- Email: [email protected]
Tarso-metatarsal fracture-dislocation: treatment by percutaneous pinning or open reduction (a report on 17 cases)
Foot and Ankle Surgery 11 (2005) 17–23 www.elsevier.com/locate/fas
Tarso-metatarsal fracture-dislocation: treatment by percutaneous pinning or open reduction (a report on 17 cases) Jean-Luc Bessea,*, El Houcine Kasmaouib, Jean-Luc Lerata, Bernard Moyena a
Centre Hospitalier Lyon-Sud, Orthopaedic Surgery Department, 69495 Pierre-Be´nite Cedex, Lyon, France b Hoˆpital militaire d’instruction Mohamed V, Hay Ryad, Rabat, Maroc, France Received 24 August 2004; revised 29 September 2004; accepted 18 October 2004
Abstract Lisfranc fracture-dislocation is rare. The authors report a retrospective series of 17 cases managed by a single surgeon between 1990 and 1998. The series comprised 12 male (71%) and five female patients, aged between 11 and 62 years (mean ageZ33.4 years). Etiology was predominantly road accidents (64%). On Lerat classification, 12 lesions were homolateral and five divergent. Seventy eight percent of the patients had other associated lesions and 53% were polytraumatised. Fourteen patients were treated by pinning: percutaneous in six cases and open in eight; the other three patients were seen at a late stage and underwent Lisfranc joint realignment arthrodesis. One patient died from severe cranial trauma; 12 were followed up for between 1 and 7 years (mean follow-upZ4.5 years). The eight patients managed by open or closed K-wire fixation and who were followed up had a mean midfoot Kitaoka score of 78/100: five results were good or excellent, two fair and one poor. Only 40% of the X-ray checks were strictly normal, the others disclosing joint alterations. The three cases managed by realignment arthrodesis showed union at 4 months’ follow-up, with a mean Kitaoka score of 88.3/100 (2 excellent and one fair result). q 2004 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Lisfranc; Fracture-dislocation; Surgical management
1. Introduction Fracture-dislocations of the tarso-metatarsal joint are rare, amounting to no more than 0.2% of fractures as a whole [1], with an incidence of 1 in 55,000 persons per year [2]. This low rate is partly a matter of neglected lesions, estimated by Gossens [3] and Myerson [4] at 20% and by Vuori and Aro [5] at 39%. Quenu and Kuss’s 1909 classification [6] has been the basis for all subsequent classification systems, including those of Lerat and Trillat (1976) [7], Hardcastle (1982) [1] and Myerson (1986) [4]. Several studies have pointed out the benefits of surgical management, although the precise means are often subject to controversy. * Corresponding author. Tel.: C33 4 78 86 14 27; fax: C33 4 78 86 59 34. E-mail address: [email protected] (J.-L. Besse).
We here report a retrospective series of 17 Lisfranc joint fracture-dislocations treated by surgery, and discuss the means of managing such lesions.
2. Material and methods 2.1. Patients Between 1990 and 1998, 17 patients were treated for Lisfranc joint fracture-dislocation, 14 in emergency and 3 scheduled. All were operated by the same surgeon (JLB) in the traumatology–orthopaedics department of first the Edouard Herriot Hospital in Lyon (France) and then the Lyon-Sud Hospital. There were 12 male patients (71%) and five female, with a mean age of 33.4 years (range, 11–62 years). Etiology was principally road accidents (11 casesZ 64%); there were also two falls from windows, two other
1268-7731/$ - see front matter q 2004 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2004.10.003
18
J.-L. Besse et al. / Foot and Ankle Surgery 11 (2005) 17–23
Table 1 Distribution of lesions associated with Lisfranc dislocation Associated foot lesions
Number of patients
Peri-talar dislocation Cuboide fracture Navicular fracture Cuneiform fractures
1 2 1 3 (2 fractures and 1 dislocation of medial) 9 (10 base fractures, 1 diaphysal fracture, 7 neck or head fractures) 1 2
Metatarsal fractures Metatarso–phalangeal dislocations Homolateral ankle fracture
falls and two crushing injuries (one with a dodgem car, one with a motorbike). Twelve lesions were in the left foot and five in the right. Fracture-dislocation was diagnosed on the basis of a clinical aspect comprising mid-foot pain, swelling and deformity and X-ray examination with AP, 3/4 medial and lateral views. On Lerat’s classification [7], 12 of the lesions were homolateral: 7 (41%) spatular (i.e. second, third, fourth, and/or fifth rays) and five (29.5%) columno-spatular homolateral; five were divergent: three (17.5%) columnar (i.e. first ray) and two (12%) columno-spatular. Only three patients had isolated Lisfranc trauma, 65% having ipsilateral lower limb multiple fracture and 53% being polytraumatised. Most dislocations were associated with metatarsal and/or tarsus fracture (see Table 1). 2.2. Management 14 patients were operated in emergency, with closed reduction and percutaneous pinning in 6 cases (with 3 or 4 divergent pins, depending on the lesion), and open reduction with K-wire fixation in eight. The approach was lateral longitudinal in three of these eight cases, medial longitudinal in two cases and combined medial–lateral in the other three cases. 3 patients had secondary realignment arthrodesis 2 months after trauma: one had undergone percutaneous pinning in another hospital, with poor immediate postoperative reduction; the other two were polytrauma cases, one with a neglected Lisfranc lesion and the other with a lesion which had been managed by short-leg non-walking cast due to contraindications for anaesthesia. All patients were immobilised in non-weight-bearing cast for 45 days; on K-wire ablation on day 45, a short-leg walking cast was prescribed for a further 3–6 weeks. 2.3. Follow-up The patients had follow-up appointments with a different physician from the department. This post-operative examination comprised: clinical a check-up; functional assessment in terms of mid-foot Kitaoka grading [8]; and
weight-bearing AP, oblique (for Lisfranc joint exploration) and lateral X-ray (especially Djian angle measurement to quantify medial foot arching) comparison of the two feet.
