Repair and Fix the Lisfranc Joint Dont Fuse It Gil R. Ortega, MD, - - PowerPoint PPT Presentation

Repair and Fix the Lisfranc Joint Don’t Fuse It

Gil R. Ortega, MD, MPH Sonoran Orthopaedic Trauma Surgeons Orthopaedic Trauma Director, Mayo Clinic Arizona Residency Program Vice Chair, Department of Surgery, Scottsdale Osborn Level 1 Trauma Center, Scottsdale, AZ, USA

Disclosures

• Founding Member, Orthopaedic Board of

Advisors: Carbofix

• Founding Member, Orthopaedic Board of

Advisors: Artross Nanobone

• Consultant: Smith and Nephew

Why Fuse a joint that suffers a ligament injury without a fracture?

• Do we fuse shoulder or elbow joints after

dislocations without fractures?

• Do we fuse hips after dislocations without

fractures?

• Do we fuse knees after knee dislocations with

ligament injuries only?

• Do we fuse ankles after ankle dislocations

without fractures?

• NO OF COURSE NOT…So why fuse the

Lisfranc?

Fusing a Lisfranc joint after a dislocation makes no physiologic sense

• A Lisfranc injury is a ligamentous injury with
• r without associated fractures

The Weak Argument to Fuse a Lisfranc is based on one study

• Forty-one patients in prospective, randomized clinical

trial comparing primary arthrodesis with ORIF

• Patients followed for average of 42.5 months

Evaluation was performed with clinical examination, radiography, American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale, a visual analog pain scale, and a clinical questionnaire

The Weak Argument to Fuse a Lisfranc is based on one study

• Twenty patients-ORIF and 21-Fusion
• Two years postop, mean AOFAS Midfoot

score was 68.6 points in ORIF and 88 points in the arthrodesis group (p < 0.005)

• Five patients in open-reduction group had

persistent pain with development of deformity or osteoarthrosis, and they were eventually treated with arthrodesis

The Weak Argument to Fuse a Lisfranc is based on only one study

• Patients who had been treated with fusion

estimated that their postoperative level of activities was 92% of their preinjury level, whereas ORIF estimated postoperative level was only 65% of their preoperative level (p < 0.005)

• Was study powered enough to make these

practice guideline conclusions?

• Ly TV1, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary

arthrodesis compared with open reduction and internal fixation. A prospective, randomized study.J Bone Joint Surg Am. 2006 Mar;88(3):514-20

The major issues with that one study

• They did ORIF with transarticular screw

fixation

• Why would anyone use transarticular

screws to fix a ligament injury?

• Why would you “screw up” a joint surface?
• Do we do that with any other joint injury?

– NO!

Fusing a Lisfranc joint after a dislocation makes no physiologic sense

• Fusion has several current limitations
• NO long-term data exist regarding the

function of patients fusion for Lisfranc injury

• Perhaps, similar to ORIF, results of fusion

may diminish with time

• The ORIF comparison group underwent

transarticular fixation which likely leads to degenerative changes seen postoperatively

The Weak Argument to Fuse a Lisfranc is based on only one study

• All remaining studies have all found

equivalent, but not superior, functional

• utcomes compared with modern series of

ORIF

• Fusion is not without complication. Rates
• f nonunion of up to 33% have been

reported

• Adjacent joint degenerative changes have

been seen in 12% of patients

The Argument for Dorsal Plating for Fixation without Mucking up the Articular surfaces

• Makes more physiological sense not to

touch articular surfaces

• Anatomic reduction obtained and

maintained

• Stern al showed 15 patients at one year

follow-up with AOFAS Midfoot Scores with mean score was 85, with a range from 78 to 92 with maintenance of reductions

• Stern et al. Dorsal Multiple Plating Without Routine Transarticular Screws for Fixation of

Lisfranc Injury. Orthopedics. 2014; 37 (12): 815-819

My Personal Experience with Dorsal Plating as Compared to Transarticular Fixation or Fusion?

• Of course the findings show better
• utcomes with Dorsal Plating and

anatomic reduction

Thank You