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Ahn BJ, Quinn M, Zhao L, He EW, Dworkin M, Naphade O, Byrne RA, Molino J, Blankenhorn B. Statistical Fragility Analysis of Open Reduction Internal Fixation vs Primary Arthrodesis to Treat Lisfranc Injuries: A Systematic Review. Foot Ankle Int 2024; 45:298-308. [PMID: 38327213 DOI: 10.1177/10711007231224797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
BACKGROUND There is a lack of consensus in the use of open reduction internal fixation (ORIF) vs primary arthrodesis (PA) in the management of Lisfranc injuries. Statistical fragility represents the number of events needed to flip statistical significance and provides context to interpret P values of outcomes from conflicting studies. The current study evaluates the statistical fragility of existing research with an outcome-specific approach to provide statistical clarity to the ORIF vs PA discussion. We hypothesized that statistical fragility analysis would offer clinically relevant insight when interpreting conflicting outcomes regarding ORIF vs PA management of Lisfranc injuries. METHODS All comparative studies, RCTs, and case-series investigating ORIF vs PA management of Lisfranc injuries published through October 5, 2023, were identified. Descriptive characteristics, dichotomous outcomes, and continuous outcomes were extracted. Fragility index and continuous fragility index were calculated by the number of event reversals needed to alter significance. Outcomes were categorized by clinical relevance, and median FI and CFI were reported. RESULTS A total of 244 studies were screened. Ten studies and 67 outcomes (44 dichotomous, 23 continuous) were included in the fragility analysis. Of the 10 studies, 4 studies claimed PA to correlate with superior outcomes compared to ORIF with regard to functional scores and return to function outcomes. Of these 4 studies, 3 were statistically robust. Six studies claimed PA and ORIF to have no differences in outcomes, in which only 2 studies were statistically robust. CONCLUSION The overall research regarding ORIF vs PA is relatively robust compared with other orthopaedic areas of controversy. Although the full statistical context of each article must be considered, studies supporting PA superiority with regard to functional scores and return to function metrics were found to be statistically robust. Outcome-specific analysis revealed moderate fragility in several clinically relevant outcomes such as functional score, return to function, and wound complications.
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Affiliation(s)
- Benjamin J Ahn
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Matthew Quinn
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Leon Zhao
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Elaine W He
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Myles Dworkin
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Om Naphade
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Rory A Byrne
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Janine Molino
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Brad Blankenhorn
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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Ochuba A, Murdock CJ, Xu AL, Snow M, Schmerler J, Leland CR, McDaniel C, Thompson J, Aiyer AA. Open Reduction Internal Fixation vs Primary Arthrodesis for Lisfranc Fracture-Dislocations: A Cost Analysis. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114231224727. [PMID: 38298264 PMCID: PMC10829492 DOI: 10.1177/24730114231224727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
Abstract
Background Lisfranc fracture-dislocation is an uncommon but serious injury that currently lacks universal consensus on optimal operative treatment. Two common fixation methods are open reduction and internal fixation (ORIF) and primary arthrodesis (PA). The objective of this study is to analyze the cost difference between ORIF and PA of Lisfranc injuries, along with the contribution of medical services to overall costs. Methods This was a retrospective cost analysis of the MarketScan database from 2010 to 2020. MarketScan is an insurance and commercial claims database that integrates deidentified patient information. It captures person-specific clinical utilization, expenditures, and enrollment across inpatient and outpatient services. Patients undergoing primary ORIF (CPT code 28615) vs PA (28730 and 28740) for Lisfranc fracture-dislocation were identified. The primary independent variable was ORIF vs PA of Lisfranc injury. Total costs due to operative management was the primary objective. The utilization of and costs contributed by medical services was a secondary outcome. Results From 2010 to 2020, a total of 7268 patients underwent operative management of Lisfranc injuries, with 5689 (78.3%) ORIF and 1579 (21.7%) PA. PA was independently associated with increased net and total payment and coinsurance, clinic visits, and imaging, and patients attended significantly more PT sessions. Conclusion Using this large database that does not characterize severity or extent of injury, we found that treatment of Lisfranc fracture-dislocation with ORIF was associated with substantially lower initial episode of treatment costs compared with PA. Specific excessive cost drivers for PA were clinic visits, PT sessions, and imaging. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Arinze Ochuba
- Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Amy L. Xu
- Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Morgan Snow
- Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Christopher R. Leland
- Massachusetts General Hospital/Brigham and Women’s Hospital/Harvard Medical School, Boston, MA, USA
| | - Claire McDaniel
- Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - John Thompson
- Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
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Ahluwalia R, Yip G, Richter M, Maffulli N. Surgical controversies and current concepts in Lisfranc injuries. Br Med Bull 2022; 144:57-75. [PMID: 36151742 DOI: 10.1093/bmb/ldac020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 08/06/2022] [Accepted: 08/09/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Lisfranc injuries, not as rare as previously reported, range from ligamentous to complex fracture-dislocations. Anatomical studies have identified a complex of discrete structures, and defined the anatomical characteristics of the Lisfranc joint. SOURCES OF DATA A narrative evidence-based review encompassed and analyzed published systematic reviews. Outcomes included clinical and surgical decision-making, including clinical-presentation, diagnosis, pathological-assessment, surgical-management techniques and indications, post-surgical care and comparative outcomes. AREAS OF AGREEMENT Better understanding of the Lisfranc complex anatomy aids surgical treatment and tactics. Prognosis is related to injury severity, estimated by the number of foot columns affected. Surgical outcome is determined by anatomical reduction for most fixation and fusion techniques. Appropriate treatment allows return to sport, improving outcome scores. AREAS OF CONTROVERSY Identification of Lisfranc injuries may be improved by imaging modalities such as weight-bearing computer tomography. Recent evidence supports dorsal plate fixation as a result of better quality of reduction. In complex injuries, the use of combined techniques such as trans-articular screw and plate fixation has been associated with poorer outcomes, and fusion may instead offer greater benefits. GROWING POINTS Open reduction is mandatory if closed reduction fails, highlighting the importance of understanding surgical anatomy. If anatomical reduction is achieved, acute arthrodesis is a safe alternative to open reduction internal fixation in selected patients, as demonstrated by comparable outcomes in subgroup analysis. AREAS FOR DEVELOPING RESEARCH The current controversies in surgical treatment remain around techniques and outcomes, as randomized controlled trials are infrequent.
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Affiliation(s)
- Raju Ahluwalia
- Department of Orthopaedics, King's College Hospital, King's College Hospital NHS Foundation Trust, Bessemer Road, London, SE5 9RS, UK
| | - Grace Yip
- Department of Orthopaedics, King's College Hospital, King's College Hospital NHS Foundation Trust, Bessemer Road, London, SE5 9RS, UK
| | - Martinus Richter
- Department for Foot and Ankle Surgery Nuremberg and Rummelsberg, Hospital Rummelsberg, Rummelsberg 71, Schwarzenbruck 90592, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Salerno, Italy.,Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent ST4 7QB, UK
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Kandil MI, Abouzeid M, Eltaher SM, Eltregy S. Primary fusion versus open reduction internal fixation for purely ligamentous lisfranc injuries: A Prospective comparative study and analysis of factors affecting the outcomes. Foot Ankle Surg 2022; 28:898-905. [PMID: 34969595 DOI: 10.1016/j.fas.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/07/2021] [Accepted: 12/16/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The studies evaluating the outcomes of treatment of purely ligamentous unstable Lisfranc injuries are scarce. This study aimed at comparing outcomes of primary tarso-metatarsal joints fusion versus open reduction and internal fixation in treatment of such condition and determining the possible factors that may alter the outcomes. METHODS This study comprised 30 patients; 16 in fusion group and 14 in ORIF group. One column was operated on in 2 patients, two columns in 21, and three columns in 7. The mean follow-up period was 36 months. RESULTS There was no statistically significant difference between both groups regarding patients or injury characteristics. The mean AOFAS and FFI-Rs scores were 88.9 and 22.7 in the fusion group, compared to 61.7 and 34.5 in the ORIF group (P = .03,.04 respectively). At final follow-up all patients in the primary arthrodesis group were maintaining an anatomical reduction versus 71.5% in the ORIF group. Sixteen patients (53%) reported prominent hardware troubles that required removal. Five patients in ORIF group developed osteoarthritis, and four of them underwent secondary fusion. There was significantly higher incidence of posttraumatic osteoarthritis in patients with non-anatomical reduction and complete injuries. Better mean AOFAS and FFI-Rs scores occurred with non-smokers and with anatomical reduction. CONCLUSION Based on this limited case series, purely ligamentous Lisfranc injuries were found to have better outcomes when managed with a primary fusion as compared to ORIF. Achieving and maintaining anatomical reduction was the most important factor that is significantly attributed to improved outcomes. Possible arthritic changes and additional surgeries apart from implant removal could be avoided by primary fusion. LEVEL OF EVIDENCE level I- prospective comparative case study.
