Most foot fractures heal well and have minimal long-term sequelae. Intra-articular calcaneal fractures and Lisfranc’s fracture dislocations, however, typically have poor long-term outcomes even with open reduction internal fixation. I want to share with you my thoughts on the Lisfranc fracture.
We have all seen the ill effects of a neglected Lisfranc’s fracture. Typically there is severe bossing of bone, like a ring, around the first tarsometatarsal joint and severe abduction deformity of the forefoot.
Due to the severity of deformity and chronic arthritic pain that typically develops after a Lisfranc’s fracture, I believe we all agree that surgery is the best option in a medically stable patient.
As with any fracture repair, anatomic reduction is paramount. There are acceptable limits in residual angulation deformity in long bone fracture repair. However, there is no “wiggle room” when repairing articular surfaces. To that end, the anatomic reduction needs to be perfect.
It is my opinion that the only way you can get perfect reduction is with direct visualization. In other words, one should be making incisions and using bone clamps to reduce the fracture(s) and restore joint anatomy.
It seems that all subspecialties of surgery are trending toward minimally invasive surgery. However, I do not feel that most Lisfranc’s fracture dislocations are amenable to closed reduction and percutaneous internal fixation with cannulated screws and/or smooth wires.
It is funny how we all think. We look at an X-ray and say to ourselves, “I can throw a pin percutaneously and suck the bone over into place.” I know this sounds good but in my experience with Lisfranc’s injuries, it is rare to obtain anatomic reduction with that technique. Even with a small incision and applying a periarticular clamp, soft tissue constraints seem to prevail. There is too much resistance to get good correction.
In my opinion, if you are not going do an open visualization for reduction, you might as well just put the foot in a cast and do a wait and see approach. You will probably get the same outcome.
Most of us have learned in residency to perform open reduction and internal fixation (ORIF) for Lisfranc’s fractures. Typically, one would restore anatomic alignment with reduction forceps, temporarily hold correction with K-wires, use fluoroscopy to confirm anatomic reduction and then put in permanent fixation with 3.5 or 4.0 mm screws from the metatarsal into each cuneiform. Finally, one would insert a “Lisfranc ligament screw” from the medial cuneiform to the base of the second metatarsal.
There is controversy as to whether one should remove hardware prior to ambulation. This is similar to the ankle syndesmosis screw scenario. Some prefer to leave hardware in and do a wait and see approach. If the screw breaks and becomes a problem, then remove the hardware. If the hardware (even if it is broken) is not posing a problem for the patient, then leave it.
The aforementioned fixation technique is what I would call the “textbook” approach and I have done that for years. I have concern about the ill effects of intra-articular screw fixation. The main goals of open reduction and internal fixation are to restore joint alignment and preserve the articular surface. What condition will the joint be in after one has inserted and removed a 4 mm screw? A 4 mm defect in the center of the joint is probably a quarter of the surface area of cartilage surface.
To make matters worse, what if you insert the screw and maybe direct it too plantar on the cuneiform? Do you subsequently redirect your screw? Now you have even more joint damage. That just doesn’t make sense to me.
Needless to say, the Lisfranc’s fracture dislocation is a serious injury and even with good surgery, bad long-term outcomes occur most notably with post-traumatic arthritis.
For years, I have been wondering why surgeons do not do a primary arthrodesis on Lisfranc’s fracture dislocations. Surgeons have no qualms about doing a Lapidus bunionectomy or fusion of the lesser tarsometatarsal joint if there is arthritis. Maybe that would be a more definitive approach. Restore anatomy, fuse unstable joints and avoid the potential second and third surgeries. The second surgery is to remove hardware and the third surgery is to perform an arthrodesis when post-traumatic arthritis develops.
With those thoughts running through my head, I started looking at some other surgical fixation techniques. External fixation with mini-rails is an option. There is no hardware traversing good cartilage. I have tried this in the past but have not had good success with it. The application of the fixator and the after care is awkward. Using a mini-rail with a hinge is helpful with maintaining anatomic reduction but one typically needs to keep fiddling with it.
Another similar fixation idea that I have started to use includes staple fixation of the tarsometatarsal joints with a “Lisfranc ligament screw.” Staples are technically easy to insert and also provide extra-articular fixation, thereby avoiding damage to cartilage. Certainly, one could argue that staples are not as strong as screws. However, in both scenarios, the patient is non-weightbearing for a minimum of six weeks to allow for soft tissue healing/scarring.
Today, my thought process is that perfect anatomic reduction is necessary and the only way you can do that is to open the joint up. If the joints are severely comminuted and it seems likely that post-traumatic arthritis will develop, I will primarily fuse the affected joint(s). Remember not to fuse the fourth and fifth tarsometatarsal joints. If necessary, I will do an arthroplasty of those joints. Patients will not fare well with a fusion on the lateral metatarsal column. In cases in which I get anatomic reduction and the joint surfaces look reasonably well, I will use staple fixation and then insert the “Lisfranc ligament screw” last.
Remember to stress the first tarsometatarsal joint under anesthesia and look under fluoroscopy to ascertain ligament damage when there is no apparent radiographic abnormality. If the joint is indeed unstable, I will place a staple over that.
I will typically emphasize non-weightbearing for the patient for six weeks. Then one can transition to gradual weightbearing in a fracture boot for four more weeks. At around 10 weeks, the patient will start wearing a shoe. At 16 weeks, I will plan to remove the hardware.
When it comes to staple removal, prying them up with a Freer elevator only ruins the instrument and makes you look silly trying to manhandle the foot. A much simpler technique is using a large wire cutter to cut the staple in half. Now all you will have to do is grab the shoulder of the staple with pliers or a Kocher clamp, and the arm of the staple will slip right out.
If the staple has broken prior to your planned removal, then the first step in removal (cutting it) has already happened. All you will need to do is remove soft tissue covering the two pieces and slip the arms out. Typically, staples will break at the shoulder. If the one arm is difficult to find in the bone, then I will leave it versus doing a lot of digging around for it. Since it is not in the joint, it is not critical to remove the staple if it is buried in bone.
Consider staple fixation for ORIF on your next Lisfranc’s fracture dislocation. You may be surprised how simple the fixation is to insert. Moreover, you have the peace of mind that you are not causing any further joint damage in an already compromised joint surface.