Lisfranc Injuries: Is Primary Fusion Superior To ORIF?

Point

Here the author cites his experience and evidence from the literature regarding avoidance of multiple procedures, comparable outcomes and potential benefits of primary fusion as the preferred surgical approach for Lisfranc injuries.

By Ali Rahnama, DPM, AACFAS

When evaluating Lisfranc injuries, the debate of choosing open reduction and internal fixation (ORIF) versus primary arthrodesis as a preferred surgical treatment plan has persisted for many years. The practice of medicine is indeed an art, and there are many examples of clinical scenarios that do not have only one correct answer when it comes to determining management. Lisfranc injuries are a prime example of just this concept. Having said that, I believe and will contend here that primary arthrodesis is a superior choice compared to ORIF for several reasons.

Might Primary Fusion Avoid Additional Procedures?

First, and in my opinion, the most important point to consider is that fusion has the potential to offer the patient one surgery versus two or three. In primary arthrodesis, the surgeon places hardware after thorough joint preparation and denuding of cartilage. Ideally, this eventually results in consolidation and arthrodesis of the joints in question. In my experience, the patient seldom needs further surgical management, assuming all heals without any issues. In the scenario where the surgeon elects to proceed with ORIF, the patient has a greater chance of needing further surgery in multiple scenarios, specifically, if the hardware placed for ORIF necessitates removal (which I find it often does).

Furthermore, if ORIF does not resolve the patient’s symptoms, such as in the case that they develop post-traumatic arthritis, this may necessitate further surgery to fuse the affected joints anyway. This means an additional one to two surgical procedures that may ultimately lead to the same outcome as if the patient had a primary arthrodesis in the first place. Indeed, in one of the only two prospective randomized control trials on the topic to date, Henning and colleagues found that while no significant differences existed in either the SF-36 or Short Musculoskeletal Function Assessment (SMFA) questionnaires, patients in the group that underwent ORIF did end up with more surgery when routinely performing hardware removal.¹ Researchers administered the questionnaires to 32 patients at three, six, 12 and 24 months after surgery, along with a patient satisfaction survey via telephone. The ORIF cohort has a 78.6 percent rate of secondary surgeries, compared to 16.7 percent in the arthrodesis group.¹

This calls into question whether patients are better off with primary arthrodesis if outcomes are similar to that for ORIF without the need for further surgery.

What The Literature Reveals About Outcomes For Procedures For LisFranc Injury Repair

Second, when looking at both procedure pathways in question, the outcomes seem to be about the same in the short term, if not outright favoring primary fusion. In the first prospective randomized controlled trial comparing primary arthrodesis to ORIF, Ly and Coetzee found that short- and medium-term outcomes tend to favor patients who underwent primary fusion over those that had ORIF.² They studied 41 patients over an average of 42.5 months, evaluating clinical examination, radiographs, American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scales, visual analog pain scales and clinical questionnaires. Twenty patients underwent ORIF and 21 had treatment with primary fusion. At two years postop, mean AOFAS scores were higher in the arthrodesis group than in the ORIF group. Five ORIF cohort patients went on to arthrodesis. Lastly, patients post-arthrodesis related 92 percent return to pre-injury activity levels, where ORIF subjects exhibited only 65 percent in this metric.²

Third, even in a younger, more athletic, and higher functional demand group of patients with a low mechanism of injury pattern, there is evidence to suggest that primary arthrodesis allows for faster return to functional activity and sport. Cochran and colleagues found that low-energy Lisfranc injuries in active-duty military personnel treated with primary arthrodesis had a lower implant removal rate, an earlier return to full military activity, and better fitness test scores after one year.³ However, there was no difference in Foot and Ankle Ability Measure scores between the two groups after three years.³

While admittedly, this particular study had a small sample size, and their results may have differed had they looked at a larger group, it still suggests that these patients do just as well, if not better, when they have primary arthrodesis compared to ORIF. I do feel that preserving joint mobility is an important principle to strive to adhere to. At the same time, it is important to remember that in these “non-essential” joints of the midfoot, the need to preserve the joint at all costs may not be as critical of a goal compared to, say, ankle fractures or pilon fractures, where there is a significant difference when talking about primary arthrodesis versus joint preservation.

