A Novel Approach To Treating Lisfranc Fractures
Given the potential for debilitating complications with Lisfranc fractures, the authors discuss the advantages of closed reduction with percutaneous screw fixation and offer a step-by-step guide to the procedure.
Acute fracture/dislocations of the tarsometatarsal (Lisfranc) joint in the sensate patient continue to be challenging injuries to treat given the potential for the development of painful arthritis and chronic disability. Current day Lisfranc fracture/dislocation injuries represent approximately 0.2 percent of all fractures reported.1 Males are 2 to 10 times more likely to sustain Lisfranc injuries in comparison to females and most injuries occur in the fourth decade of life.1
The potential for disability increases if treatment is not expedited. Researchers have reported that a delay in diagnosis of fracture/dislocations of the Lisfranc joint occurs up to 20 percent of the time.2 Surgical management of Lisfranc injuries is uniquely challenging and warrants further discussion of available operative techniques.
One of the most important considerations in surgical management of Lisfranc injuries is anatomic reduction of the Lisfranc joint complex followed by rigid stabilization until osteoligamentous healing occurs. Several treatment options exist for the treatment of Lisfranc fracture/dislocations. Unfortunately, the current and most acceptable classification system for evaluating these injuries does not give insight into the choice of surgical procedure and is not predictive of outcome after treatment.3 Regardless of the chosen surgical technique, an accurate anatomic reduction is consistently associated with improved functional outcomes.4,5
Conservative treatment options exist and include casting with and without closed reduction of the unstable joints. Research has proven this to be ineffective.6-8 Open reduction internal fixation (ORIF) with primary arthrodesis is certainly indicated with greater articular damage or for primarily ligamentous injuries. Although ORIF with primary arthrodesis is represented in the literature as a surgical option and is currently in vogue, it occurs infrequently.9 Secondary arthrodesis also remains an option after the failure of other treatment options. Percutaneous wire fixation with casting has proven suitable but is not ideal.10
What A Systematic Literature Review On Percutaneous Screw Fixation Reveals
Closed reduction with percutaneous screw fixation can be an effective surgical technique to deliver internal fixation and maintain closed reduction. To our knowledge, the literature has not commonly described closed reduction with percutaneous fixation. This prompted further investigation in the form of a systematic review, which addressed the efficacy of percutaneously delivered internal screw fixation following closed anatomic reduction of acute traumatic Lisfranc fracture/dislocations.
In September 2010, we conducted a systematic review of electronic databases and relevant peer-reviewed sources including Infotrieve-Pubmed/Medline (www4. infotrieve.com/newmedline/search.asp). We then searched each identified manuscript for pertinent references. For this review, we only included manuscripts that involved closed anatomic reduction of acute traumatic Lisfranc fracture/dislocations and percutaneous delivery of internal screw fixation. Additionally, the injury had to involve a closed soft tissue envelope and a minimum mean follow-up of three years to determine postoperative sequela.
The search for potentially eligible information for inclusion in the systematic review yielded a total of 15 references.1,4,9-21 After considering all of the potentially eligible references, one evidence-based medicine Level 3 comparative study met our inclusion criteria.2 This study involved a total of 42 patients (42 feet) with a mean age ± SD of 37.7 ± 14.2 years. The mean ± SD follow-up was 58.4 ± 17.3 months. The study reported no significant difference in the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scores for patients with perfect or near anatomical reduction. However, those with osteoligamentous injuries fared better than those with purely ligamentous injuries.
The results of our systematic review reveal that a percutaneous approach appears efficacious, especially when an osteoligamentous injury exists. However, based on the limited data available, additional prospective investigations are warranted.
A Step-By-Step Guide To Closed Reduction Percutaneous Internal Fixation
Surgical treatment of Lisfranc fracture dislocations via closed reduction with percutaneous delivery of internal fixation is a viable technique for injuries that the surgeon can passively reduce under image intensification. Additionally, this approach may offer advantages over traditional open procedures. These advantages may include less soft tissue trauma, which potentially leads to fewer wound complications. This is particularly important in a diabetic, rheumatologic or smoking population. Another key advantage is smaller, aesthetically pleasing scars.
