Myerson Classification Research Articles

Internal Brace Fixation Technique for Lisfranc Injury: A Retrospective Study.

BACKGROUND The Lisfranc ligament is crucial for maintaining the transverse and longitudinal arch of the foot. Owing to the disruption between the medial cuneiform bone and the base of the second metatarsal bone, the currently preferred fixation method remains controversial. Our fixation technique involves screwing one anchor to the medial and intermediate cuneiform bones and using the anchor to carry the ligament to bind the Lisfranc joint and first and second metatarsal joints altogether for elastic fixation. This study evaluated the clinical and functional outcomes of InternalBrace fixation for Lisfranc injury. MATERIAL AND METHODS This retrospective study included 58 patients who underwent InternalBrace fixation for Lisfranc injury between January 2019 and September 2022 by an experienced surgeon. One-way analysis of variance or t test was used. Preoperative classification was performed according to the Myerson classification with imaging data. Postoperative follow-up was performed based on intraoperative blood loss, fracture healing time, visual analog scale (VAS) score, the American Orthopedic Foot and Ankle Society (AOFAS) score, Tegner score, and complications. RESULTS Surgery was completed in all patients, and follow-up was performed. The patients' ages ranged from 19 to 62 years (average: 34.6±9.4 years). The postoperative follow-up time was 12-24 months (average: 16.9±3.0 months). The average time for fracture healing was 12.8±3.0 (10-24) weeks. The VAS, AOFAS, and Tegner scores significantly improved postoperatively (from 5.33±1.0 (3-7) to 1.24±0.57 (0-2); 28.02±6.70 (18-51) to 91.59±4.76 (82-96); and 2.40±0.67 (1-4) to 6.53±0.54 (6-7), respectively), which was statistically significant (P<0.01), and the good rate of AOFAS was 91.4%. The postoperative complications were traumatic arthritis, incision infection, and temporary dorsal foot numbness, which gradually recovered. No other rejection reactions or Lisfranc fracture/dislocations recurrence occurred during the follow-up period. CONCLUSIONS InternalBrace fixation for Lisfranc injury is beneficial for restoring Lisfranc joint stability and function and allows for early and more aggressive rehabilitation for patients, with fewer surgical complications.

Inter- and intra-observer reliability of a novel Lisfranc injury classification in comparison to the Myerson classification

AimWe investigated the inter- and intra-observer reliability of the novel Column Involvement Severity System (CISS) in comparison to the commonly used Myerson classification for Lisfranc injuries. MethodsSixteen observers (orthopedic or trauma surgeons with experience in foot and ankle trauma) rated radiographs and computed tomography videos of 31 cases of patients treated at our level 1 trauma center between 2010 and 2020. Four weeks after completing the first rating session, eight observers (50%) rated the cases again. The inter- and intra-observer reliability for both classifications were assessed using intraclass correlation coefficients (ICC). ResultsICC for Myerson classification was 0,277 (0,056–0,944) for interobserver and 0,505 (0,390–0,604) for intra-observer reliability. However, the Myerson classification was found to be non-applicable by at least 25% of observers in 48,4% of cases (range 0–63%). For the CISS classification, overall ICC was 0,455 (moderate) and 0,676 (substantial) for interobserver and intra-observer reliability respectively. ConclusionThe Myerson classification was found to be non-applicable by a large number of observers. The CISS classification demonstrated better interobserver and intra-observer reliability. It may thus provide better communication about the injury severity and involvement of the three midfoot columns in Lisfranc injuries.

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.

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.