In Summary

While I am a strong proponent of primary arthrodesis for the reasons mentioned above, I do think that every clinical scenario warrants careful evaluation based on the facts pertaining to that patient and their unique injury. I can definitely see the appeal of a less invasive ORIF procedure in a minimally displaced Lisfranc injury. This is true particularly with the availability of newly emerging technologies such as commercially available suture tape that, in my experience, allows for a small incision and reduction of the injury with a faster return to activity and sport. Having said that, we will have to see how the outcomes data pans out for these new treatment constructs and options. In the meantime, most of the Lisfranc injuries in my practice will undergo fusion. 

Dr. Ali Rahnama is a fellowship-trained foot and ankle surgeon and an Assistant Professor at the Georgetown University School of Medicine in Washington, D.C. You can follow him on Instagram @DrAliRahnama for interesting cases and educational material.

Counterpoint

Citing the extent of fracture involvement and more robust literature data, the author maintains that open reduction and internal fixation (ORIF) of Lisfranc injuries have comparable outcomes to primary arthrodesis while preserving foot flexibility.

By Zeeshan S. Husain, DPM, FACFAS, FASPS

The literature is conflicting when assessing the best surgical treatment for Lisfranc injuries. A high-energy Lisfranc dislocation resulting in comminution across the tarsometatarsal joints and a low-energy Lisfranc injury without comminution, but with ligamentous instability have different characteristics that warrant separate evaluation to determine which treatment method to pursue. Reports of rates of post-traumatic osteoarthritis following Lisfranc injuries range between 20 and 50 percent.^1,2 The most significant predictor of outcomes in surgical management of these injuries is anatomic realignment, regardless of fixation method.^3-6 Understanding which patient and fracture characteristics would benefit from open reduction and internal fixation (ORIF) and primary arthrodesis is imperative as part of an objective preoperative evaluation.

The tarsometatarsal joint complex has osseous features and soft tissue structures that make it an inherently stable joint. A recessed second metatarsal within a longitudinal and transverse arch creates this structural stability. A cadaver-based study assessing 33 Lisfranc injuries found found injured specimens had shallower recessed second metatarsals.⁷ Additional investigations showed that the tarsometatarsal joint ligaments provide substantial stability while maintaining flexibility, with the strongest ligament being the first cuneiform-second metatarsal ligament, commonly referred to as the Lisfranc ligament.^8,9

When evaluating acute Lisfranc injuries, the extent of compromise to these structures is an important consideration when deciding upon a surgical intervention. Advanced imaging is essential in surgical planning in these cases. Computed tomography (CT) has proven the best for visualizing fracture patterns and joint involvement.¹⁰ Surgeons should utilize information from this advanced imaging when discussing treatment recommendations with patients.

Although the first through third tarsometatarsal joints have the least amount of motion¹¹ and are often considered “non-essential” joints, there may be specific reasons to preserve these joints and avoid compensatory osteoarthritis to adjacent joints. Surgeons should afford patients the possibility of preserving these joints, especially in young and healthy subjects. Patients who do not have a high body mass index and have relatively low activity levels may also benefit from ORIF over an arthrodesis. In my opinion, Lisfranc injuries that result in compromised osseous and soft tissue integrity, as well as significant articular cartilage injury, should have primary arthrodesis as definitive treatment.

What The Literature Reveals About Lisfranc ORIF Outcomes

Ly and Coetzee’s publication compared Lisfranc injuries treated by ORIF and primary arthrodesis, and concluded that primary arthrodesis of the medial two or three rays has better short and medium-term outcome than ORIF of high-energy ligamentous Lisfranc joint injuries.¹ This landmark paper attempted to assess the two treatment options in a randomized fashion (prospective study with alternating treatment on 41 patients). Sixteen out of the 20 patients in the ORIF group had hardware removal at an average of 6.75 months (three to sixteen month range). Follow-up of these patients showed loss of correction, increasing deformity, and degenerative joint disease.¹ The primary arthrodesis group showed higher satisfaction rates (21 out of 21 very or somewhat satisfied) than the ORIF group (11 out of 20 very or somewhat satisfied).

However, researchers did not clearly delineate the circumstances under which they decided to remove hardware in 16 out of 20 cases in the ORIF group, simply stating that the hardware became symptomatic.¹ There is no discussion regarding whether research surgeons took conservative measures to delay hardware removal. Readers should keep in mind that these were purely high-energy ligamentous injuries, and there is no research available regarding how long it takes for these ligaments to sufficiently heal for stability prior to hardware removal. With an average of over six months before hardware removal in Ly and Coatzee’s study, this may greatly contribute to the ORIF group’s poorer outcomes and introduce bias to the final results. In my discussions with colleagues, they frequently cite this paper for globally advocating primary arthrodesis for Lisfranc injuries. However, this paper gives a relatively narrow insight into Lisfranc injury outcomes with a relatively small sample size on which to base recommendations for all Lisfranc injuries.

