the literature search.^11,12 and of the 1, only 1 directly compares AOFAS scores of the 2 surgical interventions. The lack of comparative data makes it difficult to state definitively if one surgical method is superior to the other. In the current study, most of the data regarding AOFAS/VAS scores and complication rates were obtained from articles examining solely one surgical intervention. The functional score and rate of complications for the patients could depend on the skill of the surgeon, rather than on what type of intervention was performed. Increased comparative studies could help to control these external variables and allow more definitive conclusions to be drawn. Very little literature currently exists that directly compare the results of ORIF and primary arthrodesis within the same study.

Another limitation of the current study is the huge differences in the type of Lisfranc injury sustained. Some studies limited the scope of their subjects to those with specific Lisfranc injuries,²⁵ while others did not place specific parameters on what type of injury was included in the study.¹⁷ Lisfranc injuries encompass a broad spectrum of insults to the foot, as they are caused by many different types of trauma.³⁴ The variation in the degree of the injury—whether ligamentous, osseous, or mixed—can affect how well the injury will heal in the future.^15,29 These injuries may also be high-energy or low-energy, resulting in yet another factor that may influence recovery time and long-term outcome. The different types of injuries merit future exploration, in order to see what sorts of trends there may be. For example, some studies suggest that arthrodesis should only be used for high-energy Lisfranc injuries or as a salvage procedure,²⁴ while others recommend arthrodesis over ORIF for pure ligamentous injuries.^12,33

Future studies should compare both procedures directly, as well as investigate if different types of Lisfranc injuries have different outcomes depending on the type of procedure performed. Examination of the complication rates and revision surgery rates also merit further exploration. Few articles included in the current study fully examined both the functional outcomes and the risks involved in the surgeries. While this review found significant results, more research can be done utilizing prospective studies to compare ORIF and arthrodesis to determine the effectiveness of each treatment in the handling of Lisfranc injuries.

In conclusion, the results of this study indicate that while both surgical procedures are effective treatments, arthrodesis may be a better option for the treatment of Lisfranc joint injuries than open reduction and internal fixation. No difference was found in VAS scores, rates of revision surgery, or rates of secondary arthrodesis. Furthermore, patients undergoing primary arthrodesis displayed a higher average foot function score and had a lesser risk of developing complications compared with those treated with ORIF.

Footnotes

Author Contributions

Christopher J. Levy: Acquisition, analysis, interpretation of data and drafting. David Yatsonsky II and Muhammad Z. Moral: Analysis, interpretation of data and revised the draft. Jiayong Liu and Nabil A. Ebraheim: Conception, design and interpretation of data of the work and final proofreading.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

Not applicable.

Informed Consent

Not applicable.

Trial Registration

Not applicable.

ORCID iD

Jiayong Liu

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