title: Does Open Reduction and Internal Fixation versus Primary Arthrodesis Improve Patient Outcomes for Lisfranc Trauma? A Systematic Review and Meta-analysis.
abstract: BACKGROUND
  Although Lisfranc injuries are uncommon, representing approximately 0.2% of all fractures, they are complex and can result in persistent pain, degenerative arthritis, and loss of function. Both open reduction and internal fixation (ORIF) and primary fusion have been proposed as treatment options for these injuries, but debate remains as to which approach is better.
  
  
  OBJECTIVE
  We asked whether ORIF or primary fusion led to (1) fewer reoperations for hardware removal; (2) less frequent revision surgery; (3) higher patient outcome scores; and (4) more frequent anatomic reduction.
  
  
  METHODS
  A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Three trials met the criteria for inclusion within the meta-analysis. Qualifying articles for the meta-analysis had data extracted independently by two authors (NS, AF). The quality of each study was assessed using the Center for Evidence Based Medicine's evaluation strategy; data were extracted from articles rated as good and fair: two and one article, respectively.
  
  
  RESULTS
  The risk ratio for hardware removal was 0.23 (95% confidence interval [CI], 0.11-0.45; p < 0.001) indicating more hardware removal for ORIF than fusion. For other revision surgery, the risk ratio for ORIF was 0.36 (95% CI, 0.08-1.59; p = 0.18) favoring neither. Similarly, neither was favored using patient-reported outcomes; the standard mean difference was calculated to be 0.50 (95% CI, -2.13 to 3.12; p = 0.71). When considering the risk of nonanatomic alignment, neither was favored (risk ratio, 1.48; 95% CI, 0.34-6.38; p = 0.60).
  
  
  CONCLUSIONS
  The surgeon should consider the increased risk of hardware removal along with its associated morbidity and discuss this with the patient preoperatively when considering ORIF of Lisfranc injuries. Because no new trials have been performed since 2012, further randomized controlled trials will be needed improve our understanding of these interventions.
  
  
  METHODS
  Level I, therapeutic study.
authors.affiliation: Memorial University of Newfoundland, St John's, NL, Canada.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Smith
authors.affiliation: General Orthopaedics/Foot and Ankle Surgery, Department of Orthopaedic Surgery, Discipline of Surgery, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada.
authors.forename: Craig
authors.initials: C
authors.lastname: Stone
authors.affiliation: Orthopaedic Traumatology, Department of Surgery, Discipline of Surgery, Faculty of Medicine, Memorial University of Newfoundland, Room 1380, Health Science Center, 300 Prince Philip Drive, St John's, NL, A1B3V6, Canada. andrewfurey@hotmail.com.
authors.forename: Andrew
authors.initials: A
authors.lastname: Furey
mesh_terms: D001174:Arthrodesis / Q000009:adverse effects / Q000295:instrumentation; D016009:Chi-Square Distribution; D020878:Device Removal; D005529:Foot Bones / Q000000981:diagnostic imaging / Q000293:injuries / Q000503:physiopathology / Q000601:surgery*; D018409:Foot Injuries / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D005593:Fracture Fixation, Internal / Q000009:adverse effects / Q000295:instrumentation; D017102:Fracture Healing; D050723:Fractures, Bone / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008023:Ligaments, Articular / Q000000981:diagnostic imaging / Q000293:injuries / Q000503:physiopathology / Q000601:surgery*; D016017:Odds Ratio; D000070799:Open Fracture Reduction / Q000009:adverse effects / Q000295:instrumentation; D011183:Postoperative Complications / Q000209:etiology / Q000601:surgery; D012086:Reoperation; D012307:Risk Factors; D016896:Treatment Outcome