Release of gastrocnemius aponeurosis and suture of the Achilles tendon end scar tissue managing the chronic Achilles tendon rupture

To investigate the clinical effect of scar tissue suture at the broken end of Achilles tendon after gastrocnemius aponeurosis release in the treatment of chronic Achilles tendon rupture. The clinical data of 17 patients with old achilles tendon rupture treated from January 2017 to December 2019 were analyzed retrospectively, including 15 males and 2 females, aged 26 to 53 years with an average of (35.2±11.6) years old, and the time from injury to operation was 37 to 92 days with an average of (49.3±13.3) days. Myerson's classification included 6 cases of typeⅡ and 11 cases of typeⅢ. The defect of the broken end of Achilles tendon was 2 to 5 cm with an average of(4.1±1.5) cm after partial scar tissue was removed. All patients were treated with gastrocnemius aponeurosis, appropriate excision of scar tissue at the broken end of Achilles tendon and direct suture. The continuity and healing of Achilles tendon were evaluated by color Doppler ultrasound 3 months after operation. The ankle plantar flexor strength was measured by ankle plantar flexor strength tester before operation and 1 year after operation. American Orthopaedic Foot and Ankle Society ankle hindfoot score (AOFAS) and Achilles tendon rupture score were used before operation and 1 year after operation Achilles tendon total fracture score (ATRS) was used to evaluate the clinical rehabilitation of Achilles tendon rupture. All patients were followed up for 12 to 18 months with an average of(13.6±1.8) months. The surgical incision healed in stageⅠ. Color Doppler ultrasound showed good continuity of Achilles tendon, local Achilles tendon slightly thickened and irregular fiber direction. The ankle plantar flexor force (92.2±3.9) N at 1 year after operation was significantly higher than that before operation (29.5±4.2) N (P<0.05);One year after operation, the AOFAS(91.20±3.30) was significantly higher than that before operation (42.20±4.40)(P<0.05);the ATRS (90.70±3.00) was significantly higher than that before operation(40.00±2.90)(P<0.05). The gastrocnemius aponeurosis release combined with scar suture of Achilles tendon end is an effective technique for the treatment of chronic Achilles tendon rupture, avoid injury to hallux flexor longus or flexor digitorum longus, with the plantar flexor muscle strength of the ankle was recovered well, is an effective method to treat chronic Achilles tendon rupture.

Early incision, decompression and screw fixation for the treatment of Lisfranc injuries with foot osteofascial compartment syndrome

To explore clinical effect of early incision and decompression combined with screw fixation in treating Lisfranc injury and foot osteofascial compartment syndrome. Clinical data of 5 patients with Lisfranc injury and foot osteofascial compartment syndrome were retrospective analysized from January 2017 to December 2018, including 4 males and 1 female, aged from 19 to 62 years old. All patients were suffered from closed injuries. The time from injury to treatment ranged from 1 to 14 h. According to Myerson classification, 1 patient was type A, 1 patient was type B, and 3 patients were type C. All patients were performed early incision decompression and screw fixation. Maryland foot functional scoring standard at 12 months after opertaion was used to evaluate clinical effect. All patients were followed up for 10 to 48 months. All fractures were achieved bone union, and healing time ranged from 3 to 9 months. All metatarsal and tarsal joints were reached to anatomical reduction. No infection, osteomyelitis, loosening or breaking of internal fixation occurred. Postopertaive Maryland foot function score at 12 months was from 44 to 97, and 2 patients got excellent result, 2 good, and 1 poor. Early incision and decompression with screw fixation for the treatment of Lisfranc injury and foot osteofascial compartment syndrome, which has advantages of simple opertaion, thoroughly decompression, screw fixation does not occupy space, stable decompression and fixation, and could receive satisfied clinical effect.

External column lengthening with peek cage and modified single approach

Objective: To show the results obtained with the treatment of stage 2B flatfoot according to Myerson classification (reducible and flexible), through external column lengthening with interposition of a peek cage filled with spongious graft taken from the same calcaneus, without osteosynthesis, combined with medial slide calcaneal osteotomy with step plate, both using the a single approach. Medial time was associated with latero-lateral transfer of common flexor tendon of toes to posterior tibial. Methods: Sixteen patients were assessed from 2015 to 2018, of which 11 were women and 5 were men. In all cases, surgery was performed with a first lateral time for osteotomies and a second time for tendon repair. Mean patients’ follow-up was 28 months. Results: All patients achieved consolidation of both osteotomies at nearly 12 postoperative weeks. No patient presented signs of peek cage migration due to lack of stability or dorsal cutaneous nerve branch injuries resulting from this modified single approach. Two patients evolved with wound dehiscence and only one with calcaneocuboid pain so far. No patient required reoperation. Conclusion: The modified single tuberosity approach for the two osteotomies has shown to be a simple procedure that prevents damages to dorsal cutaneous nerve branches described with dorsal approach. Leve lof Evidence IV; Therapeutic Studies; Case Series.

