Lisfranc Fracture-dislocation Research Articles

Effect of dorsoplantar miniscrew fixation of the second metatarsal base fracture on residual diastases in acute lisfranc fracture-dislocation.

This study aimed to evaluate and compare the clinico-radiographic outcomes between two techniques for acute Lisfranc fracture-dislocation with a large, displaced second metatarsal base plantar fracture: isolated Lisfranc screw fixation versus Lisfranc joint fixation with dorsoplantar miniscrew fixation of the second metatarsal base. We retrospectively compared the clinico-radiographic outcome between patients who underwent isolated Lisfranc screw fixation (Group 1, 26 patients) and those who underwent Lisfranc joint fixation with dorsoplantar miniscrew fixation of the second metatarsal base (Group 2, 23 patients). The main outcome measurements were the postoperative distance between the medial cuneiform and second metatarsal base on standing anteroposterior foot radiographs, known as the C1-M2 distance. Residual diastasis was defined as C1-M2 distance ≥ 2mm on the affected side compared with that on the contralateral side. We also assessed the Foot and Ankle Ability Measure (FAAM)-activities of daily living (ADL) and sports subscale scores at three, six and ≥ 18 months postoperatively. At the final follow-up, the mean C1-M2 distance on the affected side compared with that on the contralateral side was significantly greater in Group 1 than in Group 2 (3.9 versus 0.7mm, P = 0.027). Furthermore, Group 1 showed a higher incidence of residual diastases at the final follow-up (69.2%) than the Group 2 (13.0%, P < 0.001). The FAAM-ADL scores at the final follow-up did not differ significantly between the groups (P = 0.518), but the FAAM Sports score was significantly higher in Group 2 than in Group 1 (P = 0.001). The postoperative C1-M2 distance was better maintained with Lisfranc joint fixation with dorsoplantar miniscrew fixation of the second metatarsal base than with isolated Lisfranc screw fixation. We recommend that surgeons exercise caution when dealing with a second metatarsal plantar fracture and consider performing secure fixation using the dorsoplantar miniscrew technique for improved clinical outcomes.

Nitinol Staple Use in Primary Arthrodesis of Lisfranc Fracture-Dislocations.

Primary arthrodesis of Lisfranc fracture-dislocations is a reliable treatment option, yet concerns remain about nonunion. Nitinol staple use has recently proliferated in midfoot arthrodesis. The purpose of this study is to examine the union rate of primary arthrodesis of acute Lisfranc fracture-dislocations treated with nitinol staples compared with traditional plate-and-screw fixation. The secondary objective is to assess the difference in operative times and reoperation rates. Midfoot fracture-dislocations treated with primary arthrodesis by 7 foot and ankle orthopaedic surgeons were reviewed. Of 160 eligible patients, 121 patients (305 joints) met the required 4-month minimum radiographic follow-up. Radiographic outcomes were analyzed at the individual joint level. Each joint was classified as either staples alone (45 patients, 154 joints), staples plus plates and screws (hybrid) (45 patients, 40 joints), or plates and screws alone (31 patients, 111 joints). The primary outcome was arthrodesis union at each joint fused. Nonunion was more common (9.0%, 10/111) among joints fixed with plate and screws than with hybrid (2.5%, 1/40) or staples only (1.3%, 2/154) (P = .0085). Multivariable regression demonstrated that autograft use was independent associated with union (P = .0035) and plate-and-screw only fixation was an independent risk factor for nonunion (P = .0407). Median operating room and tourniquet times were shorter for hybrid (92 and 83 minutes) and staple only (67 and 63 minutes) constructs compared to plate-and-screw only fixation (105 and 95 minutes) (P ≤ .0001 and .0003). There was no difference in reoperation rates among patients with different fixation types. We found that use of nitinol compression staple and bone autograft in primary arthrodesis of Lisfranc and midfoot fracture-dislocations was associated with both improved union rates and shorter tourniquet and operative times compared to traditional plate-and-screw fixation techniques. Level III, therapeutic.

Open Reduction Internal Fixation vs Primary Arthrodesis for Lisfranc Fracture-Dislocations: A Cost Analysis.

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. 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. 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. 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 III, retrospective cohort study.

Use of Bio-integrative Screws for Fixation of Lisfranc Instability; Pros and Cons from Surgeons' Point of View in a Cadaver Study.

