Lisfranc fracture-dislocations: current treatment and new surgical approaches

Multidisciplinary Management and Rehabilitation of Severe Crush Injury Resulting in Lisfranc Fracture: A Case Report

A 58-year-old male patient was seriously injured in his left foot as a result of a passenger car accident, resulting in a Lisfranc fracture and complications on his left side. The initial injury resulted in a 20-cm laceration, severe pain, and severe swelling. After primary care at the government hospital, the patient was referred to Acharya Vinoba Bhave Rural Hospital (AVBRH) for further treatment. Clinical examination revealed infection, Lisfranc ligament rupture, bone exposure, restriction of movement, and muscle strength. His fracture was managed with Kirschner wire(K-wire) fixation surgically. A holistic physical management plan includes immobilization and a comprehensive medical program to reduce edema, muscle atrophy, and joint stiffness. Post physiotherapy showed significant improvements in joint function, muscle strength, and functional scores after rehabilitation. Outcome measures such as the Lower Extremity Functional Scale, Olerud-Molander Ankle Score, and Patient-Reported Outcomes Measurement Information System-29 are related to physical recovery, stress reduction, and healing as a whole-life treatment. These data highlight the importance of a collaborative, multidisciplinary approach in the effective management of Lisfranc fracture injuries and confirm the advantages of timely intervention and physical therapy for the benefit of these patients.

Suspensory Device Fixation of Lisfranc Injuries in a Southeast Asian Urban Population: Patient-Reported Functional Outcomes

Introduction Open reduction internal fixation (ORIF) and primary arthrodesis are two conventional options for the treatment of Lisfranc injuries. However, they are associated with implant-related complications. An alternative suspensory device construct using interosseous nonabsorbable sutures with endobuttons has been described with satisfactory results. This study aims to explore functional outcomes after suture button fixation of Lisfranc injuries in a Southeast Asian population. Methods This was a single-surgeon retrospective study of patients with Lisfranc injuries treated surgically using a suture button fixation technique between 2017 and 2019. Data collected included demographic information, pre-injury levels of activity, nature of injury, and type of surgery performed. The minimum postoperative follow-up was one year. The Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM) were used to evaluate patient-reported outcomes. Scores were reported in percentage (%) with median and interquartile range. Results Twenty-nine patients with a mean age of 29 years (21-76) were recruited. Sixteen underwent suture button fixation only (SB), and 13 underwent suture button fixation with intercuneiform screw fixation and plating (SBM). The median scores for the FAOS and FAAM questionnaires were at least 80% in all domains. Twenty-eight patients (97%) were able to return to pre-injury activity level, 27 patients (93%) were able to return to sports. Only one patient was not satisfied with the outcomes of surgery. No patients had post-traumatic arthritis or hardware failure necessitating implant removal at the final follow-up. Conclusion This study has demonstrated that treatment of Lisfranc injuries with a suspensory device construct resulted in good outcomes with 97% of patients being able to return to pre-injury activity levels, and 93% of patients being able to return to sports. It may not be necessary to perform primary arthrodesis in uncomplicated Lisfranc injuries. This technique is also advantageous as implant removal is not routinely required due to the design and biomechanical properties of suspensory devices.

Treatment of Lisfranc Injuries Using Interosseous Suture Button: A Retrospective Review of 84 Cases With a Minimum 3-Year Follow-Up

Lisfranc fracture dislocation is an injury often encountered by the foot and ankle surgeon. This injury, depending on the severity and level of energy, has been shown to lead to posttraumatic osteoarthritis and chronic pain if undiagnosed or improperly managed. The purpose of this study was to retrospectively evaluate the surgical repair with the use of an interosseous suture button for Lisfranc injuries with isolated ligamentous disruption. From 2008 through 2016, 104 patients were consecutively enrolled who underwent open reduction internal fixation (ORIF) of the Lisfranc complex with a suture button and stabilization of the medial and intermediate cuneiform with a 4.0-mm screw. Eighty-four patients were available for a 3-year minimum follow-up. The mean return to full weightbearing was 11 days protected in a controlled ankle motion (CAM) boot. American Orthopedic Foot & Ankle Society (AOFAS) and visual analog scale (VAS) scores improved from 30 and 8.4, respectfully, preoperatively to 90 and 1.3 postoperatively. The mean preoperative step-off between the second metatarsal base and intermediate cuneiform was found to be 3.15 mm. The immediate postreduction weightbearing radiograph measured 0.25 mm and 0.43 mm at the final follow-up evaluation, a difference that was found to be significant. There were no revision arthrodeses performed and no removal of the suture button during this time period. ORIF using an interosseous suture button appears to have an adequate medium-term patient satisfaction; however, there is evidence of minimal diastasis in some patients at 3 years postoperatively in ligamentous Lisfranc fracture dislocations.