3. Results Among the 17 patients, 1 polytrauma victim died on day 15 following severe cranial and thoraco-abdominal trauma, and 3 were lost to follow-up. Ten (59%) kept their postoperative appointment, two were questioned by phone and 1 refused to cooperate. Mean follow-up was 4.5 years (range, 1–7 years). 3.1. Osteosynthesis reductions (14 cases) Four patients presented algodystrophy of the affected foot (two secondarily to open K-wire fixation and two secondarily to percutaneous pinning). This number may seem high, but this diagnosis was made only on clinical criteria (night pain, extended regional pain and swelling) with or without X-ray criteria (osteoporosis), without bonescan proof. We did not find evident causal factors: no compartment syndrome or peripheral nerve damage. Three others had persistent lower limb oedema. Partial break-up of the osteosynthesis (K-wire fixation of an M1 base fracture-dislocation) was observed in one patient who had undergone open reduction. One patient required repeat surgery: he had had complex mid-foot trauma with associated comminuted 2nd and 3rd metatarsal head fracture and 4th metatarso–phalangeal fracture-dislocation, initially treated by open K-wire fixation. Significant residual pain persisted, for which partial (3rd cuneiform/3rd metatarsal, and 4th and 5th metatarso–cuboid) Lisfranc arthrodesis was performed, by a different surgeon, 3 years after the accident, followed by further medial arthrodesis performed by our own team 6 months later. At 7 years’ follow-up, the result was poor (Kitaoka scoreZ45/100) functionally, clinically and radiographically, despite the fact that there was fusion of the arthrodesis. The non-reoperated patients (13 out of 14) followed up in our study had a mean Kitaoka score of 78.4/100 (range, 53–91): i.e. five excellent or good results, and one fair and one poor result; there was no difference in this respect between percutaneous synthesis and open reduction (see Table 2). Only one patient was wholly pain-free. The others all moderate presented occasional or daily pain, without limiting walking distances. Three patients were not limited at all in their activity; the others were limited only in certain sports activities or experienced difficulty on rough ground. Six patients had footwear problems, needing to wear comfortable shoes, with or without orthopaedic insoles. On clinical examination, the aspect was never strictly normal; to a greater or lesser extent, a slightly hunched dorsal mid-foot, cavus foot, forefoot abduction or claw-toes
J.-L. Besse et al. / Foot and Ankle Surgery 11 (2005) 17–23
19
Table 2 Kitaoka score [8] according to type osteosynthesis: percutaneous pinning (P.P.) vs open pinning (O.P.) Pain 40 points
Activity 10 points
Shoe 5 points
Walking distance 10 points
Walking surface 10 points
Gait 10 points
Alignment 15 points
Total 100 points
Percutaneous pinning, N/4/6
Case 1 Case 2 Case 3 Case 4 Mean score
40 30 30 30 32.5
10 7 7 10 8.5
3 5 3 5 4
10 10 10 10 10
10 10 5 5 7.5
10 10 10 10 10
8 15 15 8 11.5
91 87 80 78 84
Open pinning, N/4/8
Case 1 Case 2 Case 3 Case 4 Mean score
20 30 30 20 25
7 10 7 7 7.8
3 3 3 3 3
10 10 10 10 10
0 10 5 5 5
5 10 10 10 8.8
8 15 15 15 13.3
53 88 80 70 72.8
3.5
10
9.4
12.4
78.4
Overall mean score
28.8
8.1
were to be observed. On follow-up, only 40% of the patients had strictly normal standard X-rays; the others showed prearthritis alterations (Fig. 1) or moderate arthritis (Fig. 2), without correlative clinical signs. 3.2. Realignment-arthrodesis No complications were to be observed in the three patients managed by realignment-arthrodesis. Their mean Kitaoka score was 88.3/100, with two excellent results and one fair (see Table 3). From a clinical point of view, the same residual deformities as above—cavus foot, claw-toes or forefoot abduction—were to be found. On X-ray, all three arthrodeses had fused (Fig. 3) in under 4 months, with Djian angles of between 1158 and 1208.
