Figure 15.1
Radiographs of the patient’s left foot taken 3 days after the injury. (a) Weight-bearing AP view showing >2 mm diastasis of the first intermetatarsal space and loss of alignment between the medial borders of the middle cuneiform and the base of the second metatarsal. The arrow is showing the fleck sign: an avulsion of the Lisfranc ligament from the base of the second metatarsal. (b) Oblique view shows congruent third and fourth TMT joints. (c) Lateral view showing no dorsal or plantar displacements
The first step in the management of any Lisfranc injury is to decide whether surgical fixation is needed. Anatomic reduction and internal fixation is the preferred option for injuries with a diastasis of more than 2 mm at the first metatarsal space [1, 5]. The different fixation options are screws, low profile plates, interosseous sutures, and K-wires, but, regardless of the implant used for fixation, the mainstay of treatment is to obtain an anatomic reduction of the Lisfranc joint, stabilizing the medial and middle columns of the foot while preserving motion of the lateral column [1, 5–7]. The advantages and limitations of various treatment modalities are as follows.
Screws: They remain the most popular treatment option, representing approximately 82% of the implants used for internal fixation of Lisfranc fractures [5]. Compared to fixation with Kirschner pins, small fragment fully threaded screws have better biomechanical features; they achieve superior stabilization and tolerate higher bearing forces without loss of reduction [7, 8]. On the other hand, they are trans-articular implants with an inherent risk of causing thermal injury to cartilage possibly resulting in an increased risk of posttraumatic arthritis [9]. Another disadvantage of screws is the necessity for hardware removal. Although most authors suggest that screws should be removed between the third and sixth postoperative months, there is still no clear evidence regarding the indications for removal and when should this surgery be performed [1, 10].
Interosseous suture techniques: Open reduction and internal fixation (ORIF) using suture techniques have been recently developed trying to overcome the problem of damaging the articular surface with screws and possibly decreasing the incidence of posttraumatic arthritis. Studies have shown equivalent stability compared to screws, and suture systems do not require an additional procedure for hardware removal [11, 12]. Theoretically, suture techniques can be effectively used for fixation because they mimic the Lisfranc ligament and can help maintain reduction, making them a suitable treatment option for athletes [2, 13, 14]. There is inadequate evidence to support a routine use of this technique over screws.
Plates: Low-profile plates have been utilized in the treatment of Lisfranc injuries; they are joint-spanning implants and therefore are less likely to cause damage to the articular surface, and they are removed only if the patient becomes symptomatic [1]. The surgical approach and exposure are wider with respect to the approach needed for screws and this can compromise blood supply and soft tissues, potentially affecting bone healing [15]. Although to date there are no clear indications for their use, plates are helpful for ORIF of comminuted fractures [1]. The stability achieved with plates is similar to the stability obtained when using trans-articular screws and loss of reduction with weight-bearing forces is comparable to screws [16, 17].
Based on these factors, the decision was made to perform ORIF with screws.
Intraoperative Tips and Tricks for Reduction and Fixation
The procedure was performed with the patient in a supine position with his knee flexed and using a triangular support in order to allow a plantigrade position of the foot. A dorsal longitudinal incision over the first TMT joint space between the extensor hallucis longus and the extensor hallucis brevis tendons was made. The neurovascular bundle was carefully preserved while exposing the first intermetatarsal space. Under direct visualization, the first TMT joint was tested and found to be unstable, so the first ray was stabilized with an axial screw from the metatarsal to the medial cuneiform and a pointed reduction clamp was then placed across the medial cuneiform to the second metatarsal base to reduce the Lisfranc complex. The Lisfranc screw was placed from the medial aspect of the medial cuneiform to the second metatarsal base and the second metatarsal was additionally stabilized with a screw from the base to the middle cuneiform. Intraoperatively, the third metatarsal was stressed and found to be unstable; hence a screw was placed across the third TMT joint. The lateral column was stable when tested intraoperatively; therefore no further fixation was required. Finally, the quality of the reduction was confirmed clinically and radiographically (Fig. 15.2).
Figure 15.2
Fluoroscopic images of the final reduction and fixation of the Lisfranc injury. (a) AP view showing fixation with a Lisfranc screw. Note that the medial borders of the second metatarsal and the middle cuneiform are aligned. The first and second metatarsals are fixed to the medial and middle cuneiforms, respectively, using fully threaded screws. (b) Oblique view shows the third metatarsal fixed to the lateral cuneiform and congruent fourth and fifth TMT joints. (c) No vertical instability documented on the lateral view
In cases where the joints in the lateral column are found to be unstable, attempts for close reduction and percutaneous fixation can be done. If reduction cannot be maintained, or is difficult to achieve by these means, open reduction is required. A dorsal longitudinal incision over the fourth intermetatarsal space will allow access to the third and fourth TMT joints and reduction under direct visualization can be performed. Flexible fixation with Kirschner wires will help maintain reduction without completely restricting motion of the lateral column and they are typically removed after 6 weeks [1, 10].
Key Points/Pearls
Make longitudinal incisions to address the affected joints: A dorsomedial approach will give access to the first and second TMT joints and a dorsolateral approach will give access to the TMT in the lateral column. Beware: Protect skin flaps to avoid necrosis [10].
If anatomic reduction can’t be obtained look for soft-tissue interposition (tibialis anterior tendon) [1, 18].
The sequence of reduction of Lisfranc fractures should go from proximal to distal and from medial to lateral, reducing and temporarily fixing the medial column first, following reduction of the middle and lateral columns [10, 18].
Anatomic reduction and rigid fixation of the medial and middle columns + flexible fixation (pins) of the lateral column if needed [19].
The Lisfranc screw can be placed from the base of the second metatarsal towards the medial cuneiform as the target is bigger [15].
Avoid using lag or partially threaded screws because they can increase stress across the articular surface [2].Related posts:
Trimalleolar Ankle Fracture: Screws Only for Posterior Malleolus
Trimalleolar Ankle Fracture: Posterior Plate for Posterior Malleolus Fractures
Bimalleolar Ankle Fracture: Medial Plate
Lisfranc Fracture/Dislocation Treated with Primary Arthrodesis
Calcaneus Malunion with Subtalar Fusion (Bone Block Arthrodesis)
Cuboid and Nutcracker Fractures
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