Majority of Lisfranc fracture-dislocations require anatomic reduction and rigid internal fixation to prevent debilitating sequelae. Current methods include solid screws and flexible fixations which have been in use for many years. Biointegrative screw is a newer option that has not yet been thoroughly investigated for its effectiveness for Lisfranc injuries. The ligaments of the Lisfranc complex were resected in eight lower-leg cadaveric specimens. This was done by eight foot and ankle surgeons individually. Distraction forces were applied from opposite sides at the joint to replicate weight bearing conditions. Three methods of fixation - flexible fixation, metal, and biointegrative screws- were evaluated. The diastasis and area at the level of the ligament were measured at four conditions (replicated injury and each type of fixation) in neutral and distraction conditions using fluoroscopy images. The Wilcoxon test and Kruskal Wallis test were used for comparison. P value <0.05 was considered statistically significant. The diastasis value for the transected ligament scenario (2.47 ± 0.51 mm) was greater than those after all three fixation methods without distraction (2.02 ± 0.5 for flexible fixation, 1.72 ± 0.63 mm for metal screw fixation and 1.67 ± 0.77 mm for biointegrative screw fixation). The transected ligament diastasis was also greater than that for metal screw (1.61 ± 1.31mm) and biointegrative screws (1.69 ± 0.64 mm) with distraction (p<0.001). The area at the level of the ligament showed higher values for transected ligament (32.7 ± 13.08 mm2) than the three fixatives (30.75 ± 7.42 mm2 for flexible fixation, 30.75 ± 17.13 mm2 for metal screw fixation and 29.53 ± 9.15 mm2 for biointegrative screw fixation; p<0.05). Metal screws, flexible fixation and biointegrative screws showed comparable effectiveness intra-op, in the correction of diastasis created as a consequence of Lisfranc injury.

A novel technique for successful closed reduction of a lisfranc fracture-dislocation

The purpose of this study is to present a novel technique for the closed reduction of a divergent Lisfranc fracture-dislocation. Successful closed reduction of this injury limits the morbidity associated with soft tissue compromise that may otherwise delay definitive surgical fixation. A combination of weighted axial traction/counter-traction with a two-stage manipulation of the medial/middle and middle/lateral columns of the mid- and forefoot was performed. A Kling was affixed to the hallux and second ray within closed loops, then mounted to an intravenous pole. Weight was then applied to the distal tibia. Axial traction-counter traction and manual plantar translation with medial to lateral compression were then combined until successful reduction of the first and second metatarsal was achieved. The third, fourth and fifth metatarsals were hyper-dorsiflexed and abducted with subsequent inline manual traction and lateral to medial compression over the base of the metatarsals. This was followed by plantarflexion and adduction to complete the reduction maneuver. : A combination of weighted axial traction/counter-traction with two-stage manipulation of the medial/middle and middle/lateral columns of the mid- and forefoot was performed to successfully reduce a divergent Lisfranc fracture-dislocation. Successful closed reduction avoided the need for acute open reduction and mitigated the risk of soft tissue compromise, neurovascular complication, and compartment syndrome. This novel technique for reduction permitted percutaneous internal fixation due to the satisfactory alignment obtained from the closed reduction maneuver. Early closed reduction obviates the need for acute open reduction and limits soft tissue morbidity. This permits orthopaedic surgeons to non-urgently manage Lisfranc fracture-dislocations with definitive surgical fixation that is amenable to either percutaneous techniques or open reduction and internal fixation.

Open Reduction And Internal Fixation of Tarsometatarsal (Lisfranc) Fracture Dislocations-Is Arthrodesis Necessary?