4. Discussion Orthopaedic management by closed reduction and cast immobilisation gave high rates of failure [1,9,10], and no longer has any role to play. Lerat [7], on the basis of a personal series of 81 cases plus a review of the literature, reported virtually constant poor results from cast immobilisation alone and 60% failure after closed reduction followed by cast immobilisation. All authors are agreed on the need for surgical management, but there are still some points which remain controversial. Should reduction be closed or open? What means of synthesis (screws or K-wires) should be used in open surgery? What place does primary arthrodesis have in the surgical management of new Lisfranc fractures? Whatever the means used, tarso-metatarsal fracture-dislocation management has to meet 3 criteria: anatomic reduction of the fracture, stable fixation [1,4,10–13], and restoration of lateral foot (‘calcaneal foot’) length in case of so-called ‘nutcracker’ impaction fractures of the cuboid [10,13].
6.3
Certain authors favour percutaneous pinning whenever closed reduction under fluoroscopy is feasible [1,4,9,13]. This technique has the advantage of being non-traumatic for the soft tissue and of being easier to perform. Myerson [4] insists on getting as perfect a reduction as possible: a reduction defect in excess of 2 mm on AP and 3/4 oblique views or a talus/1st metatarsal angle in excess of 158 on lateral view mandate open reduction. Interposed soft tissue, particularly the anterior tibial tendon, significant comminution, or the presence of a large bony fragment can make reduction imprecise or even impossible, and thus set limits to the practice of closed pin fixation [5,13]. For other authors [7,11,14,15], open reduction should be more-or-less systematic, enabling as it does fracture haematoma to be removed and post-operative oedema to be kept to a minimum. Recently, with open reduction and Kwires fixation, Dukto [15] reported that full anatomical reconstruction was a predominent factor of early and late good results. It also eases anatomic reduction and stable fixation. In open reduction, fixation is ensured by K-wire fixation given the straightforwardness of the technique [1,7, 9,14]. The instability certain authors have complained of is due to faulty technique. Thus Hardcastle [1] stresses the interest of fixation of the 1st metatarso–cuneiform joint by means of double K-wire fixation, especially in cases of isolated columnar fracture. Arntz [11], Buzzard [2] and Kuo [16] have reported that screw fixation is preferable to Kwire fixation for metatarso–cuneiform joint fixation, due to the improved stability, reduced infection risk and the possibility it provides of early rehabilitation and of avoiding resort to short-leg cast immobilisation. Non-systematic screw removal is another advantage, although running the risk of fracture by screw fatigue, as found in 27% of Kuo’s series [16]. Furthermore, screwing may result in bone fragmentation, often requiring synthesis by K-wire fixation, either isolated or associated with screw fixation [13]. We tend to favour open reduction with K-wire fixation. Percutaneous pinning was, however, performed in this
20
J.-L. Besse et al. / Foot and Ankle Surgery 11 (2005) 17–23
Fig. 1. Percutaneous pinning. (a) Female 37 year old: columno-spatular dislocation (oblique and lateral views). (b) Percutaneous pinning (AP, oblique, lateral control views). (c) X-rays at 6.5 year follow-up (only slight alteration C2–M2 joint).
series, especially in the case of simple fracture-dislocation, and sometimes in cases of polytrauma because of the other lesions needing to be managed jointly. Any difficulty or defect in reduction found under fluoroscopy led us to perform open K-wire fixation. The fact that the functional results (in terms of Kitaoka score) were exactly the same with both methods, despite the fact that the more complex cases were managed by open reduction, confirms that open
reduction–fixation is preferable to closed reduction, as already reported by Myerson [4], for whom 53% of results were excellent with closed osteosynthesis compared to 77% with open fixation. K-wire fixation gives stable fixation, but needs to be protected by a cast. Early K-wire ablation runs the risk of loss of reduction. Like most authors, we favour a non-weight-bearing cast for between 6 and 8 weeks according to the seriousness of the Lisfranc and associated
J.-L. Besse et al. / Foot and Ankle Surgery 11 (2005) 17–23
21
Fig. 2. Open reduction and pinning. (a) Male 40 year old: spatular dislocation with M2 base and neck fractures (AP view). Open pinning (oblique view). (b) X-rays at 2 years follow-up (moderate arthritic alteration of medial Lisfranc).
lesions. K-wires are ablated after an interval of at least 6 weeks; a short-leg walking cast is then prescribed, with gradual resumption of weight-bearing over a further 3–6 weeks. Associating several divergent K-wires has helped us get satisfactory results, avoiding loss of reduction secondary
to ablation, apart from one case of columnar fracturedislocation break-up. We have subsequently kept screws for cases of isolated columnar fracture-dislocation where reduction and synthesis by K-wire fixation is difficult, and in certain complex cases we even perform synthesis by
Table 3 Kitaoka score [8] of patients treated by realignments arthrodesis
Case 1 Case 2 Case 3 Mean score
Pain 40 points
Activity 10 points
Shoe five points
Walking distance 10 points
Walking surface 10 points
Gait 10 points
Alignment 15 points
Total 100 points
40 20 40 33.3
10 7 7 8
5 3 3 3.7
10 10 10 10
10 5 10 8.3
10 10 10 10
15 15 15 15
100 70 95 88.3
22
J.-L. Besse et al. / Foot and Ankle Surgery 11 (2005) 17–23
Fig. 3. Realignment-arthrodesis. (a) Female 51 year old ‘badly operated’ (percutaneous pinning with poor reduction—X-rays at 6 weeks f.u.) (b) medial Lisfranc realignment-arthrodesis. (c) X-rays at 18 months f.u. (AP, oblique, lateral views): fusion with correct 1st ray and medial arch reconstruction (Djian angle).
