This Level I prospective randomized trial compared primary arthrodesis (PA) to primary ORIF (PORIF) for acute Lisfranc tarsometatarsal injuries. Forty patients were randomized, with 32 completing follow-up through two years. The central question: does fusing the joint upfront avoid the morbidity of staged hardware removal and salvage arthrodesis without sacrificing function?
The question of whether to fuse or fix Lisfranc injuries has long been debated — ORIF was standard, but the high arthrosis rate (up to 40% for purely ligamentous injuries) and the near-universal need for hardware removal made the total surgical burden much larger than it first appeared.
This trial quantifies that burden directly: choosing ORIF means roughly a 4-in-5 chance of returning to the OR, mostly for hardware removal.
When you see a purely ligamentous Lisfranc injury or any unstable TMT fracture-dislocation in a reliable patient, primary arthrodesis of the medial three joints is a defensible first-line choice. It delivers equivalent function and satisfaction while dramatically cutting re-operation risk.
Remember the anatomic rule: fuse only the non-essential medial three TMT joints (1st, 2nd, 3rd); the lateral two (4th, 5th) are mobile and should be temporarily stabilized with K-wires only. The two-year functional equivalence is reassuring, but the editor's note is worth keeping in mind: ORIF outcomes may deteriorate further as post-traumatic arthrosis progresses beyond two years.
This Level I prospective randomized trial compared primary arthrodesis (PA) to primary ORIF (PORIF) for acute Lisfranc tarsometatarsal injuries. Forty patients were randomized, with 32 completing follow-up through two years. The central question: does fusing the joint upfront avoid the morbidity of staged hardware removal and salvage arthrodesis without sacrificing function?
The question of whether to fuse or fix Lisfranc injuries has long been debated — ORIF was standard, but the high arthrosis rate (up to 40% for purely ligamentous injuries) and the near-universal need for hardware removal made the total surgical burden much larger than it first appeared.
This trial quantifies that burden directly: choosing ORIF means roughly a 4-in-5 chance of returning to the OR, mostly for hardware removal.
When you see a purely ligamentous Lisfranc injury or any unstable TMT fracture-dislocation in a reliable patient, primary arthrodesis of the medial three joints is a defensible first-line choice. It delivers equivalent function and satisfaction while dramatically cutting re-operation risk.
Remember the anatomic rule: fuse only the non-essential medial three TMT joints (1st, 2nd, 3rd); the lateral two (4th, 5th) are mobile and should be temporarily stabilized with K-wires only. The two-year functional equivalence is reassuring, but the editor's note is worth keeping in mind: ORIF outcomes may deteriorate further as post-traumatic arthrosis progresses beyond two years.