Controversy remains regarding the optimal management of tarsometatarsal (Lisfranc) fracture dislocations. Open reduction and internal fixation (ORIF) and ORIF with primary arthrodesis (PA) have been described in the treatment of these injuries, although adverse sequelae remain problematic. Previous work has yielded small cohorts with heterogenous results. We aimed to describe the outcomes of Lisfranc fracture dislocations managed with ORIF and/or PA to identify risk factors for complications, such as nonunion and revision surgery. A retrospective review of 206 consecutive tarsometatarsal fracture dislocations that underwent surgical repair between 2015 and 2021 was performed. Time to radiographic union was noted. Complications were recorded, including revision surgery, infection, symptomatic implant removal, posttraumatic arthritis, secondary arthrodesis, and nonunion. A comparative subgroup analysis of outcomes by treatment modality (ie, PA versus ORIF) and by injury severity (isolated injury versus concomitant lower extremity fracture) were performed. Logistic regression analysis was performed to assess factors associated with revision surgery. 104 patients met the inclusion criteria with a mean 13-month follow-up. Ninety-three (n = 93) patients underwent ORIF, and 11 patients underwent PA. Radiographic union was achieved in 94.2% of cases (98/104) at an average 106 days. Complications included superficial infection (3.8%), deep infection (7.7%), symptomatic implant removal (19.2%), posttraumatic arthritis (12.5%), secondary arthrodesis (4.8%), and nonunion (2.9%). No difference existed in the complication rates between those who underwent ORIF and those who underwent PA ( P = 0.50). Revision surgery rates were similar between patients who sustained isolated injuries and those with concomitant lower extremity fractures ( P = 0.31). Risk factors for revision surgery included open fractures (OR 4.01, P = 0.042) and previous psychiatric illness (OR 5.77, P = 0.016). The vast spectrum of injury in Lisfranc fracture dislocations makes uniform treatment challenging. In this large consecutive series, few failed to achieve union or required secondary arthrodesis. Open fractures and previous psychiatric illness portended worse clinical outcomes. ORIF without PA remains a viable treatment in these injuries. Level III, retrospective cohort study.

Primary Arthrodesis vs Open Reduction Internal Fixation for Lisfranc Fracture-Dislocations: A Cost Analysis

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: 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 2010-2020. Patients undergoing primary ORIF (CPT code 28615) versus PA (28730 and 28740) for Lisfranc fracture-dislocation were identified. The primary independent variable was ORIF versus PA of Lisfranc injury. Costs accrued due to operative management was the primary objective, and was analyzed according to net payment, total payment, coinsurance, copayment, deductible, and coordination of benefits per savings (COB/savings) amounts. Outpatient surgery setting (hospital versus ambulatory surgical center (ASC)) and requirement for secondary arthrodesis within the primary ORIF group were secondary independent variables. The utilization of and costs contributed by medical services were secondary outcomes. These included outpatient clinic visits, foot radiographs, lower extremity magnetic resonance imaging (MRI), lower extremity computed tomography (CT), physical therapy (PT), and opioid prescriptions. Student’s t-test, chi-squared test, and Poisson multivariable regression were used for statistical analysis, with significance set as P &lt; 0.05. Results: From 2010 to 2020, 7,268 patients underwent operative management of Lisfranc injuries, with 5,689 (78.3%) ORIF and 1,579 (21.7%) PA. Of those undergoing initial ORIF, 22 (0.39%) were converted to secondary arthrodesis at a mean ± standard deviation of 10.2 ± 12.1 months after the index surgery. PA was independently associated with increased net payment, total payment, and coinsurance. When compared to primary ORIF, patients undergoing PA utilized more clinic and PT visits and imaging sessions. However, primary ORIF with secondary arthrodesis was associated with more clinic visits, imaging, and generated higher costs from these medical services compared to PA alone. Within hospital and ASCs, PA was associated with increased net and total payments. However, out-of-pocket (OOP) costs were found to be higher in ASCs. Conclusion: Treatment of Lisfranc fracture-dislocation with PA is associated with higher initial costs compared to ORIF with subsequent secondary arthrodesis. Conversely, secondary arthrodesis demonstrated significantly higher costs and resource utilization compared to primary procedures. Specific cost drivers for PA and secondary arthrodesis were clinic visits and perioperative imaging.

Evaluating the Utility of Plain Radiograph and Computerised Tomography Scanning in Identifying Concomitant Foot Fractures in Patients with Unstable Lisfranc Injuries