a screwed-on mini-plate (although there were no such patients in the series reported here). In contrast, we recommend realignment-arthrodesis for neglected or mismanaged fractures and/or dislocations
seen more than a month later. Isolated 1st metatarso– cuneiform joint arthrodesis may be indicated for severe columnar lesions, whereas partial, spatula arthrodesis gives consistently poor results [7,14], making realignment
J.-L. Besse et al. / Foot and Ankle Surgery 11 (2005) 17–23
arthrodesis of all of the tarso-metatarsal joints a preferable option. Neglected Lisfranc lesions cause serious disability [3,10– 13]. Positive diagnosis thus requires clinical examination and a strict X-ray examination with AP, strict lateral and oblique views [10,13]. If there is any doubt, comparative dynamic views under anaesthesia in abduction-pronation and adduction-supination are needed [3]. Other authors consider CTscan or MRI to be indicated from the outset if the standard Xray assessment is inconclusive [2]. Early complications are mainly a matter of soft part lesions and a risk of compartment syndrome which needs screening for and revealing by tissue pressure measurement [13]. Long-term complications such as cavus, flat-foot or forefoot abductus are the result of faulty technique. Arthritic alteration has been reported to varying degrees: from 30% according to Hardcastle [1] to 95% according to Mu¨ller [9]. In our series it had occurred in 60% of cases at 4.5 years’ follow-up. Arthritic alteration may not always be correlated with poor results, but does derive from non-anatomic reduction, secondary displacement of synthesised fractures or equally from osteo-chondral lesions related to the initial trauma [13]. According to Myerson [4], the rate of arthritis increases from 17% in case of anatomic to 85% in case of non-anatomic reduction, whereas for Kuo [16] these rates were, respectively, 16 and 60%.
5. Conclusion Lisfranc fractures need diagnosing early on the basis of a clinical examination and a strict X-ray assessment comprising AP, strict lateral and 3/4 oblique views. The prime prognostic factor is the quality of the reduction and the stability of the assembly. If closed anatomic reduction is achieved, fixation is to be ensured by percutaneous pinning. In case of fractures which are complex or hard to reduce, open reduction is mandatory, synthesis being ensured by Kwire fixation or else screw fixation in the case of the metatarso–cuneiform joints.
23
References [1] Hardcastle PH, Reschauer R, Kutcha-Lissberg E, Schoffmann W. Injuries of the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg 1982;64B:349–56. [2] Buzzard BM, Briggs PJ. Surgical management of acute tarsometatarsal fracture dislocation in the adult. Clin Orthop 1988;353: 125–33. [3] Gossens M, De Stoop N. Lisfranc’s fracture-dislocations: etiology, radiology and results of treatment. A review of 20 cases. Clin orthop 1983;176:154–62. [4] Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joint: end results correlated with pathology and treatment. Foot Ankle 1986;6:225–42. [5] Vuori J, Aro HT. Lisfranc joint injuries: trauma mechanisms and associated injuries. J Trauma 1993;35:40–5. [6] Quenu E, Kuss E. Etude sur les luxations du me´tatarse (luxations me´tatarso-tarsiennes), du diastasis entre le 1er et le 2e`me me´tatarsien. Rev Chir 1909;39:1–72. [7] Trillat A, Lerat JL, Leclerc P, Schuster P. Les fractures-luxations tarso-me´tatarsiennes. Rev Chir Orthop 1976;62:685–702. [8] Kitaoka HB, Alexander IJ, Adelaar RS, Robert S, Numeley JA, Myerson MS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux and lesser toes. Foot Ankle Int 1994;15:349–53. [9] Muller T, Reynders P, Sioen W, Van den Bergh J, De Reymaeker G, Reynaert P, et al. The treatment of Lisfranc injuries. Acta Orthop Belgica 1997;63:82–90. [10] Myerson MS. The diagnosis and treatment of injury of the tarsometatarsal joint complex. J Bone Joint Surg 1999;81B: 756–63. [11] Arntz CT, Veith RG, Hanse ST. Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg 1988;70A:173–81. [12] Faciszewski T, Burks RT, Manaster BJ. Subtle injuries of the Lisfranc joint. J Bone Joint Surg Am 1990;72:1519–22. [13] Thoradson DB. Fractures of the midfoot and forefoot. In: Myerson MS, editor. Foot and ankle disorders, vol. 2. Philadelphia: WB Saunders; 2000. p. 1265–96. [14] Jarde O, Trinquier-Lautard JL, Filloux JF, De Lestang M, Vives P. Fractures-luxations de l’interligne de Lisfranc. Rev Chir Orthop 1995; 81:724–30. [15] Dudko S, Kusz D, Pierzchaa A. Lisfranc injury—fixation with Kirschner wires. Foot Ankle Surg 2004;10:5–8. [16] Kuo RS, Tejwani NC, Digiovanni CW, Holt SK, Benirschke SK, Hansen ST, Sangeorzan BJ. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg 2000; 82A:1609–18.