One should perform this procedure with the patient under general or spinal anesthesia. Place the patient on the operating room table in the supine position. Surgical prep and draping should include the entire foot, ankle and knee of the affected extremity. One may also prep and drape the contralateral extremity in similar fashion for intraoperative comparison. Apply a well padded pneumatic thigh tourniquet to the operative extremity in case there is failure to achieve closed reduction, which would require conversion to an open procedure.
Otherwise, the percutaneous technique should not require use of a tourniquet. This is an additional benefit of this surgical technique. Image intensification should be positioned opposite the surgeon in order to allow fluid unrestricted access to the operative extremity.
In order to fully assess the degree of injury to the tarsometatarsal joint, visualize the injured foot under direct image intensification. Specifically, use one hand to stabilize the rearfoot by cupping the posterior plantar heel. Use the opposite hand to grasp the distal metatarsals. Abduct, adduct, invert (pronate) and evert (supinate) the forefoot on the midfoot under direct image intensification.
Evaluate gross instability across the tarsometatarsal joint complex and compare this with preoperative plain film radiographs or computed tomography images. This can be helpful to elicit instability of the first metatarsocuneiform joint and/or intercuneiform instability that otherwise may appear normal on preoperative assessment.
To assess the capacity for the reduction of a Lisfranc fracture dislocation injury, adduct the forefoot on the midfoot while simultaneously engaging the windlass mechanism by dorsiflexing the toes at the level of the metatarsophalangeal joints. This maneuver provides stability across the Lisfranc joint complex and midfoot articulations by engaging the plantar soft tissue structures, including the plantar fascia and long flexors.
After fully assessing the Lisfranc fracture dislocation injury for the extent of instability and amplitude of injury under direct image intensification, use a temporary external fixation device, such as a large pointed Weber reduction clamp, to reduce the involved dislocated metatarsals. Foremost, under direct image intensification, place the reduction clamp with one point positioned on the plantar medial aspect of the medial cuneiform. Ensure positioning of the opposite point of the clamp on the dorsal lateral aspect of the second or third metatarsal base (depending on whether the third metatarsal is dislocated/unstable or not).
Tighten the clamp until the medial three tarsometatarsal articulations are anatomically reduced in all three cardinal planes, providing temporary reduction and stability across this region. Additionally, place the reduction clamp in a manner that permits easy, unobstructed delivery of guide wires and eventual permanent fixation in the form of cannulated screws.
Then insert a guide wire from the cannulated small fragment screw system of your preference across the cuneiform region. In terms of placement, start medially on the midfoot at a point slightly dorsal and central on the medial cuneiform. Advance the wire in a lateral direction through the intermediate cuneiform into the lateral cuneiform, ending in the central and slightly plantar aspect of the lateral cortex of the lateral cuneiform.
After properly positioning all temporary guide wires, place the first screw across this cuneiform region. This addresses any intercuneiform instability you may see on the stress exam and provides a solid proximal foundation to gain further stability distally involving the tarsometatarsal articulations. Due to the relatively soft nature of the medial cuneiform, placing a washer in this region can increase surface area, stability and prevent undesired sinking of the screw head.
Proceed to place a second guide wire. Start at the plantar medial aspect of the medial cuneiform, cross the site of the Lisfranc ligament proper and exit out of the dorsal lateral aspect of the second metatarsal base. Whether one addresses these injuries through open or closed techniques, maintaining anatomical reduction of the second metatarsal base within its intercuneiform recess is considered the most crucial step to achieving a successful outcome.
Ultimately, one will achieve internal screw fixation across this region in an orientation that permits screw threads to take advantage of the relatively dense osseous nature of the second metatarsal base. Additionally, the surgeon should place this screw as a positional screw, which maintains the reduction achieved by the Weber reduction clamp.