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Lisfranc fracture dislocations are uncommon injuries, which frequently require surgical intervention. Currently, there is varying evidence on the diagnostic utility of plain radiographs (XR) and CT in identifying Lisfranc injuries and concomitant fractures. Our aim was to identify the utility of XR as compared to CT, with the nul hypothesis that there was no difference in fracture identification. Methods: A retrospective assessment of patients who had sustained a Lisfranc injury between 2013 and 2022 across two trauma centres within the United Kingdom who underwent surgery. Pre-operative XR and CT images were reviewed independently by 2 reviewers to identify the presence of associated fractures. Results: A total of 175 patients were included. Our assessment identified that XR images significantly under-diagnosed all metatarsal and midfoot fractures. The largest discrepancies between XR and CT in their rates of detection were in fractures of the cuboid (5.7% vs 28%, p&lt; 0.001), medial cuneiform (20% vs 51%, p=0.008), lateral cuneiform (4% vs 36%, p=0.113), second metatarsal (57% vs 82%, p&lt; 0.001), third metatarsal (37% vs 61%, p&lt; 0.001) and fourth metatarsal (26% vs 43%, p&lt; 0.001). As compared to CT, the sensitivity of XR was low. The lowest sensitivity for identification however was lateral foot injuries, specifically fractures of the lateral cuneiform (sensitivity 7.94%, specificity 97.3%), cuboid (sensitivity 18.37%, specificity 99.21%), fourth (sensitivity 46.7%, specificity 89.80%) and fifth metatarsal (sensitivity 45.00%, specificity 96.10%). Conclusion: From our analysis, we can determine that XR significantly under-diagnoses associated injuries in patient sustaining an unstable Lisfranc injury, with lateral foot injuries being the worst identified. We advised the use of CT imaging in all cases for appropriate surgical planning.

Management of Lisfranc Injuries: A Critical Analysis Review.

There is a spectrum of midtarsal injuries, ranging from mild midfoot sprains to complex Lisfranc fracture-dislocations. Use of appropriate imaging can reduce patient morbidity, by reducing the number of missed diagnoses and, conversely, avoiding overtreatment. Weight-bearing radiographs are of great value when investigating the so-called subtle Lisfranc injury. Regardless of the operative strategy, anatomical reduction and stable fixation is a prerequisite for a satisfactory outcome in the management of displaced injuries. Fixation device removal is less frequently reported after primary arthrodesis compared with open reduction and internal fixation based on 6 published meta-analyses. However, the indications for further surgery are often unclear, and the evidence of the included studies is of typically low quality. Further high-quality prospective randomized trials with robust cost-effectiveness analyses are required in this area. We have proposed an investigation and treatment algorithm based on the current literature and clinical experience of our trauma center.

Screws Alone for Acute Lisfranc Injuries Fixed Without Arthrodesis: A Better “Value” Than Plating in the Short Term

This study compares outcomes of patients with Lisfranc injuries treated with screw only fixation constructs to those treated with dorsal plate and screw constructs. Seventy patients who underwent surgical treatment for acute Lisfranc injury without arthrodesis and minimum 6-month (mean > 1-year) follow-up were identified. Demographics, surgical information, and radiographic imaging were reviewed. Cost data was compared. The primary outcome measure was the American Orthopedic Foot and Ankle Surgery (AOFAS) midfoot score. Univariate analysis through independent sample t-tests, Mann-Whitney U, and chi squared compared the populations. Twenty-three (33%) patients were treated with plate constructs and 47 (67%) with screw only fixation. The plate group was older (49±18 vs. 40±16 years, P=0.029). More screw constructs treated isolated medial column injuries compared to plate constructs (92% vs. 65%, P=0.006). At latest follow-up (mean 14±13 months), all tarsometatarsal joints were aligned. There was no difference in AOFAS midfoot scores. Plate patients experienced longer operations (131 ±70 vs. 75±31 minutes, P<0.001) and tourniquet time (101±41 vs. 69±25 minutes, P=0.001). Plate constructs were more expensive than screw ($2.3X±$2.3X vs. $X±$0.4X, P<0.001) ($X is the mean cost of screws alone). Plate patients had a higher incidence of wound complications (13% vs. 0%, P=0.012). Treatment of Lisfranc fracture dislocation injuries with screws only demonstrated a higher value procedure as similar outcomes were found amidst lower implant costs. Screw only fixation required a shorter operative and tourniquet time with less frequent wound complications. Screw only fixations proved mechanically sound enough to achieve goals of repair without inferior outcomes. LEVEL OF EVIDENCE: Level III.