Tarso-metatarsal fracture-dislocation: treatment by percutaneous pinning or open reduction (a report on 17 cases) Jean-Luc Bessea,*, El Houcine Kasmaouib, Jean-Luc Lerata, Bernard Moyena a
Centre Hospitalier Lyon-Sud, Orthopaedic Surgery Department, 69495 Pierre-Be´nite Cedex, Lyon, France b Hoˆpital militaire d’instruction Mohamed V, Hay Ryad, Rabat, Maroc, France Received 24 August 2004; revised 29 September 2004; accepted 18 October 2004
Abstract Lisfranc fracture-dislocation is rare. The authors report a retrospective series of 17 cases managed by a single surgeon between 1990 and 1998. The series comprised 12 male (71%) and five female patients, aged between 11 and 62 years (mean ageZ33.4 years). Etiology was predominantly road accidents (64%). On Lerat classification, 12 lesions were homolateral and five divergent. Seventy eight percent of the patients had other associated lesions and 53% were polytraumatised. Fourteen patients were treated by pinning: percutaneous in six cases and open in eight; the other three patients were seen at a late stage and underwent Lisfranc joint realignment arthrodesis. One patient died from severe cranial trauma; 12 were followed up for between 1 and 7 years (mean follow-upZ4.5 years). The eight patients managed by open or closed K-wire fixation and who were followed up had a mean midfoot Kitaoka score of 78/100: five results were good or excellent, two fair and one poor. Only 40% of the X-ray checks were strictly normal, the others disclosing joint alterations. The three cases managed by realignment arthrodesis showed union at 4 months’ follow-up, with a mean Kitaoka score of 88.3/100 (2 excellent and one fair result). q 2004 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Lisfranc; Fracture-dislocation; Surgical management
1. Introduction Fracture-dislocations of the tarso-metatarsal joint are rare, amounting to no more than 0.2% of fractures as a whole [1], with an incidence of 1 in 55,000 persons per year [2]. This low rate is partly a matter of neglected lesions, estimated by Gossens [3] and Myerson [4] at 20% and by Vuori and Aro [5] at 39%. Quenu and Kuss’s 1909 classification [6] has been the basis for all subsequent classification systems, including those of Lerat and Trillat (1976) [7], Hardcastle (1982) [1] and Myerson (1986) [4]. Several studies have pointed out the benefits of surgical management, although the precise means are often subject to controversy. * Corresponding author. Tel.: C33 4 78 86 14 27; fax: C33 4 78 86 59 34. E-mail address: [email protected] (J.-L. Besse).
We here report a retrospective series of 17 Lisfranc joint fracture-dislocations treated by surgery, and discuss the means of managing such lesions.
2. Material and methods 2.1. Patients Between 1990 and 1998, 17 patients were treated for Lisfranc joint fracture-dislocation, 14 in emergency and 3 scheduled. All were operated by the same surgeon (JLB) in the traumatology–orthopaedics department of first the Edouard Herriot Hospital in Lyon (France) and then the Lyon-Sud Hospital. There were 12 male patients (71%) and five female, with a mean age of 33.4 years (range, 11–62 years). Etiology was principally road accidents (11 casesZ 64%); there were also two falls from windows, two other
1268-7731/$ - see front matter q 2004 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2004.10.003
18
J.-L. Besse et al. / Foot and Ankle Surgery 11 (2005) 17–23
Table 1 Distribution of lesions associated with Lisfranc dislocation Associated foot lesions
Number of patients
Peri-talar dislocation Cuboide fracture Navicular fracture Cuneiform fractures
1 2 1 3 (2 fractures and 1 dislocation of medial) 9 (10 base fractures, 1 diaphysal fracture, 7 neck or head fractures) 1 2
Metatarsal fractures Metatarso–phalangeal dislocations Homolateral ankle fracture
falls and two crushing injuries (one with a dodgem car, one with a motorbike). Twelve lesions were in the left foot and five in the right. Fracture-dislocation was diagnosed on the basis of a clinical aspect comprising mid-foot pain, swelling and deformity and X-ray examination with AP, 3/4 medial and lateral views. On Lerat’s classification [7], 12 of the lesions were homolateral: 7 (41%) spatular (i.e. second, third, fourth, and/or fifth rays) and five (29.5%) columno-spatular homolateral; five were divergent: three (17.5%) columnar (i.e. first ray) and two (12%) columno-spatular. Only three patients had isolated Lisfranc trauma, 65% having ipsilateral lower limb multiple fracture and 53% being polytraumatised. Most dislocations were associated with metatarsal and/or tarsus fracture (see Table 1). 2.2. Management 14 patients were operated in emergency, with closed reduction and percutaneous pinning in 6 cases (with 3 or 4 divergent pins, depending on the lesion), and open reduction with K-wire fixation in eight. The approach was lateral longitudinal in three of these eight cases, medial longitudinal in two cases and combined medial–lateral in the other three cases. 3 patients had secondary realignment arthrodesis 2 months after trauma: one had undergone percutaneous pinning in another hospital, with poor immediate postoperative reduction; the other two were polytrauma cases, one with a neglected Lisfranc lesion and the other with a lesion which had been managed by short-leg non-walking cast due to contraindications for anaesthesia. All patients were immobilised in non-weight-bearing cast for 45 days; on K-wire ablation on day 45, a short-leg walking cast was prescribed for a further 3–6 weeks. 2.3. Follow-up The patients had follow-up appointments with a different physician from the department. This post-operative examination comprised: clinical a check-up; functional assessment in terms of mid-foot Kitaoka grading [8]; and
weight-bearing AP, oblique (for Lisfranc joint exploration) and lateral X-ray (especially Djian angle measurement to quantify medial foot arching) comparison of the two feet.