Reoperation rate is a common measure of poor outcomes, which Buda and colleagues investigated.¹² They excluded planned or staged hardware removal in their ORIF group.¹² In their study of 217 patients, those treated with ORIF (n = 163) had a higher rate of reoperation (75.5 percent) than primary arthrodesis (31.5 percent), which was statistically significant (p < 0.001). However, after excluding planned hardware removal, there was no statistical significance in reoperation rates (29.5 versus 29.6 percent, respectively). The authors noted that the relatively short follow-up period was a limitation in their study, as the major cause of reoperation in the ORIF group was post-traumatic arthritis.¹²

Ultimately, functional outcome results from larger studies should guide treatment for Lisfranc injuries. Hawkinson and team investigated outcomes of Lisfranc injuries in an active-duty military population.13 In a retrospective review of 171 low-energy closed Lisfranc dislocations from the Department of Defense trauma registry, return to active duty rate was not statistically significant (p = 0.4), with 80 percent in the ORIF group and 65 percent in the primary arthrodesis group.

Pertinent Considerations In Lisfranc ORIF Surgery

Advanced imaging will help in determining the amount of joint dislocation and articular violation.¹⁰ My discussion with patients preoperatively includes the possibility of primary arthrodesis based on the viability of the tarsometatarsal joint(s). In the presence of radiographic comminution or significant articular injury intraoperatively, I will favor primary arthrodesis for these selected joints. On the other hand, if there is no comminution or there are easily reducible intra-articular fractures, I will favor joint salvage to the involved joint(s). To avoid contributing to intra-articular injury, bridge plating is an alternative to trans-articular screw fixation.¹⁴ However, a cadaver study demonstrated the amount of articular destruction of the first three tarsometatarsal joints with a 4mm diameter screw to be relatively low (first tarsometatarsal joint 4.87 percent, second tarsometatarsal joint 4.79 percent, and third tarsometatarsal joint 4.86 percent).¹⁵ We do not yet know the clinical significance of this added amount of articular injury.

In my experience, anatomic restoration and ligamentous stabilization are essential when performing Lisfranc ORIF. One should assess the first intercuneiform joint for instability before fracture reduction. I will frequently place a percutaneous screw from medial-to-lateral through this joint without preparing the articular surface, as I find it provides added stability to the first ray. Direct exposure to of the affected tarsometatarsal joints will allow for proper evaluation of articular injury and provide the option to perform selected primary arthrodesis or ORIF. Frequently, there is diastasis between the bases of the first two metatarsals and injury of the Lisfranc ligament. In my experience, the surgeon should adequately clean the first intermetatarsal space of hematoma and fibrotic tissue to allow anatomic reduction with bone clamps. Soft tissue interposition may compromise a percutaneous approach.

One can place a ‘home run’ screw to reduce the second metatarsal to the first cuneiform, oriented either from the second metatarsal base to the first cuneiform or vice versa. Cadaver testing of both orientations did not show any significant difference with regards to strength.¹⁶ Additional fixation is also possible with a trans-articular screw or bridge plating across the first tarsometatarsal joint. Stabilization of the third tarsometatarsal joint can take place after reduction with bone clamps. If there is lateral column dislocation or suspected instability, the surgeon may reduce the fourth and fifth metatarsals with bone clamps, and a percutaneous K-wire can stabilize the fifth metatarsal base to the cuboid to minimize joint arthrosis.

Post-operatively, I advocate for patients non-weight bearing for about ten weeks, then transitioning into partial-weight bearing with use of arch supports and appropriate shoe gear. I do not pursue hardware removal for at least nine months postoperatively to ensure sufficient soft tissue healing. If performing hardware removal, then the patient should understand that arthrodesis may become necessary if there is persistent instability.

Concluding Thoughts

There is no consensus on treating Lisfranc injuries with ORIF versus primary arthrodesis. Larger studies show comparable reoperation rates when excluding planned hardware removal and return to activity rates between the two treatment options. In this piece, I outlined specific parameters have been outlined to help determine when ORIF is a wise choice and reserve arthrodesis for selective situations or as a salvage procedure. 