TEN-YEAR OUTCOMES OF LISFRANC FIXATION DEMONSTRATES THAT COLUMN INVOLVEMENT PREDICTS OUTCOME

The Lisfranc fracture dislocation of the tarsometatarsal joint (TMTJ) is a complex injury with a reported incidence of 9.2 to 14/100,000 person-years. Lisfranc fixation involves dorsal bridge plating, transarticular screws, combination or primary arthrodesis. We aimed to identify predictors of poor patient reported outcome measures at long term follow up after operative intervention.127 patients underwent Lisfranc fixation at our Level One Trauma Centre between November 2007 and July 2013. At mean follow-up of 10.7 years (8.0-13.9), 85 patients (66.92%) were successfully contacted. Epidemiological data including age, gender and mechanism of injury and fracture characteristics such as number of columns injured, direction of subluxation/dislocation and classification based on those proposed by Hardcastle and Lau were recorded. Descriptive analysis was performed to compare our primary outcomes (AOFAS and FFI scores). Univariate analysis and multivariate regression analysis was done adjusted for age and sex to compare the entirety of our data set. p&lt;0.05 was considered significant. The primary outcomes were the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score and the Foot Function Index (FFI).The number of columns involved in the injury best predicts functional outcomes (FFI, P &lt;0.05, AOFAS, p&lt;0.05) with more columns involved resulting in poorer outcomes. Functional outcomes were not significantly associated with any of the fixation groups (FFI, P = 0.21, AOFAS, P = 0.14). Injury type by Myerson classification systems (FFI, P = 0.17, AOFAS, P = 0.58) or open versus closed status (FFI, P = 0.29, AOFAS, P = 0.20) was also not significantly associated with any fixation group.We concluded that 10 years post-surgery, patients generally had a good functional outcome with minimal complications. Prognosis of functional outcomes is based on number of columns involved and injured. Sagittal plane disruption, mechanism and fracture type does not seem to make a difference in outcomes.

Nitinol Staple versus Traditional Plate Osteosynthesis for Primary Arthrodesis of Lisfranc Injuries: A Retrospective Analysis

Category: Trauma; Midfoot/Forefoot Introduction/ Purpose: Primary arthrodesis of Lisfranc and midfoot fracture-dislocations is a reliable treatment option, yet concerns remain about nonunion and dorsiflexion malunion. The use of a new generation of nitinol staples has proliferated in midfoot arthrodesis. The purpose of this study is to examine the use of nitinol staples in primary arthrodesis of acute Lisfranc fracture-dislocations, comparing outcomes to traditional plate and screw fixation. The primary hypothesis is that nonunion rates are lower with constructs that include nitinol staples than those with plates and screws alone. Secondary hypotheses are: 1. Total operative and tourniquet time are shorter using nitinol staples. 2. Reoperation rates are lower using nitinol staples. 3. Dorsiflexion malunion rates are lower using nitinol staples. 4. Functional outcome scores will indicate comparable post-arthrodesis disability. Methods: Midfoot fracture-dislocations treated with primary arthrodesis by seven foot and ankle orthopaedic surgeons at a tertiary referral center from 1/1/2012 to 8/1/2021 were reviewed. Patients with open fractures, fractures managed with external fixation, Charcot arthropathy, neuropathy, previous midfoot surgery, or concomitant hindfoot/ankle fractures were excluded. Of 160 eligible patients, 121 patients met the required 4-month minimum radiographic follow-up. Preoperative records were reviewed, evaluating for associated metatarsal and cuneiform fractures, operative and tourniquet time, joints included, and fixation construct. Outcomes were analyzed at both patient and individual joint levels. Patients (121 total) and individual joints (305 total) were categorized as either staples alone (45 patients, 154 joints), staples plus plates and screws (hybrid) (45 patients, 40 joints), or plates and screws alone (31 patients, 111 joints). Postoperative radiographs were analyzed for union and malunion at each joint fused. Medical records were reviewed for postoperative complications. FAAM, VR-12, and NPRS were collected. Results: When assessed at the individual joint level, the nonunion rate was higher (8.1%, 9/111) among joints fixed with plate and screw constructs than with hybrid (2.5%, 1/40) or staple only constructs (1.3%, 2/154) (P = 0.017). Of the 12 nonunions in the study, 6 had either a metatarsal or cuneiform fracture. Median OR and tourniquet time were both shorter for hybrid (92 &amp; 83 minutes) and staple only (67 &amp; 63 minutes) constructs compared to plate and screw only fixation (106 &amp; 95 minutes) (P = 0.0003 &amp; &lt; 0.0001). There were 15 (12.4%) reoperations including 10 hardware removals, 3 nonunion revisions, and 1 malunion revision. There was no difference in reoperation, malunion (14 total, 11.6%), or patient reported outcome measure between fixation types. Conclusion: Nitinol staples are effective in achieving bony fusion when used alone or in combination with plates and screws. Their use should be considered for primary arthrodesis of Lisfranc and midfoot fracture-dislocations due to lower rates of nonunion and shorter tourniquet and operative time compared to traditional plate and screw fixation. Further studies are needed to determine if staples decrease the risk for dorsiflexion malunion and improve patient reported outcomes.