3. Results Among the 17 patients, 1 polytrauma victim died on day 15 following severe cranial and thoraco-abdominal trauma, and 3 were lost to follow-up. Ten (59%) kept their postoperative appointment, two were questioned by phone and 1 refused to cooperate. Mean follow-up was 4.5 years (range, 1–7 years). 3.1. Osteosynthesis reductions (14 cases) Four patients presented algodystrophy of the affected foot (two secondarily to open K-wire fixation and two secondarily to percutaneous pinning). This number may seem high, but this diagnosis was made only on clinical criteria (night pain, extended regional pain and swelling) with or without X-ray criteria (osteoporosis), without bonescan proof. We did not find evident causal factors: no compartment syndrome or peripheral nerve damage. Three others had persistent lower limb oedema. Partial break-up of the osteosynthesis (K-wire fixation of an M1 base fracture-dislocation) was observed in one patient who had undergone open reduction. One patient required repeat surgery: he had had complex mid-foot trauma with associated comminuted 2nd and 3rd metatarsal head fracture and 4th metatarso–phalangeal fracture-dislocation, initially treated by open K-wire fixation. Significant residual pain persisted, for which partial (3rd cuneiform/3rd metatarsal, and 4th and 5th metatarso–cuboid) Lisfranc arthrodesis was performed, by a different surgeon, 3 years after the accident, followed by further medial arthrodesis performed by our own team 6 months later. At 7 years’ follow-up, the result was poor (Kitaoka scoreZ45/100) functionally, clinically and radiographically, despite the fact that there was fusion of the arthrodesis. The non-reoperated patients (13 out of 14) followed up in our study had a mean Kitaoka score of 78.4/100 (range, 53–91): i.e. five excellent or good results, and one fair and one poor result; there was no difference in this respect between percutaneous synthesis and open reduction (see Table 2). Only one patient was wholly pain-free. The others all moderate presented occasional or daily pain, without limiting walking distances. Three patients were not limited at all in their activity; the others were limited only in certain sports activities or experienced difficulty on rough ground. Six patients had footwear problems, needing to wear comfortable shoes, with or without orthopaedic insoles. On clinical examination, the aspect was never strictly normal; to a greater or lesser extent, a slightly hunched dorsal mid-foot, cavus foot, forefoot abduction or claw-toes
J.-L. Besse et al. / Foot and Ankle Surgery 11 (2005) 17–23
19
Table 2 Kitaoka score [8] according to type osteosynthesis: percutaneous pinning (P.P.) vs open pinning (O.P.) Pain 40 points
Activity 10 points
Shoe 5 points
Walking distance 10 points
Walking surface 10 points
Gait 10 points
Alignment 15 points
Total 100 points
Percutaneous pinning, N/4/6
Case 1 Case 2 Case 3 Case 4 Mean score
40 30 30 30 32.5
10 7 7 10 8.5
3 5 3 5 4
10 10 10 10 10
10 10 5 5 7.5
10 10 10 10 10
8 15 15 8 11.5
91 87 80 78 84
Open pinning, N/4/8
Case 1 Case 2 Case 3 Case 4 Mean score
20 30 30 20 25
7 10 7 7 7.8
3 3 3 3 3
10 10 10 10 10
0 10 5 5 5
5 10 10 10 8.8
8 15 15 15 13.3
53 88 80 70 72.8
3.5
10
9.4
12.4
78.4
Overall mean score
28.8
8.1
were to be observed. On follow-up, only 40% of the patients had strictly normal standard X-rays; the others showed prearthritis alterations (Fig. 1) or moderate arthritis (Fig. 2), without correlative clinical signs. 3.2. Realignment-arthrodesis No complications were to be observed in the three patients managed by realignment-arthrodesis. Their mean Kitaoka score was 88.3/100, with two excellent results and one fair (see Table 3). From a clinical point of view, the same residual deformities as above—cavus foot, claw-toes or forefoot abduction—were to be found. On X-ray, all three arthrodeses had fused (Fig. 3) in under 4 months, with Djian angles of between 1158 and 1208.