Indirect fixation of the third tarsometatarsal joint for high-energy Lisfranc injury

To evaluate the effectiveness of indirect fixation of the 3rd tarsometatarsal joint in the treatment of high-energy Lisfranc injury. Between February 2015 and February 2019, 15 patients with high-energy Lisfranc injury were treated. There were 12 males and 3 females with an average age of 44.8 years (range, 29-73 years). The average time from injury to admission was 8.8 hours (range, 2-28 hours). According to Myerson classification, there were 6 cases of type A, 4 cases of type B2, 1 case of type C1, and 4 cases of type C2; 8 cases were open injury. The 3rd tarsometatarsal joint was injured in all patients, including intact intermetatarsal ligament in 7 cases, the 2nd-3rd intermetatarsal ligament injury in 6 cases, the 3rd-4th intermetatarsal ligament injury in 1 case, and the 2nd-3rd-4th intermetatarsal ligament injury in 1 case. Among them, the 3rd tarsometatarsal joint was not fixed directly and indirectly fixed by stabilized the 2nd and 4th tarsometatarsal joints in 13 cases. The 3rd tarsometatarsal joint was fixed with Kirschner wire in 2 cases for 1 patient had complete injury of the intermetatarsal ligament and the other 1 had comminuted fracture of the base of the 3rd metatarsal. The reduction of fracture and dislocation was evaluated by X-ray films, focusing on the re-displacement of the 3rd tarsometatarsal joint. The effectiveness was evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue scale (VAS) score. Thirteen of the 15 patients were followed up 12-26 months, with an average of 15.6 months. One case had superficial infection of the incision and healed after symptomatic treatment; the other incisions healed by first intention. At last follow-up, the VAS score was 0-3 (mean, 1.1) and the AOFAS score was 70-99 (mean, 87.5). Twelve patients achieved anatomical reduction and 1 patient had increased talar-first metatarsal angle and the mild forefoot abduction. During the follow-up, no loss of reduction of the 3rd tarsometatarsal joint was found, while the spontaneous fusion of the joint was observed in 2 patients. In high-energy Lisfranc injury, as long as the intermetatarsal ligament is not completely destroyed and the bony structure of the tarsometatarsal joint is intact, the 3rd tarsometatarsal joint does not need to be fixed routinely, the stability of the joint can be obtained indirectly by fixing the adjacent tarsometatarsal joint.

Percutaneous fixation of Lisfranc joint injuries: A systematic review of the literature

ObjectiveThe aim of this systematic review was to present the outcome of Lisfranc joint injuries treated with closed reduction and screw percutaneous fixation. MethodsWe searched in Pubmed and Google Scholar Databases for articles regarding screw percutaneous fixation of Lisfranc injuries. Seven studies in total were found to be compatible to our search, according to PRISMA guidelines. Four of those met the criteria of the review and they were included in the meta-analysis. A total number of 106 patients were separated into five groups according to the type of injury and the mean AOFAS score of each group was calculated. Cases in which percutaneous fixation was converted to open treatment due to poor reduction were not included in the study. In addition we compared the outcome score between types of injury according to Myerson classification as well as between purely ligamentous and osseoligamentous injuries. The characteristics of all seven selected studies, such as kind of screw used for fixation, post operative protocol, complications and outcome are mentioned as well. ResultsAverage AOFAS score was 86,2 for type A, 87,54 for type B, and 85 for type C injuries respectively. In pure dislocation group the average AOFAS score was 86,43 and in fracture dislocation group was 87,36. Good to excellent outcome can be expected in patients with different types of injury according to Myerson classification following percutaneous fixation of lisfranc joint injury. Patients with type B injury or a fracture dislocation injury might have better outcome, although this difference was not found to be statistically significant. ConclusionPercutaneous fixation of tarsometatarsal joint injuries is a relatively simple and safe method of treatment, leading to a good functional outcome, especially for Myerson type B as well as for fracture dislocation type of injuries, provided that an anatomical reduction has been achieved. Level of EvidenceLevel III, Therapeutic Study.