Patient experiences and preferences during treatment and recovery of Lisfranc fractures: A qualitative interview study

AimTo determine from a patient perspective what improves the quality of care and patient satisfaction during the treatment and recovery process of Lisfranc fractures and to reveal possible points for improvement in this process. MethodsWe performed a qualitative study based on semi-structured interviews with patients treated for a Lisfranc fracture-dislocation in the Netherlands with either open reduction and internal fixation or primary arthrodesis, until data saturation was reached, focusing on the quality of care during treatment and recovery, from a patient perspective. ResultsData saturation was reached after interviewing 10 patients. The main themes emerging from the analysis were expectation management regarding the recovery period; communication with and between health care providers; information provided during consultations; and support during the recovery period. Participants expressed a need for improved provision of information about the different treatment options, the different kinds of pain that can arise, the expected duration of the recovery period, education on strong pain killers, likelihood of a second surgery, risks of osteoarthritis, risks of the surgery itself, allied health care and patient experiences. Participants mentioned the importance of good allied health care and a preference for starting allied health care as soon as possible. Insoles and compression socks were also appreciated by various participants. Finally, multiple patients saw a positive attitude on the part of the health care providers towards the recovery period as a key factor in recovery. ConclusionThis study found that patients value more tailored approaches to the pre-and post-operative care program, more guidance regarding allied health care (physiotherapy), and a broader scope of available references and information for patients, both oral (during consultations and in informative videos) and written, such as brochures or evidence-based web pages and mobile platforms, which may be offered during consultations or when being discharged from the hospital.

Factors Influencing Postoperative Residual Diastasis after the Operative Treatment of Acute Lisfranc Fracture-Dislocation

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Clinically, surgeons may frequently encounter residual diastasis between the medial cuneiform and 2nd metatarsal base after the operative treatment of acute Lisfranc fracture-dislocations. The purpose of this study was to identify factors influencing postoperative residual diastasis. We specifically focused on the preoperative fracture pattern using 3- dimensional computed tomography (3D-CT). Methods: Radiographic and clinical findings of 66 patients who underwent operative treatment for acute Lisfranc fracture- dislocation were reviewed. Patients were grouped according to residual diastasis evaluated by weight-bearing anteroposterior radiograph of the foot at the final follow-up. Residual diastasis was defined as distance between the medial cuneiform and 2nd metatarsal base greater than the distance on the contralateral side by 2 mm or more. Demographic parameters and fracture patterns based on preoperative foot 3D-CT were compared. A paired t-test was used to compare continuous numeric parameters, while a chi-square test was used for the proportional parameters. Statistical significance was set at P-value less than 0.05 for all analyses. Results: The mean age at operation, sex, body mass index, and the rate of underlying diabetes were not significantly different between the two groups (P&gt;0.05 each). Preoperative foot 3D-CT evaluation showed that the rate of large (&gt;25% of 2nd tarsometatarsal joint involvement), displaced (&gt;2 mm) fracture fragments on the plantar side of the 2nd metatarsal base was more pronounced in the group with residual diastasis (P=0.001), while medial wall avulsion of the 2nd metatarsal base was more frequent in the group without residual diastasis (P=0.001). Conclusion: While treating acute Lisfranc injuries, surgeons should be aware of the presence of a 2nd metatarsal base plantar fracture. A dorsoplantar inter-fragmentary fixation can be considered if the fragment is large and displaced.

Nitinol Staple vs Traditional Plate Osteosynthesis for Primary Arthrodesis of Lisfranc Injuries: A Retrospective Analysis

