Management of complex open fracture injuries of the midfoot with external fixation

A Novel Uni- and Biplanar External Fixator for Initial and Definitive Complex Foot Trauma

Background

Evidence concerning the complex foot trauma, especially its definitive management, is scarce. Soft tissue envelope sequalae are the primary parameters that delay or make internal fixation implausible. Stability conferred by external fixators makes them a reasonable initial treatment choice. Although AO or circular fixators can be applied around the foot, this can involve a learning curve and substantial costs, especially for the circular fixator. There is little evidence as to how well external fixators work as a definite method of fixation in patients where progression to internal fixation cannot be made.

Methods

We prospectively evaluated 10 adult patients with severe and complex foot trauma who were consecutively treated at our clinic. Initial reduction and stabilization were performed with an external fixator that was initially conceived for distal radius fractures, applied during the initial procedure and mantained throughout the treatment.

Results

Fracture healing was obtained in all 10 cases, and both internal and external column length was restored. One of the patients developed chronic osteomyelitis. At the 1-year follow-up visit, these patients averaged 45.6 points in the physical and 44.8 points on the mental status sections of the 12-Item Short Form Health Survey (SF-12). The Foot Function Index findings for pain, disability, and daily activities limitations were 33.3, 39, and 41.5, respectively, which suggest moderate residual impairment.

Conclusion

In this relatively small case series of complex foot trauma, we found that the use of simple external fixation as definitive treatment worked reasonably well.

Level of Evidence

Level III, prospective cohort study.

Combined limited internal fixation and multiplanar external fixation for immediate weight bearing of fractures around the foot and ankle

Treatment of fractures around the foot and ankle can be challenging in patients who are unable to remain non weight bearing on their lower extremity. Traditional implants are not sufficient to resist loads incurred during weight bearing and can also lead to complications related to wound healing and infection. We describe a technique for fracture fixation of the foot and ankle that uses low profile implants to minimize soft tissue insult combined with multiplanar external fixation to allow for immediate weight bearing.

Management algorithm of external fixation in lower leg arterial injury for limb salvages

Purpose

The aim of this study is to investigate the outcome of these limb-threatening injuries through external fixation treatment and to discuss the case of patients’ functional recovery after external fixation.

Methods

Demographics, surgical treatment and outcomes in 88 patients with lower leg arterial injuries treated by external fixation at two trauma centers from 2009 to 2018 were reviewed. The primary outcome was the rate of successful lower leg salvage, while secondary outcomes were complications and functional recovery.

Results

Eighty-eight patients were identified and 80 patients (90 legs) maintained a successful lower leg salvage. The mean age was 32.7 ± 10.8 years, and 81.8% were male. The primary outcomes included the following complications: pin-tract infection (8 legs), pins loosening (4 pins), wound superficial infection (7 legs), deep infection developed osteomyelitis (3 legs), bone nonunion or bone defect (17 legs) and amputation (8 legs). The average healing time of fracture was 5.6 ± 4.3 months. The maintain of external fixation average time was 5.8 ± 3.6 months. The improvement of scores of the pain, function and quality of life in our follow-up was statistically significant.

Conclusion

For the lower extremity fracture patients with vascular injuries, using external fixation correctly can improve clinical outcomes and produce the improvement of pain, function and the quality of life.

Level of evidence

Retrospective cohort, level IV.

The success rate of the lower leg salvage is high, reach the percentage of 91.8% (90/98).

External fixation is less invasive, with achieving adequate stability to repair the arterial injury timely, can lower the ischemic time, and beneficial for the following bone or soft tissue repair.

Treating the patients with external fixators timely is beneficial to the following vascular anticoagulation, bone defect and vein graft, as a result, the protection of lower limb can be improved.

Stress Distributions and Micromovement of Fragment Bone of Pilon Fracture Treated With External Fixator: A Finite Element Analysis