Open reduction combined with a variable angle foot plate for treatment of acute Lisfranc frac-ture-dislocation

Objective To analyze the clinical outcomes of a standard protocol of open reduction and internal fixation using a variable angle foot plate for a consecutive series of patients with acute Lisfranc joint injury. Methods This study retrospectively evaluated the clinical outcomes of 11 Chinese patients (13 feet) with acute Lisfranc joint injury who had been treated by open reduction and internal fixation with a variable angle foot plate from December 2016 to June 2017 at Department of Orthopaedics, West China Hospital.They were 8 men (10 feet) and 3 women (3 feet), aged from 19 to 57 years (average, 36.4 years).Of them, 10 were complicated with fracture of metatarsus, 6 with cuneiform fracture and/or dislocation, 4 with cuboid fracture, and one with cuboid fracture.According to the Myerson classification for Lisfranc frac-ture-dislocations, one case (one foot) belonged to type A, 2 (2 feet) to type B1, 5 (6 feet) to type B2, 2 (3 feet) to type C1 and one (one foot) to type C2.The outcomes were evaluated using the visual analogue scale (VAS) and the midfoot scores of American Orthopedic Foot and Ankle Society (AOFAS). Results This cohort was followed up for 18 to 24 months (average, 22 months).Their VAS scores were decreased signif-icantly from preoperative 7.3±1.2 (from 6 to 9) to postoperative 1.2±0.2 (from 0 to 2) (P<0.05); their AOFAS midfoot scores were increased significantly from preoperative 0 to postoperative 84.6±4.6 (P< 0.05).Anatomic reduction was obtained in all the patients and all the fractures united successfully without any delayed union or nonunion.Superficial necrosis of the wound edge occurred in 2 cases without deep in-fection; skin anesthesia occurred in 2 and skin hypesthesia in 4, indicating a lesion of the superficial peroneal nerve. Conclusion Fixation of acute Lisfranc joint injury with a variable angle foot plate can lead to rigid stability, precise reduction and satisfactory short-term clinical outcomes. Key words: Foot; Wounds and injuries; Bone plate; Lisfranc

Suture-button technique for acute Lisfranc injury

Objective To observe operative outcomes of suture-button technique for acute Lisfranc injury. Methods A retrospective observation was conducted of the 11 patients who had been operatively treated with suture-button technique and plate fixation for acute Lisfranc injury from January 2015 to December 2016.They were 8 men and 3 women, aged from 22 to 54 years (mean, 32.1 years).By the Myerson classification for the injury, there were 9 cases of type B2 and 2 cases of type C1; by the Chiodo classifica-tion, there were 7 cases of middle column injury, 2 cases of injury to middle and lateral columns and 2 cases of injury to medial and middle columns.Their scores on the visual analogue scale (VAS), mid-foot scores of American Orthopedic Foot and Ankle Society (AOFAS), bone union and complications were observed post-operatively. Results Follow-ups for this cohort lasted for 14 to 34 months (mean, 20.5 months).Follow-ups revealed that their VAS scores for the affected foot averaged 0.6 (from 0 to 2), significantly higher than those for the nomal foot (Z=2.070, P=0.038) .Their AOFAS scores averaged 95.2(from 87 to 100), significantly lowerer than those for the nomal foot (Z=2.121, P=0.034) .All fractures were united well. Conclusion Suture-button technique can lead to satisfactory outcomes for acute Lisfranc injury. Key words: Foot; Wounds and injuries; Bone plate; Lisfranc

Lisfranc ligament anatomical reconstruction surgery is beneficial for chronic Lisfranc injuries

