What is the role of acute fusion in the treatment of Lisfranc fracture dislocation?

Updated: Apr 20, 2020
  • Author: Nirmal Tejwani, MD, MPA; Chief Editor: Thomas M DeBerardino, MD  more...
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Answer

Stability at this joint level of the foot is the primary concern, and instability appears to be the primary pain generator. Because of the unpredictability of adequate ligamentous healing to support the foot, primary fusion of the medial three TMT joints has been advocated; however, studies have been inconsistent with regard to assessing open reduction with internal fixation (ORIF) versus primary arthrodesis (PA) for optimal acute treatment. [23, 24, 25]

In a study evaluating PA of the medial two or three TMT joints (n = 21) against ORIF (n = 20) in primarily ligamentous Lisfranc injuries, Ly et al reported that the PA group reached a postoperative activity level that was an estimated 92% of the preinjury level, whereas the ORIF group achieved an activity level that was only 65% of the preinjury level. [26, 27] They concluded that a stable PA seemed to have better short- and medium-term outcomes. It was unclear whether long-term results were improved.

Henning et al prospectively studied 40 patients who were randomly assigned to receive either primary ORIF (PORIF) or PA of the first, second, and third TMT joint combined with Kirschner-wire (K-wire) fixation of the fourth and fifth TMT joints. [28] At an average of 53 months postoperatively, 32 patients were interviewed by telephone. Using Short Form (SF)-36 and Short Musculoskeletal Function Assessment (SMFA) scores, the authors found no significant differences in patient satisfaction between the two groups.

Because of planned hardware removal in the PORIF group, the reoperation rate in this group was significantly higher than that in the PA group. [28] The PA group did have different complications from the PORIF group, including a nonunion and a delayed union, both of which were treated nonoperatively. Although this was a level 1 study, it was limited by sample size, a low rate of participation among eligible patients, and a 20% loss of patients to follow-up.

A meta-analysis of three randomized controlled trials by Smith et al demonstrated higher rates of removal of hardware with ORIF as compared with PA; there were otherwise no differences in risk for revision surgery, reported patient outcomes, or risk for nonanatomic reduction. [24]

A trial by Buda et al focused on the higher rate of removal of hardware seen in ORIF. [25] In this trial, removal of hardware was planned as part of the ORIF procedure. No difference in reoperation rates between ORIF and PA was noted.

Albright et al performed a cost-effectiveness analysis of PA versus ORIF and found that PA was significantly more cost-effective; the group cost for PA was $1429 per quality-adjusted life year (QALY), whereas that for ORIF was $3958/QALY. [29]  In view of the relatively limited resources available to the field, this difference in cost-effectiveness may play a larger role in future surgical considerations.


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