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Primary arthrodesis of Lisfranc and midfoot fracture-dislocations is a reliable treatment option, yet concerns remain about nonunion and dorsiflexion malunion. The use of a new generation of nitinol staples has proliferated in midfoot arthrodesis. The purpose of this study is to examine the use of nitinol staples in primary arthrodesis of acute Lisfranc fracture-dislocations, comparing outcomes to traditional plate and screw fixation. The primary hypothesis is that nonunion rates are lower with constructs that include nitinol staples than those with plates and screws alone. Secondary hypotheses are: 1. Total operative and tourniquet time are shorter using nitinol staples. 2. Reoperation rates are lower using nitinol staples. 3. Dorsiflexion malunion rates are lower using nitinol staples. 4. Functional outcome scores will indicate comparable post-arthrodesis disability. Methods: Midfoot fracture-dislocations treated with primary arthrodesis by seven foot and ankle orthopaedic surgeons at a tertiary referral center from 1/1/2012 to 8/1/2021 were reviewed. Patients with open fractures, fractures managed with external fixation, Charcot arthropathy, neuropathy, previous midfoot surgery, or concomitant hindfoot/ankle fractures were excluded. Of the 160 eligible patients, 121 met the required 4-month minimum radiographic follow-up. Preoperative imaging and operative records were reviewed, evaluating for associated metatarsal and cuneiform fractures, operative and tourniquet time, joints included, and fixation construct. Patients and individual joints (303 total) were categorized as either staples alone (47 patients), staples plus plates and screws (hybrid) (47), or plates and screws alone (35). Postoperative radiographs at last follow-up were then analyzed for union and malunion at each joint fused. CT scans were used, when available (41 patients), to assess for union. Medical records were reviewed for postoperative complications. FAAM, VR-12, and NPRS were collected. Results: When assessed at the individual joint level, the nonunion rate was higher (8%, 9/101) among joints fixed with plate and screw constructs than with hybrid (2.4%, 1/41) or staple only constructs (1.3%, 2/152) (P = 0.015). Of the 12 nonunions in the study, 6 had either a metatarsal or cuneiform fracture. Median OR and tourniquet time were both shorter for hybrid (92 &amp; 83 minutes) and staple only (67 &amp; 63 minutes) constructs than plate and screw only fixation (107 &amp; 96 minutes) (P = 0.0002 &amp; 0.0009). There were 17 (14%) reoperations including 10 hardware removals, 3 nonunion revisions, and 1 malunion revision. There was no difference in reoperation, malunion (14 total, 12%), or patient reported outcome measure between fixation types. Conclusion: Nitinol staples are effective in achieving bony fusion when used alone or in combination with plates and screws. With lower rates of nonunion and shorter tourniquet and operative time compared to traditional plate and screw fixation, their use should be considered for primary arthrodesis of Lisfranc and midfoot fracture-dislocations. Further studies are needed to determine if staples decrease the risk for dorsiflexion malunion and improve patient reported outcomes.

Treatment Of Complex Open Lisfranc Injury In A Professional Bull Rider

HISTORY: An otherwise healthy 30-year-old male professional bull rider presented to our hospital as a transfer for an open left foot fracture after a bull stepped on his left foot during a professional competitive rodeo event. He immediately experienced pain in the affected foot. He denied any other injuries including trauma to the head or loss of consciousness. Although he has had multiple orthopedic injuries in the past, he denied any previous foot injuries to the left foot. PHYSICAL EXAMINATION: Physical examination revealed a large laceration on the medial aspect of the left foot over the 1st metatarsal with an open dislocation of the MT head. The open laceration site was 9 cm x 4 cm. The patient had mild loss of sensation and was unable to elicit movement in his toes. There was no trauma or tenderness present on the left hip, femur, knee or lower leg. DIFFERENTIAL DIAGNOSIS: 1. Open Lisfranc injury 2. Tarsometatarsal dislocation TEST AND RESULTS: Anterior-Posterior, lateral & oblique radiographs: 1. Complete dislocation of the first metatarsophalangeal joint 2. Lisfranc fracture/dislocation 3. Neck and base fractures of the second, third, and fourth metatarsals, base of fifth metatarsal 4. Cuboid fracture FINAL WORKING DIAGNOSIS: Open left first metatarsophalangeal dislocation and Lisfranc fracture-dislocation with multiple metatarsal fractures TREATMENT AND OUTCOMES: 1. Surgical irrigation & debridement of the wound, followed by open or closed fixation of fractures and dislocations. 2. Pin removal at 6 weeks post op and negative pressure wound therapy for 9 months postoperative. 3. Non-weight bearing for the first 8 weeks postoperative followed by progression to weight bearing as tolerated. 4. At 18 months post-operative, the patient was able to return to professional bull riding. 5. At 3.5 years from injury, there is residual pain and swelling present with development of hallux valgus. The foot/ankle is otherwise functioning appropriately and does not inhibit him from professional bull riding.

