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Improved outcomes with primary arthrodesis in treating ligamentous Lisfranc joint injuries
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August 2013
Improved outcomes with primary arthrodesis in treating ligamentous Lisfranc joint injuries
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A
Treatment of Primarily Ligamentous Lisfranc Joint Injuries: Primary Arthrodesis Compared with Open Reduction and Internal Fixation: A prospective, randomised study
J Bone Joint Surg Am. 2006 Mar;88(3):514-20Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
41 patients with isolated acute or subacute primary ligamentous Lisfranc injuries were randomised to undergo either a primary open reduction and internal fixation procedure or a primary partial arthrodesis procedure. Short- and long-term functional and clinical outcomes were examined. The results indicated that the primary arthrodesis intervention produced better short- and medium-term outcomes compared to the open reduction and internal fixation procedure.
Publication Funding Details
+
Funding:
Non-funded
Conflicts:
None disclosed
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
3/4
Randomization
2/4
Outcome Measurements
2/4
Inclusion / Exclusion
4/4
Therapy Description
4/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Lisfranc joint injuries are tarsometatarsal dislocations or fracture-dislocations of the foot. This injury is not common and are often misdiagnosed or missed. The accepted method of treatment for this injury is an open reduction and internal fixation procedure. However, the optimal method of treatment is debated. This study compares the open reduction and internal fixation treatment with primary partial arthrodesis in treating high-energy ligamentous Lisfranc injuries.
What was the principal research question?
What are the short- and long-term clinical and functional outcomes of treating patients with primary ligamentous Lisfranc injuries with primary open reduction and internal fixation compared to primary partial arthrodesis?
Study Characteristics
-
Population:
41 patients with isolated acute or subacute primary ligamentous Lisfranc injuries.
Intervention:
Primary partial arthrodesis of the medial two or three rays. (Mean age: 32 (19-42) years) (n=21)
Comparison:
Primary open reduction and internal fixation with screws. (Mean age: 32.4 (19-52) years) (n=20)
Outcomes:
Clinical outcomes (the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale, and a clinical questionnaire); Alignment (radiographic results); pain (visual analog scale)
Methods:
RCT
Time:
Mean 42.5 months (Follow-up at 2 weeks, 6 weeks, 3 months, 6 months, and then annually)
What were the important findings?
- 18/20 patients from the open-reduction group obtained an anatomic initial reduction compared to 20/21 patients from the arthrodesis group.
- The open-reduction group reported a mean AOFAS Midfoot score of 68.6 points compared to 88 points from the arthrodesis group at the two-year follow-up. (p=0.005)
- Persistent pain was reported by 5 patients from the open-reduction group due to osteoarthrosis or the development of deformity. These patients were treated with arthrodesis.
- The estimated postoperative level of activities reported by the patients from the primary arthrodesis group was 92% of their preinjury, preoperative level, compared to an estimation of 65% from the open-reduction group. (p<0.005)
What should I remember most?
The primary arthrodesis intervention resulted in better short- and medium-term clinical and functional outcomes in the treatment of ligamentous Lisfranc joint injuries.
How will this affect the care of my patients?
The results from this study indicate that patients with ligamentous Lisfranc joint injuries may find improved clinical and radiographic outcomes when undergoing a primary partial arthrodesis intervention compared to the more traditional open reduction and internal fixation procedure.
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Orthopaedic Resident/Intern - Canada
When you look at the network meta-analytic diagnostics of over 10,000 Lisfranc fractures, this paper is an outlier as per the residual deviance. Although the message is correct of the effect is much larger than other trials. This may be due to the subacute nature of the injuries which may have inferior outcomes with ORIF. These effect modifiers must be considered when interpreting the results of this trial.