Category: Midfoot/Forefoot Introduction/Purpose: Chronic Lisfranc fracture dislocation had been commonly treated with arthrodesis, but were these treatments suitable? The Lisfranc joint has sagittal motion with articular cartilage and functioning as a shock absorber. We reported the middle-term outcomes after performing Lisfranc ligament anatomical reconstruction surgery (LARS), using an optimal route of reconstruction based on anatomical measurements of and biomechanical experiments with cadavers. The purpose of this study is to determine the usefulness of LARS for chronic Lisfranc injuries to preserve the joint function. Methods: We underwent LARS for 8 cases of Chronic Lisfranc injuries (6 males, 2 females) from May 2012 to June 2017. Average age at surgery 26.1 years (18-38), average follow-up period is 28 months (2-46). The reconstruction route was via a burr hole created at a position 6 mm distal to the tarsometatarsal joint on the 2nd metatarsal, and at a depth of 10 mm. A burr hole was then created from the medial cuneiform bone to the 2nd metatarsal bone in a plantar and horizontal direction. The graft tendon was guided through the burr hole from the medial cuneiform bone to the 2nd metatarsal (double-layered side), was looped, and was guided back around the dorsum of the medial cuneiform(single layer) to reconstruct the dorsal ligament. We examined Myerson classification, Kaar evaluation and the postoperative clinical evaluation using Japanese Society for Surgery of Foot (JSSF) midfoot scale. Results: In Myerson classification, Type B2 6 cases and Type C1 2 cases. In Kaar evaluation, transverse instability (TI) 6 cases, longitudinal instability (LI) 2 cases. The average time from injury to surgery is 156 days on average (37-404). JSSF scores averaged 95 points (90-100). X - ray evaluations were almost good, but in 2 cases with weight bearing, a slight diastasis between the base of the first cuneiform and second metatarsal was observed. But there were no clinical symptoms such as pain. In the surgical procedure, scar is mediated in chronic cases. Therefore, we had to take time to obtain the reduction. Conclusion: Arthrodesis is gold standard for chronic Lisfranc joint injuries, but decline in foot flexibility is inevitable. LARS is beneficial for maintaining anatomical reduction, preserving the joint function, and shortening the post-therapy period. LARS gave stable results against Chronic Lisfranc joint injuries. LARS for chronic Lisfranc joint injuries is a useful procedure.

Effects of multi-block reconstructive plate on the treatment of complex tarsometatarsal joint injury

Objective To evaluate the effect of multi-plate reconstruction plate in the treatment of partial complex tarsometatarsal joint injury injuries. Methods Seven patients treated complex tarsometatarsal joint injuries with multi-plate reconstruction plate in Nanjing Hospital Affiliated to Nanjing Medical University from September 2014 to July 2016 were selected in this study.According to Myerson classification, 3 cases were A type, 3 cases were B type, 1 case was C type.The therapeutic effects were observed. Results The patients were followed up for 6-12 months, with an average of (8.6±2.0) months.According to the foot scoring criteria in American Orthopedic Foot and Ankle Society (AOFAS), the function of the foot was evaluated, 3 cases were in excellent condition, 4 cases were in good condition. Conclusion In the case of multiple metatarsal fractures of the metatarsal base involved in the joint surface, the use of multiple reconstructive plates for joint fixation reduces the iatrogenic damage of the joint surface.The fixation effect and the functional recovery are satisfactory Key words: Tarsometatarsal joint injury; Reconstructive plate; Foot scoring standard

Can patients affected by stage II Posterior Tibial Tendon Dysfunction return to sport activities after surgical treatment?