A modified three-incision approach to treating three-column Lisfranc injuries

PurposeThe most popular surgical approach to manage Lisfranc fracture-dislocations is the double-incision approach, which frequently causes a variety of complications, such as skin necrosis, rotational malreduction of the first tarsometatarsal joint (TMTJ) and lateral column dorsoplantar malreduction of the TMTJ. We introduce a three-incision approach to treat Lisfranc fracture-dislocations with only minor postoperative complications and good foot function. MethodsWe prospectively selected 30 previously healthy patients, ranging from 18 to 60 years of age, but only 23 patients completed the follow-up and thus were finally included, with an average age of 38.1 ± 12.9 years. All patients have sustained Lisfranc fracture-dislocations involving all three-column; 13.0% (3/23) were Myerson classification type A (medial), 47.8% (11/23) were type A (lateral), and 39.1% (9/23) were type C2. All patients were treated via a three-incision approach: a long incision made along the lateral border of the second ray was used as a working incision to visualize and reduce the first three TMTJs, as well as to apply internal fixation instrumentation; a 2 cm medial incision was made at the medial side of the first TMTJ as an inspecting incision, ensuring good reduction of the first TMTJ in medial and plantar view; another 1 cm inspecting incision was made at the dorsal side of the fourth/fifth TMTJ to prevent sagittal subluxation of the lateral column. Mean ± SD was used for quantitative data such as operation time, follow-up time and foot function scores. Postoperative complications were documented, and foot function was evaluated using the American orthopaedic foot & ankle society score, foot function index and Maryland foot score at follow-up. The foot function of the injured foot and contralateral foot of the same patient was at the end of follow-up, and independent sample t-test was used for statistical analysis. ResultsThe median operation time was 117.9 ± 14.6 min (range 93 - 142 min). All complications occurred within three months after the operation, and included delayed wound healing (17.4%), superficial infection (8.7%), complex regional pain syndrome (4.3%) and neuroma (4.3%). There was no case of postoperative skin necrosis or malreduction. At the end of follow-up of 14.1 ± 1.2 months (range 12–16 months), the median American orthopaedic foot & ankle society score of the operated foot was 89.7 ± 5.7, the median foot function index was 21.7 ± 9.9, and the median Maryland foot score was 88.7 ± 4.8. There were no significant differences between the operated and contralateral sides, in terms of foot function, at the end of followup (p > 0.05). ConclusionThe three-incision approach can provide adequate visualization of all TMTJs to ensure anatomical reduction and offer sufficient working space to apply internal fixation instrumentation, which is effective in treating three-column Lisfranc fracture-dislocations with minor soft tissue complications and satisfactory functional recovery.

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

BackgroundInjuries 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.MethodsThis 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.ResultsTwenty 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).ConclusionsRadiographic and clinical outcomes of unstable Lisfranc fracture-dislocation treatment support temporary lateral column screw fixation as an alternate technique.Level of clinical evidence3 (retrospective cohort study)

Short Term Assessment of Surgical Treatment of Lisfranc Fracture Dislocation

Background: Lisfranc fractures are rare injuries, with reported incidence of 0.2% of all fractures and 1/55,000 per year incidence in the population. These are reported to occur 2–4 times more commonly in men, and the peak incidence is in the third decade of life. Objective: This study was aimed to assess the functional outcome of using open reduction and internal fixation in management of ligamentous Lisfranc injuries. Patients and Methods: This prospective operative study was conducted on 18 patients with Displaced Lisfranc injury admitted to the Orthopedic Surgery Department, Faculty of Medicine, Zagazig University, during the period from February 2021 to August 2021. The diagnosis was made by medical history taking, clinical examination and radiological assessment. Results: The mean operation time was 140.0±27.43 minutes with minimum 90 and maximum 200 minutes and mean hospital stay was 4.38±1.33 with minimum 3 and maximum 8 days. The mean healing time 8.38±2.45 with minimum 6 and maximum 16 weeks. The most prevalent complication was infection (22.2%), Transient numbness (5.6%), Delay healing (5.6%), Loss reduction (5.6%) and overall complicated cases were 5 cases 27.8%. Conclusion: It could be concluded that anatomical reduction of Lisfranc injury can be achieved by open reduction and internal fixation with the Kirschner wires (K-wires) and Cannulated Screws.

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

BackgroundThe 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.MethodsStudy 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.DiscussionThis 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