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He W, Xia J, Zhou H, Li Z, Zhao Y, Yang Y, Li B. Staged surgery for closed Lisfranc injury with dislocation. Front Surg 2022; 9:984669. [PMID: 36061041 PMCID: PMC9437587 DOI: 10.3389/fsurg.2022.984669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To investigate the clinical efficacy of staged surgery for patients with closed Lisfranc injury and dislocation. Methods This study included 48 patients with acute closed Lisfranc injury and dislocation admitted between July 2016 and July 2021. The patients were divided into two groups. 23 patients in group A underwent staged surgeries included emergency reduction within 4–8 h after injury, and open reduction and internal fixation of Lisfranc injury and first tarsometatarsal joint fusion after the swelling had subsided. 25 patients in group B underwent open reduction and internal fixation as an elective procedure after the swelling had subsided. American Orthopedic Foot and Ankle Society (AOFAS) midfoot scores and visual analog scale (VAS) scores were used for assessment at the final follow-up. Results A total of 48 patients with closed Lisfranc injury and dislocation were included. The lengths of hospitalization were 11.52 ± 1.61 day and 19.80 ± 2.37 day in groups A and B, respectively. The total lengths of surgery were 67.34 ± 1.71 min and 104.36 ± 8.31 min in groups A and B, respectively. 48 patients completed the final follow-up (follow-up period range: 12–24 months, mean: 18 months). All fractures had healed at 12–18 weeks after surgery (mean: 14.6 weeks). At the 1-year postoperative follow-up, the AOFAS and VAS score was 86.87 ± 4.24 and 1.91 ± 0.78, respectively, during weight-bearing walking in group A patients and 71.72 ± 5.46 and 3.20 ± 1.17 in group B. By the end of the follow-up period, only 2 patients in group B had developed traumatic arthritis and no patients had joint re-dislocation or required secondary surgery. Conclusion Staged surgery for closed Lisfranc injury with dislocation reduced the incidence of perioperative complications and achieved good surgical outcomes while shortening the lengths of surgery and hospitalization.