Osteoporosis and osteoarthritis are common pathological problems of the human bone tissue. There are some cases of pilon fractures associated with these 2 pathological conditions. In terms of treatment, for a normal and healthy bone with pilon fracture, the use of the Delta external fixator is a favorable option because it can allow early mobilization for patients and provide stability for the healing process. However, the stability of the external fixator differs when there is low bone stiffness, which has not been previously investigated. Therefore, this study was conducted to determine the stability of the external fixator to treat pilon fracture associated with osteoporosis and osteoarthritis, particularly to differentiate the stress distribution and micromovement of fracture fragment. Three-dimensional finite element models of the ankle and foot bones were reconstructed based on the computed tomography datasets. The bones consisted of 5 metatarsal, 3 cuneiform, and 1 each of cuboid, navicular, calcaneus, talus, fibula, and tibia bones. They were assigned with linear isotropic behavior. The ankle joint consisted of ligament and cartilage, and they were assigned with the use of linear links and the Mooney-Rivlin model, respectively. During simulation of the gait cycle, 70 N and 350 N were applied axially to the tibia bone to represent the swing and stance phases, respectively. The metatarsal and calcaneus bones were fixed to prevent any movement of the rigid body. The study found that the greatest von Mises stress value was observed at the pin-bone interface for the osteoporosis (108 MPa) model, followed by the osteoarthritis (87 MPa) and normal (44 MPa) models, during the stance phase. For micromovement, the osteoporosis model had the largest value at 0.26 mm, followed by the osteoarthritis (0.09 mm) and normal (0.03 mm) models. In conclusion, the greatest magnitudes of stress and micromovement were observed for the osteoporosis bone and extra care should be taken to treat pilon fracture associated with this pathological condition.

Orthoplastic Management of Open Midfoot Injuries: Is Functional Limb Salvage Possible?

High energy open midfoot injuries are uncommon but devastating injuries. A combination of complex fracture dislocations and soft tissue injury patterns render reconstruction challenging. The aim of this study was to assess the surgical and patient reported outcomes following orthoplastic management of open midfoot injuries in a Major Trauma Center. A retrospective review of all open midfoot fractures admitted to our unit between January 2015 and December 2016 was undertaken. Demographics, operative details, complications, additional surgeries, and patient reported outcomes in the form of EQ-5D and Enneking scores were collected. Fifteen patients were identified (13 male, mean age 39.2 years). One patient underwent amputation at initial debridement and 8 required additional debridement. Of these 8 patients, 3 had an amputation during their index admission. In the limb salvage group (11 patients), definitive soft tissue cover involved free flaps in 6 patients, split skin graft in 3 patients, and delayed primary closure in 2 patients. Definitive orthopedic treatment was internal fixation in 8 and external fixation in 3 patients. Two patients required a Masquelet procedure for bone loss. One patient had a toe amputation and 1 had a below knee amputation for deep infection. The median EQ-5D score was 66 (interquartile range 43), and the median Enneking score was 20.5 (interquartile range 9). Limb salvage following open midfoot fractures is technically possible in most cases, however this often involves multiple procedures and the outcomes are variable and difficult to predict. Patients should be carefully counseled, and amputation considered in all such cases.

Primary Arthrodesis for High-Energy Lisfranc Injuries

The reported incidence of Lisfranc injuries is 9.2/100.000 person-years; two-thirds of the injuries are nondisplaced. Tarsometatarsal injuries range from minor sprains and isolated ligamentous injuries to grossly unstable and multiligamentous lesions. High-energy injuries are usually linked with mechanical energy dissipation through the soft tissues. Operative treatment options include open reduction and internal fixation, open reduction with hybrid internal and external fixation, closed reduction with percutaneous internal or external fixation, and primary arthrodesis. Treatment goals are to obtain a painless, plantigrade, and stable foot. Anatomic reduction is a key factor for improved outcomes and decreased rates of post-traumatic arthritis.

Biomechanical evaluation of three different configurations of external fixators for treating distal third tibia fracture: Finite element analysis in axial, bending and torsion load

External fixators have been widely used in treating open fractures and have produced excellent outcomes, as they could successfully heal bones. The stability of external fixators lies greatly in their construction. Factors that associated with the stability of the external fixators includes stress, displacement, and relative micromotion. Three-dimensional (3D) models of bone and external fixators were constructed by using 3D modelling software, namely Materialise and SolidWorks, respectively. Three different configurations of external fixators namely Model 1, Model 2, and Model 3 were analysed. Three load cases were simulated to assess the abovementioned factors at the bone, specifically at the fracture site and at the external fixator. Findings showed that the double-cross configuration (Model 3) was the most promising in axial, bending, and torsion load cases as compared to the other two configurations. The no-cross configuration (Model 1) had the highest risk of complication due to high stress, relative micromotion, and displacement in the bending and torsion load cases. On the other hand, the single-cross configuration (Model 2) had the highest risk of complication when applied with axial load. In conclusion, the double-cross locking construct (Model 3) showed the biggest potential to be a new option for medical surgeons in treating patients associated with bone fracture. This new double-cross locking construct showed superior biomechanical stability as compared to single-cross and no-cross configurations in the axial, bending, and torsion load cases.

