Surgical Management of Lisfranc Injuries: The Role of ORIF

Randy Rizek, M.D., FRCSC
Orthopaedic Fellow
University of Toronto
Toronto, ON

Johnny T. C. Lau, M.D., MSc, FRCSC
Consultant Orthopaedic Surgeon,
University Health Network
Toronto Western Hospital,
University of Toronto
Toronto, ON

Injury to the Lisfranc ligamentous complex can lead to significant morbidity if managed poorly. While its occurrence is rare, accounting for 0.2% of all fractures, there is a wide spectrum of presentation of this injury with both bony and/or ligamentous components1. There is also an increasing presentation among sports injuries. Such low energy mechanisms of injury can cause subtle changes that are often missed. The natural history of treating Lisfranc injuries non-operatively leads to posttraumatic osteoarthritis and deformity2.

 

It is well established that one of the most important factors in achieving good outcomes is obtaining an anatomic reduction with rigid internal fixation2. The function of the Lisfranc ligament is restored by anatomically reducing the articulation between the 2nd metatarsal and the middle cuneiform along with fixing the medial cuneiform to the 2nd metatarsal. Controversy remains regarding the effectiveness of ORIF vs. primary fusion as the initial surgical treatment for these injuries.

LAU_fig_1a
Figure 1a: Preoperative Lisfranc fracture dislocation of 1-3 TMTJ
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Figure 1b: Postoperative ORIF Lisfranc fracture dislocation

There have been two prospective randomized studies that investigated whether ORIF or primary fusion produced better outcomes. Ly and Coetzee3 compared ORIF versus primary arthrodesis in a study of 41 patients with isolated acute primarily ligamentous injuries. The mean follow-up time was 42 months with a minimum of two years after treatment. The mean American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score was 68.6 for the ORIF group and was 88 in the primary arthrodesis group. Despite demonstrating favourable outcomes for a primary fusion, there are several criticisms that question the strength of this Level I study. The short follow-up period for a primary arthrodesis failed to demonstrate the risk of arthritis in adjacent joints in medium or long-term. The total number of patients was relatively small and did not capture any Lisfranc injuries involving bony components. Furthermore, the inclusion and exclusion criteria did not specify patient characteristics, i.e. whether athletes were among the patients groups.

LAU_fig_2a
Figure 2a: Preoperative homolateral Lisfranc fracture dislocation of 1st TMTJ
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Figure 2b: Postoperative ORIF homolateral Lisfranc fracture dislocation
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Figure 2c: Postoperative hardware removal from homolateral Lisfranc fracture dislocation

Henning et al.4 performed a prospectively randomized study that evaluated the clinical outcomes of Lisfranc injuries treated with primary fusion vs. ORIF. Of 185 patients selected, only 40 met the inclusion/exclusion criteria and 32 were available for follow-up evaluation. Both groups consisted of both bony and ligamentous Lisfranc injuries and were followed up to two years. The results demonstrated no significant difference in Short Form-36 (SF-36) and Short Musculoskeletal Function Assessment (SMFA) scores between the primary fusion and ORIF groups.

Even though Level I evidence exists for primary fusion vs. ORIF for Lisfranc injuries, the patient group included in these studies has been soft tissue injury only or small avulsion fractures at the base of the 2nd metatarsal. These studies fail to address the needs of a high demand patient, such as athletes, who may need the midfoot motion to successfully return to their recreational activity or sport. These studies also fail to address the Lisfranc injury with a large fracture fragment at the base of the 2nd metatarsal, which can be fixed, with reasonable return of function, not requiring a fusion. Therefore, the evidence fails to provide a clear treatment algorithm for all subsets of Lisfranc injuries. Primary ORIF allows for preservation of anatomy of the tarsometatarsal joints and remains the first line treatment for Lisfranc injuries.

References

 

  1. Wright, J.G. Evidence-Based Orthropaedics: Chapter 77. What is the best treatment for injury to the Tarsometatarsal Joint Complex? Corrieira, D. and Myerson M. 2009.
  2. Arntz C.T., Veith R.G., Hansen S.T: Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am 1988; 70:173-181.
  3. Ly T.V, Coetzee J.C.: Treatment of primarily ligamentous tarsometatarsal joint injuries: Primary Arthrodesis compared with open reduction and internal fixation. J Bone Joint Surg Am 2006; 88-A:514-520
  4. Henning J.A., Jones C.B., Sietsema D.L., Bohay D.R., Anderson J.G. Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009 Oct;30(10):913-22.

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