Dr. Husain is the Residency Director of the McLaren Oakland Hospital Podiatric Surgery and Medicine Residency Program in Pontiac, Michigan. He is a Fellow of the American College of Foot and Ankle Surgeons, and a Fellow of the American Society of Podiatric Surgeons. Dr. Husain is also the President-Elect of the Michigan Podiatric Medical Association and Chairman of the Michigan Podiatric Residency Consortium.

Point References

1. Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Open reduction internal fixation versus primary arthrodesis for Lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009;30(10):913-922.

2. Ly TV, Coetzee J. Treatment of primarily ligamentous lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. J Bone Joint Surg. 2006;88(3):514-520.

3. Cochran G, Renninger C, Tompane T, Bellamy J, Kuhn K. Primary arthrodesis versus open reduction and internal fixation for low-energy lisfranc injuries in a young athletic population. Foot Ankle Int. 2017;38(9):957-963.

Counterpoint References

1. Ly TV, Coetzee JC. Treatment of primarily ligamentous lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. a prospective, randomized study. J Bone Joint Surg Am. 2006;88(3):514-520.

2. Schepers T, Oprel PP, van Lieshout EMM. Influence of approach and implant on reduction accuracy and stability in lisfranc fracture-dislocation at the tarsometatarsal joint. Foot Ankle Int. 2013;34(5):705-710.

3. Kuo RS, Tejwani NC, Digiovanni CW, et al. Outcome after open reduction and internal fixation of lisfranc joint injuries. J Bone Joint Surg Am. 2000;82(11);1609-1618.

4. Lau S, Howells N, Millar M, De Villiers D, Joseph S, Oppy A. Plates, screws, or combination? radiologic outcomes after lisfranc fracture dislocation. J Foot Ankle Surg. 2016;55(4):799-802.

5. Lau S, Guest C, Hall M, Tacey M, Joseph S, Oppy A. Functional outcomes post lisfranc injury- transarticular screws dorsal plating or combination treatment? J Orthop Trauma. 2017:31(8);447-452.

6. Dubois-Ferrière V, Lübbeke A, Chowdhary A, Stern R, Dominguez D, Assal M. Clinical outcomes and development of symptomatic osteoarthritis 2 to 24 years after surgical treatment of tarsometatarsal joint complex injuries. J Bone Joint Surg Am. 2016;98(9):713-720.

7. Peicha G, Labovitz J, Seibert FJ, et al. The anatomy of the joint as a risk factor for lisfranc dislocation and fracture-dislocation. An anatomical and radiological case control study. J Bone Joint Surg Br. 2002;84(7):981- 985.

8. de Palma L, Santucci A, Sabetta SP, Rapali S. Anatomy of the Lisfranc joint complex. Foot Ankle Int. 1997;18(6):356-364.

9. Kaar S, Femino J, Morag Y. Lisfranc joint displacement following sequential ligament sectioning. J Bone Joint Surg Am. 2007;89(10):2225-2232.

10. Lu J, Ebreaheim NA, Skie M, Porshinsky B, Yestering RA. Radiographic and computed tomographic evaluation of lisfranc dislocation: a cadaver study. Foot Ankle Int. 1997;18(6):351-355.

11. Ouzounian TJ, Shereff MJ. In vitro determination of midfoot motion. Foot Ankle. 1989;10(3):140-146.

12. Buda M, Kink S, Stavenuiter R, et al. Reoperation rate differences between open reduction internal fixation and primary arthrodesis of lisfranc injuries. Foot Ankle Int. 2018;39(9):1089-1096.

13. Hawkinson MP, Tennent DJ, Belisle J, Osborn P. Outcomes of Lisfranc injuries in an active duty military population. Foot Ankle Int. 2017;38(10):1115-1119.

14. Alberta FG, Aranow MS, Barrero M, Diaz-Doran V, Sullivan RJ, Adams DJ. Ligamentous lisfranc joint injuries: a biomechanical comparison of dorsal plate and transarticular screw fixation. Foot Ankle Int. 2005;26(6):462-473.

15. Clements JR, Whitmer K, Nguyen H, Rich M. Cross-sectional area measurement of the central tarsometatarsal articulation: a review of computed tomography scans. J Foot Ankle Surg. 2018:57(4);732-736.

16. Cook KD, Jeffries LC, O’Connor JP, Svach D. Determining the strongest orientation for ‘Lisfranc’s screw” in transverse plane tarsometatarsal injuries: a cadaver study. J Foot Ankle Surg. 2009;48(4):427-431.