Staged surgical treatment of open Lisfranc fracture dislocations using an adjustable bilateral external fixator: A retrospective review of 21 patients

OBJECTIVE

The aim of this study was to assess the early operative results of a staged progressive reduction technique using a bilateral external fixator in the treatment of patients with open Lisfranc fracture dislocations.

METHODS

In this retrospective study, 21 patients (5 women and 16 men; mean age=44.4 years; age range=24 to 69 years) with open Lisfranc fracture dislocations were included. All the patients were treated in a staged manner from 2012 to 2015. The mean follow-up was 15.4 months (range=12 to 24 months). A two-stage surgical protocol was performed for each patient. At the first stage, a bilateral spanning external fixator was applied across the injured Lisfranc joint, and the length of the disrupted columns was restored by distraction process. Vacuum-assisted closure was used if required. At the second stage, the external fixator was removed, and open reduction and internal fixation were carried out. The time interval between the first and second stages and postoperative complications were documented. To assess the functional status of the patients, the visual analog scale (VAS) and the American Orthopaedic Foot - Ankle Society (AOFAS) midfoot scale were measured at the final follow-up. Radiographic parameters indicating the alignment of the midfoot after the second operation were examined.

RESULTS

Deep infection in one patient and superficial infection in 2 patients were observed. Venous thrombosis was detected in 3 patients. The mean interval between the first and second stages was 18.6 days (range=8 to 48 days). The first metatarso-cuneiform step-off (p=0.002) and the second metatarso-cuneiform step-off (p=0.000) significantly improved at the final follow-up. The mean VAS score was 2.4 (range=0-5), and the mean AOFAS score was 76.3 (range=63 to 97). Primary arthrodesis was performed in seven patients, and six of the remaining 14 patients developed post-traumatic arthritis.

CONCLUSION

With a low risk of complications, the staged progressive reduction protocol using an adjustable bilateral external fixator can be an effective treatment to achieve and maintain anatomic reduction for patients with open Lisfranc fracture dislocations in a short-time follow-up.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

External Fixation Diastasis Management of Kohler's Disease in a 14-Year-Old Boy: A Case Report

A case presentation of an adolescent with tarsal navicular avascular necrosis is presented. External fixation with tarsal navicular diastasis is a simple, straightforward management option to allow osseous regrowth and bone healing. In this case, the external fixator was well tolerated and the patient demonstrated a quick return to function without pain or discomfort. The external fixation technique with tarsal navicular diastasis is an uncommon but effective means of reversing the tarsal navicular avascular process and avoiding an open technique such as arthrodesis.

Antibiotic Hydroxyapatite Impregnated Bulk Autograft for Traumatic Large Bone Void. Technique & Case Report

Background: Mid-foot open fractures are rare, and usually presents with high energy trauma. Staged approach for the management of open midfoot fractures was described by few authors. Case presentation: Up to authors best knowledge, this is the first article describing the management of mid-foot open fracture that presented 6 weeks spost injury and had absent medial cuneiform at presentation, with multi-fragmentary fracture of middle and lateral cuneiform associated with fracture of proximal second, third and fourth metatarsals. Management and Outcomes: Management involved conjoint ortho-plastics care, External fixation, with iliac crest graft covered with Gentamicin Eluting Injectable Bone Graft Substitute (Cerament-G) to replace missing medial cuneiform, free Superficial Circumflex Iliac Artery Perforator (SCIP) Flap. This surgical approach resulted in successful union of iliac crest graft restoring the medial cuneiform alignment, with no evidence of infection.

Acute management of high-energy lisfranc injuries: A simple approach

INTRODUCTION

The aims of this study were to (1) describe the use of the K-wire for the initial management of high-energy Lisfranc dislocations or fracture dislocations, (2) to evaluate whether this standalone technique allowed for adequate reduction of these injuries, (3) to evaluate whether reductions were maintained until definitive fixation was performed, (4) and to determine if it contributed to any increase in complications prior to or after definitive fixation.