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Affiliation(s)
| | | | | | | | | | | | - Bing Li
- Correspondence: Bing Li Yunfeng Yang
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6
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Sun C, Miao X, Zhang M, Yang Y, Zhao H, Tang X, Yu G. Lisfranc injuries with dislocation the first tarsometatarsal joint: primary arthrodesis or internal fixation (a randomized controlled trial). INTERNATIONAL ORTHOPAEDICS 2022; 46:2529-2537. [PMID: 35723701 DOI: 10.1007/s00264-022-05478-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/08/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Open reduction and internal fixation (ORIF) is a popular method for treatment of displaced Lisfranc injuries. However, even with anatomic reduction and solid internal fixation, treatment does not provide good outcomes in certain severe dislocations. The purpose of this study was to compare ORIF and primary arthrodesis (PA) of the first tarsometatarsal (TMT) joint for Lisfranc injuries with the first TMT joint dislocation. METHODS Seventy-eight Lisfranc injuries with first TMT joint dislocation were finally enrolled and analyzed in a prospective, randomized trial comparing ORIF and PA. They were 50 males and females with a mean age of 40.7 years and randomized to ORIF group and PA group. Outcome measures included radiographs, American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale, Foot and Ankle Ability Measure (FAAM) Sports subscale, visual analog scale (VAS), and the 36-Item Short Form Health Survey (SF-36). Complications and revision rate were also analyzed. RESULTS Forty patients were treated by ORIF, while PA group includes 38 cases. Patients were followed up for 37.8(range, 24-48) months. At final follow-up, the mean AOFAS midfoot score (P < 0.01), the FAAM Sports subscale (P < 0.01), the physical function score (P < 0.05), and the Bodily Pain score of SF-36 (P < 0.05) after ORIF treatment were significantly lower than PA group. The mean VAS score in ORIF group was higher (P < 0.01). In ORIF group, redislocation of the first TMT joint was observed in ten cases, and thirteen patients had pain in midfoot. No redislocation and no hardware failure were identified in PA group. CONCLUSION PA of the first TMT joint provided a better medium-term outcome than ORIF for Lisfranc injuries with the first TMT dislocation. Possible complications and revision could be avoided by PA for dislocated first ray injuries.
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Affiliation(s)
- Chengyi Sun
- Center of Foot and Ankle Surgery, Beijing Tongren Hospital, Capital Medical University, No.1, Dong Jiao Min Lane, Dong Cheng District, Beijing, 100730, China
| | - Xudong Miao
- Department of Orthopaedics, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310000, China
| | - Mingzhu Zhang
- Center of Foot and Ankle Surgery, Beijing Tongren Hospital, Capital Medical University, No.1, Dong Jiao Min Lane, Dong Cheng District, Beijing, 100730, China.
| | - Yunfeng Yang
- Department of Orthopedics, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065, China
| | - Hongmou Zhao
- Foot and Ankle Surgery Department, Honghui Hospital of Xi'an Jiaotong University, Xi'an, 710054, China
| | - Xin Tang
- Department of Orthopedic Trauma, The First Affiliated Hospital of Dalian Medical University, Dalian, 201318, China
| | - Guangrong Yu
- Department of Orthopedics, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065, China
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Sethuraman SA, Silverstein RS, Dedhia N, Shaner AC, Asprinio DE. Radiographic outcomes of cortical screw fixation as an alternative to Kirschner wire fixation for temporary lateral column stabilization in displaced Lisfranc joint fracture-dislocations: a retrospective cohort analysis. BMC Musculoskelet Disord 2022; 23:54. [PMID: 35039033 PMCID: PMC8762863 DOI: 10.1186/s12891-021-04983-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022] Open
Abstract
Background Injuries of the tarsometatarsal joint complex ranging from purely ligamentous to multidirectionally unstable midfoot fracture-dislocations are anatomically fixed to minimize long-term sequelae including post-traumatic arthritis, pes planus deformity, and chronic pain. Lateral column disruption is commonly treated with temporary Kirschner wire (K-wire) fixation, maintaining alignment during healing and allowing resumption of physiologic motion after hardware removal. More unstable fracture patterns may require temporary cortical screw fixation to maintain adequate reduction. We evaluated the efficacy of temporary lateral column screw fixation compared to K-wire fixation for Lisfranc fracture-dislocation treatment. Methods This retrospective cohort study reviewed 45 patients over fourteen years who underwent Lisfranc fracture-dislocation fixation at a level-one trauma center. All patients underwent medial and middle column fixation; 31 underwent lateral column fixation. Twenty six patients remained after excluding those without electronic records or follow-up. The primary outcome was radiographic lateral column healing before and after hardware removal; secondary outcomes included pain, ambulation, and return to normal shoe wear. Results Twenty patients were male, with mean age 41 years. Thirteen patients underwent cortical screw fixation and twelve K-wire fixation. One had both implants. Twenty four patients underwent lateral column hardware removal; all had radiographic evidence of bony healing before hardware removal. Mean follow-up was 88.2 ± 114 weeks for all patients. The cortical screw cohort had significantly longer mean time to hardware removal (p = 0.002). The K-wire cohort had significantly more disuse osteopenia (p = 0.045) and postoperative pain (p = 0.019). Conclusions Radiographic and clinical outcomes of unstable Lisfranc fracture-dislocation treatment support temporary lateral column screw fixation as an alternate technique. Level of clinical evidence 3 (retrospective cohort study)
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Affiliation(s)
- Saranya A Sethuraman
- Westchester Medical Center, Department of Orthopedic Surgery, 100 Woods Road, Valhalla, NY, 10595, USA.