Ilizarov frame delayed internal fixation of Lisfranc fracture dislocation with severe soft tissue injury: New technique

We describe a new technique of temporary stabilisation of a divergent Lisfranc fracture dislocation of foot with severe crush injury using an Ilizarov frame. A 69-year-old man presented with severe crush injury and complete disruption of the midfoot. Examination revealed full thickness skin necrosis, haemorrhagic blisters and extensive swelling. A staged technique was used with temporary application of an Ilizarov frame followed by delayed limited internal fixation. Excellent result was achieved with restoration of medial arch, complete pain relief and good functional outcome. A staged treatment initially using an Ilizarov frame prior to limited internal fixation allows soft tissue to settle in severe crush injury.

Diabetic Lisfranc fracture-dislocations and Charcot neuroarthropathy

The goal with Lisfranc fracture-dislocations is to regain joint congruity and reestablish midfoot stability to avoid debilitating posttraumatic arthrosis and chronic pain in the sensate patient. In the diabetic population, dense peripheral neuropathy and/or vascular disease are equally important and may alter the surgical approach to traumatic tarsometatarsal injuries. The initial diagnosis in the diabetic population may be delayed due to subtle radiographic findings and/or patient unawareness of trauma in the insensate foot. Failure to initiate treatment in the early stages of acute diabetic neuropathic Lisfranc injuries can predispose the patient to midfoot instability, potential ulceration, infection, and Charcot neuroarthropathy.

Tarsometatarsal/Lisfranc joint

Accurate early diagnosis with adequate reduction and maintenance of anatomic alignment of the dislocation or fracture within the Lisfranc joint complex have been found to be the key to successful outcomes regarding this injury. Because of the anatomic variations, the thin soft tissue envelop, and the abundance of ligamentous and capsular structures in the region, repair of these injuries can be a challenge. The classification systems used to describe these injuries aid in describing the mechanism of injury or displacement type present, which may aid in determining what treatment modality can provide the best outcome.

The Lisfranc joint

The Lisfranc joint encompasses 6 articulations, weak dorsal ligaments, and strong plantar ligaments. The Lisfranc ligament serves to secure the second metatarsal in the keystone of the midfoot. Traumatic ligament injury and fracture can result in deformity, instability, pain, and degenerative joint disease of the Lisfranc joint. Increased awareness of Lisfranc joint anatomy and advanced imaging has allowed more accurate diagnosis and treatment of this injured joint complex. Nontraumatic degenerative joint disease can also result from congenital and acquired deformity such as first ray insufficiency, abnormal metatarsal parabola, and equinus. Open reduction with internal fixation (ORIF) demands accurate anatomic alignment to prevent the need for salvage arthrodesis. Early studies have shown that primary arthrodesis of the medial 3 rays has performed equally well or better than ORIF for the displaced primarily ligamentous and severe injuries. A paradigm shift may emerge as more studies favor primary arthrodesis.

Lisfranc fracture-dislocation precipitating acute Charcot arthopathy in a neuropathic diabetic foot: a case report

The Lisfranc injury is relatively uncommon yet remains popular in the literature due to its variable causative mechanisms and subtleties in radiographic features despite its potential for disabling long term outcomes if treatment is inadequate, inappropriate or delayed. These injuries are especially pertinent in diabetic patients, especially those with neuropathy, since they are more common, can lead to Charcot neuropathic joint, ulcers and have different causative mechanisms compared to the general population. We describe the case of a neuropathic diabetic patient who presented with a Lisfranc injury which precipitated the development of acute Charcot arthropathy in the right foot. The case serves to illustrate several salient points about the Lisfranc joint and related injuries in diabetic patients.

Percutaneous fixation of forefoot, midfoot, hindfoot, and ankle fracture dislocations

Open reduction with rigid internal fixation is the basic principle for surgical management in foot and ankle trauma. High-risk patients present a surgical dilemma for the foot and ankle surgeon because the possible complications are magnified in this patient population. Percutaneous fixation is a unique alternative for achieving anatomic stabilization without increased physical strain to the patient. The significant advantages of percutaneous fixation include minimizing damage to the vascular supply, maintaining and preserving a stable soft tissue envelope, and decreasing the potential risk for infection. This article provides an overview of percutaneous surgical fixation methods and their role in foot and ankle trauma for the high-risk patient.

Predictors of postoperative complications of Ilizarov external ring fixators in the foot and ankle

Our objective was to determine factors associated with complications of Ilizarov external ring fixator surgery for foot and ankle disorders in persons with diabetes mellitus. We reviewed the records of patients who underwent Charcot foot reconstruction or soft tissue offloading surgery over 1 year at a single institution. We compared the association of serious pin tract infection, pin fracture, and surgical wound dehiscence with the patient age, weight, duration device was used, preoperative glucose, preoperative hemoglobin, tourniquet time, and total operating time. Fifteen patients (16 limbs) underwent reconstructive surgery. Younger age, elevated preoperative glucose, and lengthy tourniquet times were associated with complications (P = .03). These data demonstrate that 2 modifiable factors (preoperative hyperglycemia and tourniquet time) predict complications and should be mitigated to lower risk.