PATIENTS AND METHODS

A retrospective review was performed on all patients who presented with tarsometatarsal injuries from January 2005 through June 2015. Dislocations of the tarso-metatarsal joints were classified as either Type A (total incongruity, homolateral complex), Type B (partial incongruity, homolateral incomplete) or Type C (divergent, total or partial displacement) patterns, with or without associated fractures. For the purposes of this paper, high-energy injuries were defined as patients presenting with either a Type A or Type C (total displacement) dislocations or fracture-dislocation patterns. A total of 176 patients presented with a tarsometatarsal injury. Eighteen patients with divergent or homolateral patterns underwent a staged approach. Fifteen patients were managed exclusively with K-wire fixation. Wound complications, infections or the unexpected need to return to surgery were recorded.

RESULTS

All patients demonstrated an improved alignment using K-wires. There were no compartment syndromes, vascular insufficiency, complications to the skin associated with traction or manipulation, or pin site infections. At definitive fixation, no patient demonstrated a loss in the alignment that had been obtained at the index procedure or had an unexpected return to surgery.

DISCUSSION AND CONCLUSIONS

This study demonstrates that high-energy Lisfranc injuries are uncommon and that K-wires are a simple and adequate technique that can be used for initial staged approach of these injuries. The use of 2.0mm K-wires were sufficient to obtain and maintain the reduction until definitive fixation has been obtained, without producing any increase risk for complications.

Staged management of open Lisfranc injury: Experience from 14 patients

There are still controversies on the management and outcome of open Lisfranc injury in available studies. This study evaluates the staged management of Lisfranc injury and its complications.Patients who received a staged strategy for open Lisfranc injury were reviewed.One patient with degloving injury suffered from partial skin and hallux necrosis which was treated by debridement, hallux amputation, definitive internal fixation, and local flap transfer on the 12th day after first stage management. A definitive internal fixation and simultaneous skin graft or flap coverage were performed in another 3 patients with soft tissue defects. Other patients without soft tissue problems underwent a second stage of definitive internal fixation. Bone union was observed on the 12.5th week after definitive surgery. The median AOFAS midfoot score at the last follow-up was 74.4 ± 8.7, while the average VAS score was 2.2 ± 1.8. The average return-to-work time was 8th months postoperatively in 9 patients. Flap necrosis, infection, implant failure, nonunion, and osteomyelitis were not observed during the follow-up. Two patients received Lisfranc arthrodesis for persistent pain due to posttraumatic arthritis.In the management of open Lisfranc injury, surgeons must consider soft tissue condition. Staged strategy is a rational protocol for this severe injury. Temporary K-wire fixation after early radical debridement and realignment will facilitate the definitive internal fixation until soft tissue condition improves, which also can decrease the soft tissue complication.

Complex Foot Injury: Early and Definite Management

Complex foot injuries occur infrequently, but are life-changing events. They often present with other injuries as the result of a high-energy trauma. After initial stabilization, early assessment should be regarding salvagability. All treatment strategies are intensive. The initial treatment includes prevention of progression ischemia/necrosis, prevention of infection, and considering salvage or amputation. Definitive treatment for salvage includes anatomic reconstruction with stable internal fixation and early soft tissue coverage followed by aggressive rehabilitation. Prognosis after complex injuries is hard to predict. The various stages of the treatment are reviewed and recommendations are made.

Plates, Screws, or Combination? Radiologic Outcomes After Lisfranc Fracture Dislocation

Traditionally, Lisfranc fracture dislocations have been treated with transarticular screw fixation. A more recent development has been the use of dorsal bridging plates. The aim of the present study was to compare the radiologic outcomes for these 2 methods. Currently, no data comparing the outcomes of these 2 treatment options have been reported. A total of 62 patients were treated for Lisfranc fracture dislocations during a 6-year period. The inclusion criteria included ≥6 months of follow-up data available. Each fracture was classified using the Hardcastle classification system. Each fracture was also allocated into 1 of 4 groups: transarticular screw fixation, dorsal plating, a combination of plate and screw fixation, and nonoperative management. The outcome measures included the Kellgren-Lawrence grading of osteoarthritis and the Wilppula classification of anatomic reduction. In terms of results, radiologic osteoarthritis is not associated with the type of injury according to the Hardcastle classification nor with having an open or closed fracture. The Hardcastle classification is not associated with the type of fixation used. Fractures fixed with a combination of plates and screws had a 3.01 (95% confidence interval 1.036 to 8.74) increased risk of having stage 3 or 4 radiologic osteoarthritis compared with being fixed solely with bridging plates (p = .009). Multivariate analysis revealed that this increased risk of osteoarthritis was dependent on the quality of reduction, with good reductions having a 18.2 (95% confidence interval 15.9 to 21.8) times decreased risk of severe osteoarthritis compared with fair or poor reductions, independent of the type of fixation used (p < .0001). No radiologic benefits were found when comparing plate or screw fixation for Lisfranc fracture dislocations (although screw fixation might be associated with a less planus foot and fewer complications). Instead, a good anatomic reduction was the only predictor of the radiologic outcome, and the Hardcastle classification of fractures did not predict the surgery type or radiologic outcome. Finally, treatment with combination plates and screws resulted in worse radiologic outcomes, possibly owing to more complex fracture patterns.

