Surgical Management of Lisfranc Injuries: The Role of Primary Fusion

Kevin J. Wing, M.D., FRCSC
Vancouver, BC

Injuries to the Lisfranc joint complex (tarsometatarsal joints) continue to be challenging problems. Once the spectrum of injury moves past the simplest of sprains (that do not completely disrupt the normal architecture) and moves into injuries that completely disrupt the important plantar connections between the medial cuneiform and the base of the second and third tarsometatarsals, the orthopaedist is faced with the challenge of realigning the midfoot in a way that optimizes the clinical outcome of the patient.

 

High energy injuries produce little in the way of a diagnostic challenge but the more subtle, purely soft tissue low energy injury can continue to be a diagnostic dilemma. The clinician needs a high level of suspicion and should utilize stress X-rays as well as CT and/or MRI to clarifying the pattern of instability and the degree of displacement. In the near future, weight-bearing CT will add an important diagnostic tool.

Once the orthopaedist has established any significant subluxation at the tarsometatarsal joints, surgical management is likely warranted.

Clearly defining the pattern of instability with respect to the first, second, and third tarsometatarsal joints, the intercuneiform joints (particularly the medial middle articulation) and the navicular cuneiform joints themselves is critical.

Fundamentally, the orthopaedic surgeon is faced with the challenge of deciding whether or not the articular cartilage at the first, second and third tarsometatarsal joints can be salvaged. Dr.'s Ly and Coetzee in their 2006 JBJS Article provide Level I evidence that open reduction internal fixation of the Lisfranc articulation is associated with a high incidence of post-traumatic arthritis, poor patient outcomes and a frequent need for subsequent midfoot fusion1. Their study demonstrates compelling evidence for the role of primary fusion in the setting of displaced soft tissue injury to the first, second and third tarsometatarsal joints.

As noted in the study by Ly and Coetzee, a small sentinel avulsion fracture off the plantar base of the metatarsals, particularly the second, is not a contraindication to performing fusion surgery. Their study specifically excluded more complicated fracture dislocation patterns. In the higher energy injuries that produce more significant comminution at the base of the metatarsals, primary fusion may be more technically challenging. In this setting, other management strategies (i.e. bridge plating) may be more technically achievable.

WING_Fig_1 WING_fig_2

WING_fig_3
40-year-old female 6/12 post primary fusion after a fall on the stairs.

There is growing consensus in the literature that the best patient outcomes are associated with stable, non-arthritic, anatomic alignment through the navicular-cuneiform 1, 2, 3 metatarsal articulations of the medial column of the foot1-3. For a patient with a significant subluxation and/or dislocation of the one, two and three tarsometatarsal joints, there is a clear role for primary fusion utilizing modern foot and ankle techniques of adequate joint preparation, joint compression with stable fixation and anatomic orientation of the resultant fusion. Furthermore, with modern low profile plates and screws, the need for hardware removal can be minimized.

In the lower energy purely ligamentous athletic injury with a few millimeters of subluxation at the base of the second, it may be more appropriate to consider joint sparing stabilizing procedures3.

In summary, injury to the Lisfranc joint complex that results in residual subluxation and/or the development of advanced arthritis in the joints results in an unacceptable incidence of poor functional outcome. This, of course, can have significant impact on the patient's recreational and occupational pursuits. In some cases of delayed diagnosis, it may have significant medical legal consequences.

Optimizing outcomes requires the treating surgeon to have a high index of suspicion for the injury. When a significant midfoot injury is diagnosed, the treatment algorithm needs to be selected that has the highest probability of producing a patient with an anatomically aligned non-arthritic midfoot. In moderate to high energy injuries to the tarsometatarsal joint ligament complex, it may be that a significant proportion of the patients have suffered irreversible articular cartilage damage. In this setting, there is compelling evidence that primary fusion optimizes the patient's outcome.

References

 

  1. Ly T.V., Coetzee J.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;88:514-20.
  2. Teng A.L., Pinzur M.S., Lomasney L., Mahoney L., Havey R. Functional outcome following anatomic restoration of tarsal-metatarsal fracture dislocation. Foot Ankle Int. 2002;23:922-6.
  3. Myerson M.S., Cerrato R.A. Current management of tarsometatarsal injuries in the athlete. J Bone Joint Surg Am. 2008 Nov;90(11):2522-33.

 

 

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