Category: Hindfoot, Sports Introduction/Purpose: Medial displacement calcaneal osteotomy with flexor digitorum longus transfer is considered the gold standard in treatment of adult flatfoot associated with posterior tibial tendon dysfunction (stage II in Myerson classification). The aim of this study was to estimate if patients underwent medial displacement calcaneal osteotomy with flexor digitorum longus transfer can participate to sport activities. Methods: 48 patients (21 men, 43,75%; 27 women, 56,25%) with a mean age at time of surgery of 42,3 years (range 19-74 years) were evaluated with a medium follow-up of 30 months (range, 27-34 months). All patients were evaluated clinically and by imaging before and after surgery. The clinical evaluation included for each patient the self-filling of Sports Athlete Foot and Ankle Score (SAFAS). and Pre- and postoperative sporting activities were recorded. The imaging evaluation included a pre-operative foot and ankle MRI and weight-bearing radiographs (antero-posterior, lateral and Saltzman 20° views) of the foot and ankle before surgery and at final follow-up. Moreover, each patients’ pre- and post-operative sport activities were recorded. Results: Preoperatively, 29 of 48 (60,4%) patients were engaged in athletic activities, participating in an average of 1.4 hours/week (range, 0-6 hours/week); postoperatively, 40/48 (83.3%) participated in sport and recreational activities for an average of 3.5 hours/week (range, 0-15 hours/week). Meary’s angle improved significantly from 11.3±6.3 degrees preoperatively to 7.2±5.5 degrees at final-follow-up (p&lt;0.01); calcaneal pitch improved significantly from 16.1±4.3 degrees to 19.4±4.8 degrees (p&lt;0.01). At final follow-up, patients demonstrated good SAFAS scores in symptom tolerance (85.90%), pain tolerance (88.30%), daily living performance (96.2%) and sports performance (86.45%). Conclusion: Most of patients returned or resumed to participate to sport activities after medial displacement calcaneal osteotomy and flexor digitorum longus transfer for the treatment of adult flatfoot associated with posterior tibial tendon dysfunction and the increase of the average number of activities for patient and of the mid time spent was observed.

The surgical treatment for fresh tarsometatarsal joint fracture-dislocation

Objective: To summarize the functional outcome of tarsometatarsal joint fracture-dislocation managed according to Myerson classification.Methods: Total eighty cases of tarsometatarsal joint fracture-dislocation were treated from Mar 2004 to Feb 2012. According to the Myerson classification, there were 14 cases in type A, 12 cases in type B1, 28 cases in type B2, 11 cases in type C1 and 15 cases in type C2. All the cases were treated with open reduction and internal fixation and the incisions and implants were also selected according to the Myerson classification. X-ray was examined during the follow-up period and functional evaluation was carried out by American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score system. Analysis of variance was used to test the different types of Myerson classification.Results: Sixty eight patients got a mean follow-up of 24 months (15-36 months). No patient suffered from infection, skin flap necrosis and X-ray showed there were no implants loosening or breakage. The mean AOFAS score was 88.4(47-100) and excellent and good result was 89.7%. The differences among Myerson classifications showed that there were statistical significance between type B and type A, type C (P < 0.05) Three patients suffered from severe pain and difficult walking, X-ray showed the ambiguity of the joint space, which can be diagnosed as posttraumatic arthritis. One patient had arthrodesis finally.Conclusion: The Myerson classification is helpful to make preoperative plan and judging prognosis to the tarsometatarsal joint injuries. In type B, single or double incisions with screw or plate fixation is enough, while in type A and type C, double or triple incisions with screw or plate fixation in medial joints and Kirschner wire fixation in lateral joints are needed. Postoperatively, the type B patients had better prognosis than type A and type C patients. However, the concomitant injuries around the tarsometatarsal joint were not included in Myerson classification, which is the limitation but cannot be neglected.doi: http://dx.doi.org/10.12669/pjms.304.4259How to cite this:Yu X, Pang QJ, Yang CC. Functional outcome of tarsometatarsal joint fracture dislocation managed according to Myerson classification. Pak J Med Sci 2014;30(4):773-777. doi: http://dx.doi.org/10.12669/pjms.304.4259This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The effect of the Tscherne injury pattern on the outcome of operatively treated Lisfranc fracture dislocations

