Review Question - QID 214874

When comparing open reduction and internal fixation (ORIF) versus primary arthrodesis (PA) in the treatment of Lisfranc injuries of the foot, ORIF consistently has higher hardware removal rates when compared to PA (Answer 2). The remaining answer choices are not true regarding the operative treatment of Lisfranc injuries.

The Lisfranc ligament runs from the medial cuneiform to the base of the second metatarsal, and is a primary stabilizer of both the longitudinal and transverse arches of the foot. Patients often sustain an injury to the Lisfranc ligament in high energy traumatic or sporting events, and present with severe pain with attempted weight-bearing or the inability to bear weight. Physical exam often reveals plantar ecchymosis. Optimal treatment for these injuries is hotly debated, and both PA and ORIF have been proposed as treatment options. Historically, PA has been favored for purely ligamentous injuries, yet there remains limited high-level evidence supporting this assertion.

Barnds et al. performed a review of a major insurance database to investigate complications and costs following treatment of Lisfranc injuries with ORIF or PA. Their study included 670 patients who underwent ORIF and 212 who underwent PA. Complication rates and costs were higher with PA. ORIF, however, did have a statistically significantly higher rate of hardware removal. This study did not investigate outcomes.

Smith et al. in a recent systematic review and meta-analysis compared ORIF and PA in the treatment of Lisfranc injuries synthesized results from 3 level 1 randomized controlled trials (RCTs). Overall, outcomes did not differ between ORIF and PA. There was, however, a statistically significant higher rate of hardware removal with ORIF compared to PA.

Ly et al. conducted a prospective randomized trial comparing ORIF and PA in the treatment of purely ligamentous Lisfranc injuries. 20 patients underwent ORIF and 21 underwent PA. They reported significantly better patient-reported outcomes for PA at both short and mid-term follow-up. Patients who underwent ORIF did have higher hardware removal rates, however, when compared to PA.

Figure A is an anteroposterior radiograph exhibiting a Lisfranc injury, with a fracture at the base of the second metatarsal and concomitant widening of the interval between the first and second ray. Figure B is a lateral radiograph demonstrating the same injury, with dorsal subluxation of the second metatarsal base.

Incorrect answers:

Answers 1: ORIF is less expensive than PA.
Answer 3: The rate of infection requiring surgical debridement is equivalent between the two procedures.
Answer 4: The rate of hardware and/or fixation failure is equivalent between the two procedures.
Answer 5: One procedure has yet to demonstrate superiority over the other. Recent literature has demonstrated the possibility of improved outcomes with PA for purely ligamentous injuries. Systematic review, however, has found no difference in functional outcomes between the two procedures.