Joint fusion may provide better long-term pain relief than ORIF for treating complex Lisfranc injuries, according to a study by University of Minnesota researchers.
Thuan V. Ly, MD, and J. Chris Coetzee, MD, FRCSC, of the universitys department of orthopedic surgery, Minneapolis, studied 41 patients with a primarily ligamentous Lisfranc injury. Surgeons treated 21 patients with a mean age of 32.4 years with primary arthrodesis of the medial two or three rays. The remaining 20 patients, who had a mean age of 32 years, received an open reduction and screw fixation of the medial two or three rays.
Each patient underwent surgery within three weeks of injury and were followed for more than two years postop, according to the study, published in the American edition of The Journal of Bone & Joint Surgery.
Researchers checked patients alignment radiographically to determine whether the medial border of the second metatarsal aligned with the medial border of the middle cuneiform. They also checked for dorsal displacement of the metatarsals relative to the tarsal bones, and whether the medial borders of the fourth metatarsal and the cuboid aligned.
They found that 16 ORIF patients required a second surgery to remove painful hardware at an average of 6.75 months postop. Among these patients, radiographic studies indicated loss of correction or increased deformity, and 15 patients developed degenerative joint disease. Five patients also required conversion to tarsometatarsal arthrodesis at a mean 35 months postop.
At two years follow-up, patients estimated their athletic abilities to be at 65% of their preinjury levels, according to the study.
In contrast, only four patients in the arthrodesis group required a second surgery, mainly for hardware removal. Two patients experienced arthrodesis-related complications; one patient required bone stimulation and another required a revision fusion and bone grafting.
At two years follow-up, patients in the arthrodesis group estimated they could perform athletic activities at 92% of their preinjury levels, the study authors noted.
Also at two years, arthrodesis patients had significantly higher American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scores, which averaged 88 points compared with 68.6 points for ORIF patients (P=.005). At a mean final follow-up of 42 to 43 months, AOFAS midfoot scores averaged 57.1 points among ORIF patients and 86.9 points among arthrodesis patients (P<.0001), according to the study.
When the five patients in the [ORIF] group who had had a conversion to midfoot arthrodesis were excluded, the average final AOFAS midfoot score for the remaining 15 patients was 65.2 points, and the arthrodesis group still had a better average score than
the [ORIF] group (P<.0024), the authors noted.
[Because] of the poor healing potential of the ligament-osseous interface and the trend toward a higher rate of correction loss, increasing deformity and degenerative arthritic changes, we believe that primarily ligamentous injuries are a subset of Lisfranc joint injuries that are not as amenable to internal fixation, the study authors said. We believe that stable arthrodesis is a better primary treatment for these injuries, with superior short- and medium-term outcomes than those following [ORIF].
For more information:
- 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;88:514-520.