Lisfranc fracture dislocations cause severe tarso-metatarsal malalignment. The research question of this study was to evaluate the severity of the soft tissue injury on the final clinical outcome and compare that with the effect of various determinants on the disability in daily living activities after open reduction and internal fixation of a Lisfranc injury. This study consisted of a retrospective analysis of patients with Lisfranc fracture dislocations who were treated by open reduction and internal fixation beween 2004 and 2009. Evaluation focused mainly on the severity of the soft tissue injury, age, fracture classification, time to operation, posttraumatic osteoarthritis, and the results were compared with American Foot and Ankle Society (AOFAS) scores, and Foot and Ankle Disability Index (FADI). Eight patients had Tscherne Grade 1, 13 had Grade 2, and 11 had Grade 3 soft tissue injuries. Myerson classification revealed 11 type A, 8 type B and 13 type C fractures. Six patients' operations were delayed beyond 8h. Of the 38 patients treated in the study period, 32 patients (11 female, 21 male; <30 y-old: 14, >30 y-old: 18) were available for complete follow-up (average, 55.5 months). The comparison of treatment results revealed that those patients with high grade soft tissue injuries had lower AOFAS and FADI scores (43.8±15.9, 53.7±9.4, respectively) when compared to Tscherne Grade 1 injuries (82.8±6.1, 109±13.9, respectively) (p<0.001). The overall negative impact of the severity of soft tissue injury on functional outcomes had similar significance with regard to post-traumatic osteoarthritis, and fracture type. There was also a statistically significant difference between outcome measures and post-reduction quality (p=0.002). Patient age (p=0.9) and delayed surgery (p=0.5) had no statistically significant effect on the final outcome. Satisfactory results can be achieved with open reduction for Lisfranc injuries. However, despite this treatment, both the severity of the soft tissue injury and non-anatomic reduction are negative prognostic factors in the treatment of Lisfranc fracture dislocations.

Treatment of open to the tarsometatarsal joint injury

Objective To discuss the treatment and clinical outcome of open to the tarsometatarsal joint injury. Methods From April 2009 to April 2010,14 patients,10 males and 4 females,with open to the tarsometatarsal joint injury were treated in our department.They were 45 years old on average (from 21 to 67 years old).Five of them had the tarsometatarsal complex involved.According to Chiodo and Myerson's classification,all the injuries were of three-column type. Medial and lateral column shortening was respectively concomitant in 2 cases.Two patients had combined soft tissue defects and one patient degloved dorsal skin.A thorough debridement and Kirschner wire fixation following reduction were performed for all patients in the emergency room.A mini external fixator was applied in patients with medial or lateral column shortening.The degloved skin was thinned and grafted in situ,followed by vacuum sealing drainage (VSD) to cover the wound.The soft tissue defect was covered by VSD after debridement.All the patients had a definitive internal fixation after the soft tissue condition improved, and 3 of them had soft tissue coverage simultaneously.Functional outcomes were scored by American Orthopedic Foot Ankle Society (AOFAS) system. Results One patient with degloving injury had partial skin necrosis which was treated by debridement,definitive internal fixation and local flap transfer on the 13th day after emergency operation.A definitive internal fixation and skin graft were performed in 2 patients with soft tissue defects respectively on the 7th or 11th day post-operation.No wound infection or necrosis occurred in other patients.Twelve patients were followed up for an average period of 18 months (from 13 to 25 months).Solid union was obtained 12 weeks on average (from 10 to 16 weeks) after the secondary surgery.No flap necrosis,infection,nonunion or osteomyelitis occurred during the follow-up.Two patients had tarsometatarsal arthrodesis at the 12th or 14th month respectively due to severe pain and function limitation caused by post-traumatic arthritis.The mean AOFAS midfoot score at the last follow-up was 72 (from 61 to 89). Conclusions As tnanagement of open to the tarsometatarsal joint injury is a great challenge,surgeons must take soft tissue condition into consideration.Tenporary Kirschner wire fixation or in combination with external fixation after early thorough debridement,reduction and alignment restoration,followed by secondary definitive internal fixation until soft tissue condition improves is a safe and effective treatment strategy to decrease soft tissue complications and obtain stable fixation. Key words: Foot injury; Surgical procedures,operative; Bone nails; External fixators; Staged strategy

Open reduction and internal fixation for treatment of Lisfranc joint injury at early stage