4. Discussion Orthopaedic management by closed reduction and cast immobilisation gave high rates of failure [1,9,10], and no longer has any role to play. Lerat [7], on the basis of a personal series of 81 cases plus a review of the literature, reported virtually constant poor results from cast immobilisation alone and 60% failure after closed reduction followed by cast immobilisation. All authors are agreed on the need for surgical management, but there are still some points which remain controversial. Should reduction be closed or open? What means of synthesis (screws or K-wires) should be used in open surgery? What place does primary arthrodesis have in the surgical management of new Lisfranc fractures? Whatever the means used, tarso-metatarsal fracture-dislocation management has to meet 3 criteria: anatomic reduction of the fracture, stable fixation [1,4,10–13], and restoration of lateral foot (‘calcaneal foot’) length in case of so-called ‘nutcracker’ impaction fractures of the cuboid [10,13].
6.3
Certain authors favour percutaneous pinning whenever closed reduction under fluoroscopy is feasible [1,4,9,13]. This technique has the advantage of being non-traumatic for the soft tissue and of being easier to perform. Myerson [4] insists on getting as perfect a reduction as possible: a reduction defect in excess of 2 mm on AP and 3/4 oblique views or a talus/1st metatarsal angle in excess of 158 on lateral view mandate open reduction. Interposed soft tissue, particularly the anterior tibial tendon, significant comminution, or the presence of a large bony fragment can make reduction imprecise or even impossible, and thus set limits to the practice of closed pin fixation [5,13]. For other authors [7,11,14,15], open reduction should be more-or-less systematic, enabling as it does fracture haematoma to be removed and post-operative oedema to be kept to a minimum. Recently, with open reduction and Kwires fixation, Dukto [15] reported that full anatomical reconstruction was a predominent factor of early and late good results. It also eases anatomic reduction and stable fixation. In open reduction, fixation is ensured by K-wire fixation given the straightforwardness of the technique [1,7, 9,14]. The instability certain authors have complained of is due to faulty technique. Thus Hardcastle [1] stresses the interest of fixation of the 1st metatarso–cuneiform joint by means of double K-wire fixation, especially in cases of isolated columnar fracture. Arntz [11], Buzzard [2] and Kuo [16] have reported that screw fixation is preferable to Kwire fixation for metatarso–cuneiform joint fixation, due to the improved stability, reduced infection risk and the possibility it provides of early rehabilitation and of avoiding resort to short-leg cast immobilisation. Non-systematic screw removal is another advantage, although running the risk of fracture by screw fatigue, as found in 27% of Kuo’s series [16]. Furthermore, screwing may result in bone fragmentation, often requiring synthesis by K-wire fixation, either isolated or associated with screw fixation [13]. We tend to favour open reduction with K-wire fixation. Percutaneous pinning was, however, performed in this
20
J.-L. Besse et al. / Foot and Ankle Surgery 11 (2005) 17–23
Fig. 1. Percutaneous pinning. (a) Female 37 year old: columno-spatular dislocation (oblique and lateral views). (b) Percutaneous pinning (AP, oblique, lateral control views). (c) X-rays at 6.5 year follow-up (only slight alteration C2–M2 joint).
series, especially in the case of simple fracture-dislocation, and sometimes in cases of polytrauma because of the other lesions needing to be managed jointly. Any difficulty or defect in reduction found under fluoroscopy led us to perform open K-wire fixation. The fact that the functional results (in terms of Kitaoka score) were exactly the same with both methods, despite the fact that the more complex cases were managed by open reduction, confirms that open
reduction–fixation is preferable to closed reduction, as already reported by Myerson [4], for whom 53% of results were excellent with closed osteosynthesis compared to 77% with open fixation. K-wire fixation gives stable fixation, but needs to be protected by a cast. Early K-wire ablation runs the risk of loss of reduction. Like most authors, we favour a non-weight-bearing cast for between 6 and 8 weeks according to the seriousness of the Lisfranc and associated
J.-L. Besse et al. / Foot and Ankle Surgery 11 (2005) 17–23
21
Fig. 2. Open reduction and pinning. (a) Male 40 year old: spatular dislocation with M2 base and neck fractures (AP view). Open pinning (oblique view). (b) X-rays at 2 years follow-up (moderate arthritic alteration of medial Lisfranc).
lesions. K-wires are ablated after an interval of at least 6 weeks; a short-leg walking cast is then prescribed, with gradual resumption of weight-bearing over a further 3–6 weeks. Associating several divergent K-wires has helped us get satisfactory results, avoiding loss of reduction secondary
to ablation, apart from one case of columnar fracturedislocation break-up. We have subsequently kept screws for cases of isolated columnar fracture-dislocation where reduction and synthesis by K-wire fixation is difficult, and in certain complex cases we even perform synthesis by
Table 3 Kitaoka score [8] of patients treated by realignments arthrodesis
Case 1 Case 2 Case 3 Mean score
Pain 40 points
Activity 10 points
Shoe five points
Walking distance 10 points
Walking surface 10 points
Gait 10 points
Alignment 15 points
Total 100 points
40 20 40 33.3
10 7 7 8
5 3 3 3.7
10 10 10 10
10 5 10 8.3
10 10 10 10
15 15 15 15
100 70 95 88.3
22
J.-L. Besse et al. / Foot and Ankle Surgery 11 (2005) 17–23
Fig. 3. Realignment-arthrodesis. (a) Female 51 year old ‘badly operated’ (percutaneous pinning with poor reduction—X-rays at 6 weeks f.u.) (b) medial Lisfranc realignment-arthrodesis. (c) X-rays at 18 months f.u. (AP, oblique, lateral views): fusion with correct 1st ray and medial arch reconstruction (Djian angle).
