O'Connor Kyle P, Tackett Logan B, Riehl John T
Med City UNT/TCU Orthopaedic Surgery Residency Program, 3535 S Interstate 35, Denton, TX, 76210, USA.
University of Pikeville College of Medicine, Pikeville, KY, USA.
Arch Orthop Trauma Surg. 2024 Dec 16;145(1):49. doi: 10.1007/s00402-024-05700-z.
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.
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).
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.
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.
I.
在大多数患者中，单纯存在Lisfranc损伤被视为手术指征。然而，对于一期关节融合术（PA）与切开复位内固定术（ORIF）的指征，外科医生之间存在争议。关于哪种治疗方式能带来更好的患者报告结局指标（PROMs）、再次手术率和并发症，存在相互矛盾的数据。
查询的数据库包括PubMed、OVID Medline、Embase、SCOPUS、Cochrane临床对照试验中心注册库和clinicaltrials.gov，时间范围从各数据库创建之日至2024年3月21日。如果研究纳入了急性Lisfranc损伤患者，并比较了PA和ORIF的结局，则纳入本分析。记录PROMs、再次手术率和并发症。结果以效应量（ES）和比值比（OR）报告。
本系统评价和Meta分析纳入了18项研究。13/16项报告了美国足踝外科协会（AOFAS）评分和视觉模拟评分（VAS）的研究的汇总数据显示，与ORIF相比，PA后的结局更好。PA后AOFAS评分为84.4±28.5，ORIF后为75.7±29.0。PA后VAS疼痛评分为1.4±2.7，ORIF后为2.0±3.3。另有3项研究报告了其他PROMs，且更支持ORIF。PA后恢复到伤前活动水平的比例为79.2%，ORIF后为65.7%。据报告，PA后中足创伤后关节炎的患病率为2.8%，ORIF后为17.3%。目前文献中未报告相邻关节关节炎。PA后，77/438（17.6%）的患者接受了再次手术，ORIF后，514/802（64.1%）的患者接受了再次手术。排除计划中的内固定取出术后，PA后非计划再次手术的相对发生率为14.7%（n = 62/423），ORIF后为38.3%（n = 181/472）（p < 0.001）。PA后43/406（10.6%）的患者发生了非手术并发症，ORIF后95/753（12.6%）的患者发生了非手术并发症（p = 0.31）。Meta分析表明，AOFAS（ES：0.41，CI 0.13，0.68，p = 0.004）、VAS疼痛（ES： - 0.53，CI - 0.91， - 0.15，p = 0.006）和恢复活动率（OR：2.71，CI 1.43，6.39）方面，PA优于ORIF。与ORIF相比，PA后创伤后关节炎（OR：0.29，CI 0.11，0.77）和再次手术（OR：0.16，CI 0.06，0.44）的发生率更低。
本系统评价和Meta分析表明，与采用坚强内固定的ORIF相比，PA在Lisfranc损伤的治疗中能提供更好的短期和中期结局。由于缺乏可用的临床研究，PA的长期影响在很大程度上尚不清楚，但可能包括相邻关节关节炎增加、疼痛以及需要进一步手术，尤其是在年轻且活动较多的患者中。未来关于长期结局的研究将有助于临床决策。
I级