Keys To Ensuring Sound Permanent Screw Fixation
After achieving anatomic reduction and temporary fixation, you can provide permanent screw fixation (from the small fragment screw system of your choice) through minute percutaneous incisions. As we noted previously, place a screw across the cuneiform articulations and subsequently from the medial cuneiform to the second metatarsal base. Confirm the length and position of these screws under direct image intensification. If you deem this satisfactory, remove the reduction clamp and temporary guide wires. Reassess the stability of reduction under image intensification in the same pronatory and supinatory manner as previously described for the beginning of the procedure.
After confirming stability through stress manipulation under image intensification, direct your attention toward the instability of the first metatarsocuneiform and third metatarsocuneiform joints. While engaging the windlass mechanism and creating stability across the midfoot region as we previously described, drive a guide wire from the dorsal central point of the intersection between the proximal and middle third of the first metatarsal into the plantar central portion of the medial cuneiform. Then place permanent rigid internal screw fixation through a minimal percutaneous incision only big enough to allow passage of the screw.
Finally, place a guide wire from the dorsal lateral aspect of the third metatarsal base and direct it either to the lateral or intermediate cuneiform. The oblique orientation of a screw from the third metatarsal base to the intermediate cuneiform is preferable due to its slightly stronger and more stable nature. Make a minimal percutaneous incision for passage of permanent internal screw fixation. Assess the position and length of screws for the reduction of both the first and third metatarsals. Confirm them under direct image intensification prior to the removal of the remaining temporary fixation.
If one notes gross subluxation or frank dislocation of the fourth and fifth metatarsal cuboid articulations preoperatively or during stress examination, one can percutaneously deliver transarticular Kirschner wires temporarily for a period of four to six weeks. This facilitates increased stability until edema has subsided and there are signs of ligamentous healing. When employing percutaneous fixation of the fourth and fifth metatarsals, keep in mind that the final construct should achieve complete anatomic reduction with rigid internal fixation that is stable to intraoperative stressing demonstrated under image intensification.
Pertinent Pointers On Post-Op Management
Following closed reduction with percutaneous delivery of internal fixation, emphasize protective cast immobilization for a period of three weeks in conjunction with 100 percent strict non-weightbearing of the operative extremity. This permits time for coaptation of skin margins from percutaneous incisions, reduction of soft tissue edema and the formation of scar tissue necessary for ligamentous healing. The patient can then safely transition to a removable protective walking boot and passive range of motion of the toes and ankle is permitted.
Allow gradual transition to weightbearing over the next three- to four-week period. At the six- to seven-week point, make a formal physical therapy referral and place the patient into a sturdy shoe that offers stability and a soft insole to provide adequate shock absorption.
Controversy exists over the necessity for removing the retained hardware but we prefer to remove the hardware only if the patient becomes symptomatic, which is not common. Not removing hardware avoids additional surgical procedures and the potential for disruption of correction with possible loss of anatomical reduction.
While there are several options for treating an acute closed Lisfranc joint fracture/dislocation injury, closed reduction with delivery of percutaneous screw fixation technique safely offers anatomic reduction, stability, minimal soft tissue damage, aesthetically pleasing scars and the limited need for secondary procedures involving planned removal of hardware. When one performs this procedure with the use of intraoperative image intensification, anatomic or near anatomic reduction can occur without the need for an open reduction and associated additional soft tissue damage.
A systematic review of the published literature on this topic yields limited studies and therefore warrants further prospective investigations. However, this technique appears safe and is a practical option for surgeons with interest in minimal incision surgery. The technique produces good results and offers patients additional benefits over traditional treatment strategies.
Dr. Abicht is a second-year resident (PGY-2) in the Podiatric Medicine and Surgery (PMS36) residency program at Gundersen Lutheran Medical Center in La Crosse, Wis.
Dr. Plovanich is the Chief Resident (PGY-3) in the Podiatric Medicine and Surgery (PMS36) residency program at Gundersen Lutheran Medical Center in La Crosse, Wis.