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.

Results and complications of operative and non-operative navicular fracture treatment

BACKGROUND

Navicular fractures (NF) are uncommon. The purpose of this study was to compare results of operative (ORIF) and non-operative (NOT) treatment in NF.

METHODS

A retrospective analysis was undertaken on patients diagnosed with NF between March 2002 and June 2007 at a Level I teaching trauma centre. Clinical outcome consisted of functional ability and complications.

RESULTS

Eighty-eight patients with 90 fractures were identified including 56 males and 32 females with a mean age of 38 (range 17-72) and body mass index of 28.2 (range 18.7-48.9). Twenty-one of 90 (23.3%) injuries were isolated. Ten of 90 (11.1%) injuries were open. Treatment was 49/90 (55%) NOT and 41/90 (45.6%) ORIF. 11/41 (30%) ORIF required bone grafting. Complications included one ipsilateral deep vein thrombosis, one avascular necrosis, one nonunion, seven infections (two deep and five superficial), and 56 cases of secondary osteoarthrosis (SOA). ORIF had significantly more SOA (χ(2)=0.000). Secondary surgery was 25 hardware removals (16 for irritation, five for prominent or broken plates), nine arthrodeses/-plasties, two debridements for infection, and one tarsal tunnel release. Pain was present at final follow up in 39/90 (43.3%) feet. Work status was 64 without restrictions, 17 with restrictions, and 5 did not return to work. Sixty-two of 88 (69%) patients were able to wear normal shoes, which were related to return to work without restrictions (ρ=-0.508, p=0.000). Inability to return to previous work was related to pain (ρ=-0.394), SOA (ρ=-0.280), and poor reduction quality (ρ=-0.384) with significance at p<0.01. Increased BMI (>35) related to pain (ρ=0.250) and poor reduction quality (ρ=0.326) at a σ<0.05.

CONCLUSIONS

Despite modern surgical techniques, operative treatment of displaced fractures is at high risk for complications. Obesity, pain, and secondary osteoarthrosis determine shoe wear, return to function, and employment status.

LEVEL OF EVIDENCE

Level III.

Staged treatment of high energy midfoot fracture dislocations

BACKGROUND

Staged care with interval external fixation is a successful established treatment strategy for high energy periarticular fractures with often extensive soft tissue damage such as the tibial plateau and plafond. The aim of the current study was to determine whether staged care of high energy midfoot fracture/dislocation with interval external fixation prior to definitive open reconstruction in the polytraumatized patient was both safe and efficacious.

METHODS

One hundred twenty-three patients were operated on for high energy midfoot fracture/dislocation during the 8-year study period. Eighteen polytrauma patients were selectively treated with a staged protocol. Radiographic assessment was utilized to determine if the fixator achieved gross skeletal alignment. Further, final alignment after definitive reconstruction and postoperative complications were analyzed.

RESULTS

The fixator improved both length and alignment of all high energy midfoot fracture/dislocations. Loss of acceptable reduction while in the temporary frame occurred in only 1 case. Final alignment after definitive reconstruction was anatomic in all cases. No cases of wound-related complication and/or deep infection occurred.

CONCLUSION

Delayed reconstruction of high energy midfoot fracture/dislocation using interval external fixation should be an accepted care paradigm in selected polytrauma patients.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Temporary Bridging of Severe Medial Column Injury of the Foot using Internal Fixation

Inadequate treatment of midfoot crush injury often leads to permanent disability. The principle of treatment is to restore foot column length and joint congruity while it is stable enough to allow an early rehabilitation. Choices of treatment include external fixation plus pinning, circular frame fixation, and open reduction plus internal fixation. External fixation is minimally invasive but it poses the threat of inaccurate reduction, loss of reduction secondary to pin loosening, and pin tract infections. Open reduction and internal fixation per se allows good reduction of fragments and restoration of joint congruities but it lacks the protection of the whole construct. We report a case of severe midfoot crush injury that was treated with temporary bridging fixation using a low-profile locking plate. It is an evolving technique that solves the problems of external fixation, and a stable construct can be achieved for early weight bearing.