| | - Rachel S Silverstein
- Westchester Medical Center, Department of Orthopedic Surgery, 100 Woods Road, Valhalla, NY, 10595, USA
| | - Nicket Dedhia
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Forcheimer Building, Room 251, Bronx, NY, 10461, USA
| | - Adam C Shaner
- Westchester Medical Center, Department of Orthopedic Surgery, 100 Woods Road, Valhalla, NY, 10595, USA
| | - David E Asprinio
- Westchester Medical Center, Department of Orthopedic Surgery, 100 Woods Road, Valhalla, NY, 10595, USA
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van den Boom NAC, Stollenwerck GANL, Lodewijks L, Bransen J, Evers SMAA, Poeze M. Lisfranc injuries: fix or fuse? : a systematic review and meta-analysis of current literature presenting outcome after surgical treatment for Lisfranc injuries. Bone Jt Open 2021; 2:842-849. [PMID: 34643414 PMCID: PMC8558450 DOI: 10.1302/2633-1462.210.bjo-2021-0127.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS This systematic review and meta-analysis was conducted to compare open reduction and internal fixation (ORIF) with primary arthrodesis (PA) in the treatment of Lisfranc injuries, regarding patient-reported outcome measures (PROMs), and risk of secondary surgery. The aim was to conclusively determine the best available treatment based on the most complete and recent evidence available. METHODS A systematic search was conducted in PubMed, Cochrane Controlled Register of Trials (CENTRAL), EMBASE, CINAHL, PEDro, and SPORTDiscus. Additionally, ongoing trial registers and reference lists of included articles were screened. Risk of bias (RoB) and level of evidence were assessed using the Cochrane risk of bias tools and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool. The random and fixed-effect models were used for the statistical analysis. RESULTS A total of 20 studies were selected for this review, of which 12 were comparative studies fit for meta-analysis, including three randomized controlled trials (RCTs). This resulted in a total analyzed population of 392 patients treated with ORIF and 249 patients treated with PA. The mean differences between the two groups in American Orthopedic Foot and Ankle Society (AOFAS), VAS, and SF-36 scores were -7.41 (95% confidence interval (CI) -13.31 to -1.51), 0.77 (95% CI -0.85 to 2.39), and -1.20 (95% CI -3.86 to 1.46), respectively. CONCLUSION This is the first study to find a statistically significant difference in PROMs, as measured by the AOFAS score, in favour of PA for the treatment of Lisfranc injuries. However, this difference may not be clinically relevant, and therefore drawing a definitive conclusion requires confirmation by a large prospective high-quality RCT. Such a study should also assess cost-effectiveness, as cost considerations might be decisive in decision-making. Level of Evidence: I Cite this article: Bone Jt Open 2021;2(10):842-849.
