Primary arthrodesis versus open reduction internal fixation for acute Lisfranc injuries: a systematic review and meta-analysis

Introduction: The presence of a Lisfranc injury alone is considered a surgical indication in most patients. Indications for primary arthrodesis (PA) versus open reduction internal fixation (ORIF), however, is a topic of debate among surgeons. Conflicting data exists as to which treatment modality leads to improved patient-reported outcome measures (PROMs), reoperations, and complications.

Methods: Databases queried included PubMed, OVID Medline, Embase, SCOPUS, Cochrane Central Register of Clinical Trials, and clinicaltrials.gov from their dates of inception to 3/21/2024. Studies were incorporated into this analysis if they had included patients with acute Lisfranc injuries and compared outcomes between PA and ORIF. PROMs, reoperations, and complications were captured. Results were reported as effect sizes (ES) and odds ratios (OR).

Results: There were eighteen studies included in this SRMA. Pooled data from 13/16 studies that reported AOFAS and VAS demonstrated better outcomes after PA compared to ORIF. AOFAS was 84.4 ± 28.5 after PA and 75.7 ± 29.0 after ORIF. VAS pain was 1.4 ± 2.7 after PA and 2.0 ± 3.3 after ORIF. There were 3 more studies that reported other PROMs and favored ORIF. Return to preinjury activity was 79.2% after PA and 65.7% after ORIF. The prevalence of midfoot post-traumatic arthritis was reported as 2.8% after PA and 17.3% after ORIF. Adjacent joint arthritis was not reported in the current literature. After PA, 77/438 (17.6%) patients underwent reoperations, and after ORIF, 514/802 (64.1%) patients underwent reoperations. After excluding planned hardware removals, relative rates of unplanned reoperations were 14.7% (n = 62/423) after PA and 38.3% (n = 181/472) after ORIF (p < 0.001). Non-operative complications occurred in 43/406 (10.6%) patients after PA and 95/753 (12.6%) patients after ORIF (p = 0.31). Meta-analyses demonstrated that AOFAS (ES: 0.41, CI 0.13, 0.68, p = 0.004) and VAS pain (ES: - 0.53, CI - 0.91, - 0.15, p = 0.006), and return to activity rates (OR: 2.71, CI 1.43, 6.39) favored PA over ORIF. Post-traumatic arthritis (OR: 0.29, CI 0.11, 0.77) and reoperations (OR: 0.16, CI 0.06, 0.44) were less prevalent after PA compared to ORIF.

Conclusion: This systematic review and meta-analysis suggested that PA provides better short- and medium-term outcomes in the setting of Lisfranc injuries when compared to ORIF with rigid fixation. Due to a lack of available clinical studies, the long-term effects of PA are largely unknown but may include increased adjacent joint arthritis, pain, and need for further surgery-especially in young and active patients. Future research demonstrating long-term outcomes would be helpful in clinical decision making.

Level of evidence: I.