Objective To summarize the clinical experience in treatment of the Lisfranc joint injury with open reduction and internal fixation at early stage. Methods Twelve patients ( including ten males and two females at average age of 34 years) with early stage Lisfranc joint injury received open reduction and screw/wire fixation from 2005 to 2010. According to the Myerson classification, there were two patients with type A, eight with type B and two with type C. All the patients received open reduction and internal fixation with screw or Kirschner wire within 17 days after injury. The post-operative function was estimated by mid-foot scoring scale of AOFAS. X-ray and CT scan were used in radiography estimation. Results All the patients were followed up for average 33 months ( range, 6-60 months). The mean score of post-operative mid-foot scoring scale of AOFAS was 74.5 points ( range, 53-96 points), with excellent result in eight patients, good in two and fair in two. The anatomical reduction was observed in eight patients and all the patients obtained bony union according to the results of X-ray and CT scan.There was no any complication found.Conclusions Open reduction and internal fixation is a good choice for the treatment of Lisfranc joint injury at early stage. A preoperative comprehensive analysis combined with clinical X-ray and CT scan is necessary. Key words: Foot injuries; Fracture fixation, internal; Lisfranc joint

Diagnosis and treatment of old Lisfranc joint injury

Objective To discuss causes and treatment of old fracture dislocation of tarsometatarsal joints. Methods From August 2004 to June 2008, 20 cases (16 males and 4 females, 21 to 49 years old) of old Lisfranc injure were treated. According to Myerson classification, 3 cases were type Ⅰ, 13 cases type Ⅱ, and 4 cases type Ⅲ. X-ray emanation and three dimensional CT reconstruction were conducted. Open reduction and fixation using K-wires and screws were adopted for 17 cases and tarsometatarsal joints fusion for 3 cases. Results Postoperatively only 18 cases were followed up for 6 months to 4 years. According to Maryland scoring system, 3 cases were rated as excellent, 12 good, and 3 moderate. Although no breaking of internal fixator or refracture-dislocation was found, midfoot pain and limited walking function existed in some cases. Conclusions Lisfranc injuries are sometimes easily missed because of poor radiographic repre-sentations, or incorrect methods in primary diagnosis and treatment. For most old Lisfranc injury cases, open reduction and internal fixation of tarsometatarsal fracture-dislocations leads to improved functional results. And corrective arthrodesis can also release pain and lead to greater patient satisfaction. Anatomic reduction and stable fixation, especially anatomic restoration of the foot arch, are key points in the treatment of old Lisfranc injury. Key words: Foot injuries; Foot joints; Therapy

Uni-clip staples combined with titanium alloy Bold screws for treatment of tarsometatarsal joint in-juries

Objective To investigate the clinical effects of uni-clip staples combined with titanium alloy Bold screws for the treatment of tarsometatarsal joint injuries. Methods From June 2006 to De-cember 2007, 14 cases of tarsometatarsal joint injuries were treated with a combination of uni-clip staples and Bold screws, including 4 simple dislocations and 10 fracture-dislocations. According to Myerson's classifica-tion, 2 cases were of type A, 8 type B (1 type B1 and 7 type B2), and 4 type C. Injuries involved only medial column in 2 cases, middle column in 3, medial and middle columns in 2, middle and lateral columns in 5, and 3 columns in 2. In addition, 2 were combined with cuboid fractures. Results All the wounds healed primarily. At 4 weeks all the patients began functional exercise after removal of the plaster casts. At 12-16 weeks all the patients began to walk with partial weight loading after removal of the implants, and at 22 weeks they started to walk with full weight loading. The follow-ups lasted for an average of 8.7 (4 to 14) months. The American Orthopaedic Foot & Ankle Society (AOFAS) score averaged 83.7 (75 to 91). Conclusions As the Uni-clip staple can fix tarsometatarsal dislocations without damaging the articular surface, it can reduce the occurrence of osteoarthritis. More reliable than Kirschner wire, it is capable of elastic fixation of the lateral columns. It can also treat cuboid fractures with satisfactory results. In addition, Bold screws may allow automatic reduction and stable fixation of fractures in small wounds by compressive forces. It also protects the dorsal cortex of the metatarsal bone. A combined use of the two can lead to satisfactory results in the treatment of tarsometatarsal joint injuries. Key words: Foot ioints; Foot iniuries; Internal fixator