Perspective

ORIF for Lisfranc injuries yielded lower cost, complication rate vs arthrodesis

Patients who underwent ORIF had a low progression to secondary fusion, but higher rate of hardware removal
Bryan Vopat

Treatment of Lisfranc injuries with open reduction internal fixation or ORIF was associated with lower costs and fewer complications than primary arthrodesis, but there were higher hardware removal rates with ORIF, according to results presented at the American Orthopaedic Foot & Ankle Society Annual Meeting.

“Open reduction internal fixation is definitely an option that you can use, and it is a beneficial option you can use overall,” Bryan Vopat, MD, assistant professor at University of Kansas Hospital, told Orthopedics Today. “It is not saying that fusion is necessarily bad, but for a while there was a run of a lot of people who were saying that fusion is the answer and I think that the study’s overall message is that open reduction internal fixation still has a role when fixing Lisfranc injuries and is something someone should consider.”

ORIF vs arthrodesis

Vopat, Brandon Barnds, MD, and colleagues used Pearl Diver datamining software to identify patients with Lisfranc fractures who were treated nonoperatively or who underwent primary ORIF or primary arthrodesis. Researchers performed a cost analysis, which was based on insurance companies’ reimbursement rates

Barnds, who presented the findings, said at the meeting, “We then split these up into subgroups based on patients having at least one complication after the initial surgical management, patients having subsequent hardware removal and if the revision or fusion came right after.”

Of 2,200 patients identified with Lisfranc injuries, 30% underwent ORIF and 10% underwent arthrodesis. Cost, complication rate and hardware removal was significantly different between the ORIF and arthrodesis group. Primary arthrodesis was more expensive by about $1,000, Barnds said.

“There was apparent complication rate in the arthrodesis group [of] about 7% and [in the] hardware removal category, the primary ORIF had a higher rate by about 25%,” he said.

Patients in the ORIF group had a low progression to a secondary fusion of about 2.5% which occurred at an average of 308 days. Barnds noted.

Comparison studies needed

The study has limitations in that it is a database study and researchers were unable to review patient outcomes, Vopat, whose teaching affiliation is with the University of Kansas Medical Center, said.

“Also, it is only a 7-year follow-up in the database, so some of the open reduction internal fixations may have went on to fusions and we would not catch those patients,” Vopat said. “It is difficult to tell how the patients did because there were no outcomes for this, so it does not tell how their pain scores were, what activities they were able to return back to.”

He noted future research should include a review of prospective outcomes and costs in either a comparative or randomized controlled study. – by Casey Tingle

Reference:

Barnds B, et al. Cost comparison and complication rate of Lisfranc injuries treated with open reduction internal fixation versus primary arthrodesis. Presented at: American Orthopaedic Foot & Ankle Society Annual Meeting; July 11-14, 2018; Boston.

Barnds B, et al. Injury. 2018;doi:10.1016/j.injury.2018.10.002.

For more information:

Brandon Barnds, MD, can be reached at The University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160; email: gpeters3@kumc.edu.

Bryan Vopat, MD, can be reached at 2000 Olathe Blvd. MS 3017, Kansas City, KS 66160; email: gpeters3@kumc.edu.

Disclosures: Barnds and Vopat report no relevant financial disclosures.

Bryan Vopat

Treatment of Lisfranc injuries with open reduction internal fixation or ORIF was associated with lower costs and fewer complications than primary arthrodesis, but there were higher hardware removal rates with ORIF, according to results presented at the American Orthopaedic Foot & Ankle Society Annual Meeting.

“Open reduction internal fixation is definitely an option that you can use, and it is a beneficial option you can use overall,” Bryan Vopat, MD, assistant professor at University of Kansas Hospital, told Orthopedics Today. “It is not saying that fusion is necessarily bad, but for a while there was a run of a lot of people who were saying that fusion is the answer and I think that the study’s overall message is that open reduction internal fixation still has a role when fixing Lisfranc injuries and is something someone should consider.”

ORIF vs arthrodesis

Vopat, Brandon Barnds, MD, and colleagues used Pearl Diver datamining software to identify patients with Lisfranc fractures who were treated nonoperatively or who underwent primary ORIF or primary arthrodesis. Researchers performed a cost analysis, which was based on insurance companies’ reimbursement rates

Barnds, who presented the findings, said at the meeting, “We then split these up into subgroups based on patients having at least one complication after the initial surgical management, patients having subsequent hardware removal and if the revision or fusion came right after.”

Of 2,200 patients identified with Lisfranc injuries, 30% underwent ORIF and 10% underwent arthrodesis. Cost, complication rate and hardware removal was significantly different between the ORIF and arthrodesis group. Primary arthrodesis was more expensive by about $1,000, Barnds said.

“There was apparent complication rate in the arthrodesis group [of] about 7% and [in the] hardware removal category, the primary ORIF had a higher rate by about 25%,” he said.

Patients in the ORIF group had a low progression to a secondary fusion of about 2.5% which occurred at an average of 308 days. Barnds noted.

Comparison studies needed

The study has limitations in that it is a database study and researchers were unable to review patient outcomes, Vopat, whose teaching affiliation is with the University of Kansas Medical Center, said.

“Also, it is only a 7-year follow-up in the database, so some of the open reduction internal fixations may have went on to fusions and we would not catch those patients,” Vopat said. “It is difficult to tell how the patients did because there were no outcomes for this, so it does not tell how their pain scores were, what activities they were able to return back to.”

He noted future research should include a review of prospective outcomes and costs in either a comparative or randomized controlled study. – by Casey Tingle

Reference:

Barnds B, et al. Cost comparison and complication rate of Lisfranc injuries treated with open reduction internal fixation versus primary arthrodesis. Presented at: American Orthopaedic Foot & Ankle Society Annual Meeting; July 11-14, 2018; Boston.

Barnds B, et al. Injury. 2018;doi:10.1016/j.injury.2018.10.002.

For more information:

Brandon Barnds, MD, can be reached at The University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160; email: gpeters3@kumc.edu.

Bryan Vopat, MD, can be reached at 2000 Olathe Blvd. MS 3017, Kansas City, KS 66160; email: gpeters3@kumc.edu.

Disclosures: Barnds and Vopat report no relevant financial disclosures.

    Perspective
    Andrew R. Hsu

    Andrew R. Hsu

    Each patient requires individualized treatment to achieve the best outcome possible. Although large database studies can be helpful to analyze general trends in surgical procedures, cost and outcomes, they often fail to tease out the specific subjective factors that are critical to patient treatment and surgeon decision-making. The present database study (670 ORIF, 212 fusion) found that primary fusion for acute Lisfranc injuries was more expensive and had a higher complication rate than ORIF. However, in cases of high-energy Lisfranc injuries with severe comminution, cartilage damage and/or instability, I strongly believe primary fusion "fix and fuse" with low-profile implants is the preferred treatment option with better long-term outcomes and overall decreased cost in terms of re-operation, additional clinic and imaging studies, patient time off work, disability, etc., when fusion is achieved. Factors that need to be taken into consideration with each Lisfranc injury are injury severity, patient age and activity level, comorbidities, occupation and surgeon comfort with ORIF vs. fusion. With the majority of low-energy, athletic injuries, I think ORIF is the best treatment option, but with increasing injury severity surgeons should strongly consider primary fusion.

    • Andrew R. Hsu, MD
    • Chief, division of foot and ankle surgery
      Assistant clinical professor of orthopedic surgery
      University of California, Irvine
      Irvine, California

    Disclosures: Hsu reports he is a consultant for Arthrex.