a screwed-on mini-plate (although there were no such patients in the series reported here). In contrast, we recommend realignment-arthrodesis for neglected or mismanaged fractures and/or dislocations
seen more than a month later. Isolated 1st metatarso– cuneiform joint arthrodesis may be indicated for severe columnar lesions, whereas partial, spatula arthrodesis gives consistently poor results [7,14], making realignment
J.-L. Besse et al. / Foot and Ankle Surgery 11 (2005) 17–23
arthrodesis of all of the tarso-metatarsal joints a preferable option. Neglected Lisfranc lesions cause serious disability [3,10– 13]. Positive diagnosis thus requires clinical examination and a strict X-ray examination with AP, strict lateral and oblique views [10,13]. If there is any doubt, comparative dynamic views under anaesthesia in abduction-pronation and adduction-supination are needed [3]. Other authors consider CTscan or MRI to be indicated from the outset if the standard Xray assessment is inconclusive [2]. Early complications are mainly a matter of soft part lesions and a risk of compartment syndrome which needs screening for and revealing by tissue pressure measurement [13]. Long-term complications such as cavus, flat-foot or forefoot abductus are the result of faulty technique. Arthritic alteration has been reported to varying degrees: from 30% according to Hardcastle [1] to 95% according to Mu¨ller [9]. In our series it had occurred in 60% of cases at 4.5 years’ follow-up. Arthritic alteration may not always be correlated with poor results, but does derive from non-anatomic reduction, secondary displacement of synthesised fractures or equally from osteo-chondral lesions related to the initial trauma [13]. According to Myerson [4], the rate of arthritis increases from 17% in case of anatomic to 85% in case of non-anatomic reduction, whereas for Kuo [16] these rates were, respectively, 16 and 60%.
5. Conclusion Lisfranc fractures need diagnosing early on the basis of a clinical examination and a strict X-ray assessment comprising AP, strict lateral and 3/4 oblique views. The prime prognostic factor is the quality of the reduction and the stability of the assembly. If closed anatomic reduction is achieved, fixation is to be ensured by percutaneous pinning. In case of fractures which are complex or hard to reduce, open reduction is mandatory, synthesis being ensured by Kwire fixation or else screw fixation in the case of the metatarso–cuneiform joints.
23
References [1] Hardcastle PH, Reschauer R, Kutcha-Lissberg E, Schoffmann W. Injuries of the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg 1982;64B:349–56. [2] Buzzard BM, Briggs PJ. Surgical management of acute tarsometatarsal fracture dislocation in the adult. Clin Orthop 1988;353: 125–33. [3] Gossens M, De Stoop N. Lisfranc’s fracture-dislocations: etiology, radiology and results of treatment. A review of 20 cases. Clin orthop 1983;176:154–62. [4] Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joint: end results correlated with pathology and treatment. Foot Ankle 1986;6:225–42. [5] Vuori J, Aro HT. Lisfranc joint injuries: trauma mechanisms and associated injuries. J Trauma 1993;35:40–5. [6] Quenu E, Kuss E. Etude sur les luxations du me´tatarse (luxations me´tatarso-tarsiennes), du diastasis entre le 1er et le 2e`me me´tatarsien. Rev Chir 1909;39:1–72. [7] Trillat A, Lerat JL, Leclerc P, Schuster P. Les fractures-luxations tarso-me´tatarsiennes. Rev Chir Orthop 1976;62:685–702. [8] Kitaoka HB, Alexander IJ, Adelaar RS, Robert S, Numeley JA, Myerson MS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux and lesser toes. Foot Ankle Int 1994;15:349–53. [9] Muller T, Reynders P, Sioen W, Van den Bergh J, De Reymaeker G, Reynaert P, et al. The treatment of Lisfranc injuries. Acta Orthop Belgica 1997;63:82–90. [10] Myerson MS. The diagnosis and treatment of injury of the tarsometatarsal joint complex. J Bone Joint Surg 1999;81B: 756–63. [11] Arntz CT, Veith RG, Hanse ST. Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg 1988;70A:173–81. [12] Faciszewski T, Burks RT, Manaster BJ. Subtle injuries of the Lisfranc joint. J Bone Joint Surg Am 1990;72:1519–22. [13] Thoradson DB. Fractures of the midfoot and forefoot. In: Myerson MS, editor. Foot and ankle disorders, vol. 2. Philadelphia: WB Saunders; 2000. p. 1265–96. [14] Jarde O, Trinquier-Lautard JL, Filloux JF, De Lestang M, Vives P. Fractures-luxations de l’interligne de Lisfranc. Rev Chir Orthop 1995; 81:724–30. [15] Dudko S, Kusz D, Pierzchaa A. Lisfranc injury—fixation with Kirschner wires. Foot Ankle Surg 2004;10:5–8. [16] Kuo RS, Tejwani NC, Digiovanni CW, Holt SK, Benirschke SK, Hansen ST, Sangeorzan BJ. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg 2000; 82A:1609–18.