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Affiliation(s)
- Noortje Anna Clasina van den Boom
- Department of Trauma Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
- Nutrim School of Nutrition & Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | | | - Laureanne Lodewijks
- Department of Trauma Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Jeroen Bransen
- Department of Trauma Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Silvia M A A Evers
- Nutrim School of Nutrition & Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Maastricht, the Netherlands
| | - Martijn Poeze
- Department of Trauma Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
- Nutrim School of Nutrition & Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
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van den Boom NAC, Stollenwerck GANL, Evers SMAA, Poeze M. Effectiveness and cost-effectiveness of primary arthrodesis versus open reduction and internal fixation in patients with Lisfranc fracture instability (The BFF Study) study protocol for a multicenter randomized controlled trial. BMC Surg 2021; 21:323. [PMID: 34384419 PMCID: PMC8359057 DOI: 10.1186/s12893-021-01320-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/04/2021] [Indexed: 12/20/2022] Open
Abstract
Background The Lisfranc injury is a complex injury of the midfoot. It can result in persistent pain and functional impairment if treated inappropriately. In Lisfranc fracture dislocation, treatment options are primary arthrodesis of the midfoot joints or open reduction and internal fixation. The purpose of the proposed study is to define the optimal treatment for the Lisfranc fracture dislocation, either primary arthrodesis or open reduction and internal fixation, in regard to quality of life, complications, functional outcomes, and cost effectiveness. Methods Study design: A prospective multicenter RCT. Study population: All patients of 18 years and older with an acute (< 6 weeks) traumatic fracture dislocation in the Lisfranc midfoot joints, displaced on static radiographic evaluation or unstable with dynamic evaluation, weight bearing radiographs or fluoroscopic stress testing under anesthesia, and eligible for either one of the surgical procedures. In total, this study will include n = 112 patients with Lisfranc fracture dislocation. Interventions: Patients with Lisfranc fracture dislocation will be randomly allocated to treatment in “The Better to Fix or Fuse Study” (The BFF Study) with either PA or ORIF. Main study parameters/endpoints: Primary outcome parameter: the quality of life. Secondary outcomes: complications, functional outcomes, secondary surgical interventions and cost effectiveness. Nature and extent of the burden: PA is expected to have a better outcome, however both treatments are accepted for this injury with a similar low risk of complications. Follow up is standardized and therefore this study will not add extra burden to the patient. Discussion This study protocol provides a comprehensive overview of the aims and methods of the attached clinical study. Limitations of this study are the absence of patient blinding since it is impossible in surgical intervention, and the outcome measure (AOFAS) that has limited validity not for these injuries. This study will be the first with enough power to define optimal treatment for Lisfranc fracture dislocations. This is necessary since current literature is unclear on this topic. Trial registration Current controlled Trial: NCT04519242 with registration date: 08/13/2020. Retrospectively registered; Protocol date and version: Version 4 05/06/2020 Supplementary Information The online version contains supplementary material available at 10.1186/s12893-021-01320-1.
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Affiliation(s)
- N A C van den Boom
- Dept. of Trauma Surgery, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands. .,Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands.
| | - G A N L Stollenwerck
- Dept. of Surgery-Trauma Surgery, Alrijne Hospital, Simon Smitweg 1, 2353 GA, Leiderdorp, The Netherlands
| | - S M A A Evers
- Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Da Costakade 45, 3521 VS, Utrecht, The Netherlands
| | - M Poeze
- Dept. of Trauma Surgery, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.,Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
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10
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Abstract
The reported incidence of Lisfranc injuries is 9.2/100.000 person-years; two-thirds of the injuries are nondisplaced. Tarsometatarsal injuries range from minor sprains and isolated ligamentous injuries to grossly unstable and multiligamentous lesions. High-energy injuries are usually linked with mechanical energy dissipation through the soft tissues. Operative treatment options include open reduction and internal fixation, open reduction with hybrid internal and external fixation, closed reduction with percutaneous internal or external fixation, and primary arthrodesis. Treatment goals are to obtain a painless, plantigrade, and stable foot. Anatomic reduction is a key factor for improved outcomes and decreased rates of post-traumatic arthritis.
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Affiliation(s)
- Alexandre Leme Godoy-Santos
- Department of Orthopedic Surgery, Faculdade de Medicina, Universidade de São Paulo, Rua Dr Ovídio Pires de Campos 333, Cerqueira Cesar, Sao Paulo, São Paulo 05403-010, Brazil; Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil.
| | - Cesar de Cesar Netto
- Department of Orthopedics and Rehabilitation, University of Iowa, 200 Hawkins drive, Iowa City, IA 52242, USA
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