Dr. Roukis is a member of the attending staff in the Department of Orthopaedics, Podiatry and Sports Medicine at Gundersen Lutheran Medical Center in La Crosse, Wis. He is a Member of the Board of Directors and a Fellow of the American College of Foot and Ankle Surgeons.
1. Perugia D, Basile A, Battaglia A, Stopponi M. Fracture dislocations of LisFranc’s joint treated with closed reduction and percutaneous fixation. Int Orthop 2003; 27:30-35.
2. Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of tarsometatarsal joints: end results coorelated with pathology and treatment. Foot & Ankle 1986; 6(5):225-242.
3. Desmond E, Chou L. Current concepts review: Lisfranc injuries. Foot Ankle Int 2006; 27(8):653-660.
4. Kuo R, Tejwani N, DiGiovanni C, et al. Outcome after open reduction and internal fixation of Lisfranc joint injuries. JBJS 2000;8 2-A(11):1609-1618.
5. Richter M, Wippermann B, Krettek C. Fractures and fracture dislocations of the midfoot: occurrence, causes, and long-term results. Foot Ankle Int. 2001; 22(5):392-398.
6. Goossens M, De Stoop N. Lisfranc’s fracture-dislocations: etiology, radiology and results of treatment. A review of 20 cases. Clin Orthop 1983; 176:154-162.
7. Hardcastle PH, Reschauer R, Kutscha-Lissberg E, Schoffmann W. Injuries to the tarsometatarsal joint. Incidence, classification and treatment. JBJS 1982; 64(3):349-356.
8. Jeffreys TE. Lisfranc fracture-dislocation. JBJS 1963;45-B:546-551.
9. Ly T, Coetzee C. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. a prospective, randomized study. J Bone Joint Surg Am 2006; 88:514-520.
10. Mulier T, Reynders P, Sioen W, et al. The treatment of Lisfranc injuries. Acta Orthopaedica Belgica 1997; 63(2):82-90.
11. Stavlas P, Roberts C, Xypnitos F, Giannoudis P. The role of reduction and internal fixation of Lisfranc fracture-dislocations: a systematic review of the literature. Int Orthop 2010; 34(8):1083-91.
12. Teng A, Pinzur M, Lomasney L, Mahoney L, Havey R. Functional outcome following anatomic restoration of tarsal-metatarsal fracture dislocation. Foot Ankle Int 2002; 23(10):922-926.
13. Rammelt S, Schneiders W, Schikore H, et al. Primary open reduction and fixation compared with delayed corrective arthrodesis in the treatment of tarsometatarsal (Lisfranc) fracture dislocation. JBJS 2008; 90-B(11):1499-1506.
14. Rajapakse B, Edwards A, Hong T. A single surgeon’s experience of treatment of Lisfranc joint injuries. Injury 2006; 37(9):914-921.
15. Mulier T, Reynders P, Dereymaeker G, Broos P. Severe Lisfrancs inuries: primary arthrodesis or ORIF? Foot Ankle Int. 2002; 23(10):902-905.
16. Henning J, Jones C, Sietsema D, Bohay D, Anderson J. Open reduction internal fixation versus primary arthrodesis for Lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009; 30(10):913-922.
17. Arntz C, Veith R, Hansen S. Fractures and fracture-dislocations of the tarsometatarsal joint. JBJS Am 1988;70-A(2):173-181.
18. Yuen J, Yung S, Wong M. Open reduction and temporary rigid internal fixation of Lisfranc fracture-dislocations. Singapore Med J 2001;42(6):255-258.
19. Sands A, Grose A. Lisfranc injuries. Injury 2004; 35(Suppl2):SB71-SB76.
20. Myerson M. Etiology and treatment of hallux valgus – metatarsocuneiform arthrodesis for treatment of hallux valgus and metatarsus primus varus. Orthopedics 1990; 13(9):1025-1031.
21. Zgonis T, Roukis T, Polyzois V. Lisfranc Fracture-Dislocations: Current Treatment and New Surgical Approaches. Clin Pod Med Surg 2006; 23(2):303-322.