Finite element analysis of three commonly used external fixation devices for treating Type III pilon fractures

Pilon fractures are commonly caused by high energy trauma and can result in long-term immobilization of patients. The use of an external fixator i.e. the (1) Delta, (2) Mitkovic or (3) Unilateral frame for treating type III pilon fractures is generally recommended by many experts owing to the stability provided by these constructs. This allows this type of fracture to heal quickly whilst permitting early mobilization. However, the stability of one fixator over the other has not been previously demonstrated. This study was conducted to determine the biomechanical stability of these external fixators in type III pilon fractures using finite element modelling. Three-dimensional models of the tibia, fibula, talus, calcaneus, navicular, cuboid, three cuneiforms and five metatarsal bones were reconstructed from previously obtained CT datasets. Bones were assigned with isotropic material properties, while the cartilage was assigned as hyperelastic springs with Mooney-Rivlin properties. Axial loads of 350 N and 70 N were applied at the tibia to simulate the stance and the swing phase of a gait cycle. To prevent rigid body motion, the calcaneus and metatarsals were fixed distally in all degrees of freedom. The results indicate that the model with the Delta frame produced the lowest relative micromovement (0.03 mm) compared to the Mitkovic (0.05 mm) and Unilateral (0.42 mm) fixators during the stance phase. The highest stress concentrations were found at the pin of the Unilateral external fixator (509.2 MPa) compared to the Mitkovic (286.0 MPa) and the Delta (266.7 MPa) frames. In conclusion, the Delta external fixator was found to be the most stable external fixator for treating type III pilon fractures.

Biomechanical evaluation of two commonly used external fixators in the treatment of open subtalar dislocation--a finite element analysis

Subtalar dislocation is a rare injury caused by high-energy trauma. Current treatment strategies include leg casts, internal fixation and external fixation. Among these, external fixators are the most commonly used as this method is believed to provide better stabilization. However, the biomechanical stability provided by these fixators has not been demonstrated. This biomechanical study compares two commonly used external fixators, i.e. Mitkovic and Delta. CT imaging data were used to reconstruct three-dimensional models of the tibia, fibula, talus, calcaneus, navicular, cuboid, three cuneiforms and five metatarsal bones. The 3D models of the bones and cartilages were then converted into four-noded linear tetrahedral elements, whilst the ligaments were modelled with linear spring elements. Bones and cartilage were idealized as homogeneous, isotropic and linear. To simulate loading during walking, axial loading (70 N during the swing and 350 N during the stance phase) was applied at the end of diaphyseal tibia. The results demonstrate that the Mitkovic fixator produced greater displacement (peak 3.0mm and 15.6mm) compared to the Delta fixator (peak 0.8mm and 3.9 mm), in both the swing and stance phase, respectively. This study demonstrates that the Delta external fixator provides superior stability over the Mitkovic fixator. The Delta fixator may be more effective in treating subtalar dislocation.

One Month Old Neglected Lisfrancs Fracture Dislocation Treated with Wagner's External Fixator and Percutaneous Screw Fixation : A Case Report

Introduction:

Lisfrancs Fracture dislocation is not commonly seen and it often goes missed leading to numerous complications. We present a case of neglected Lisfrancs fracture dislocation who presented after 1 month and its management.

Case Report:

A 27-year-old man came with the complaints of pain and swelling of the right foot following a fall from a motorcycle 1 month back. On Radiographic evaluation it showed presence Lisfrancs fracture Dislocation with comminuted fracture of the proximal phalanx of the great toe and distal fibula fracture. Closed reduction was attempted initially which was unsuccessful and was followed by open reduction which also failed. Reduction was then achieved using Wagner’s external fixation distractor device and supplemented with percutaneously passed screws. The external fixator was continued for 3 weeks followed by below knee cast for 6 weeks. The patient regained normal gait and returned to work and his previous physical activity level without recurrent dislocation.

Conclusion:

This report highlights the necessity of prompt open reduction and the need of external fixation to achieve and maintain reduction in case of neglected cases. We advocate this approach to achieve reduction in neglected cases where open reduction is unsuccessful.

Lisfranc injuries: an update

Lisfranc injuries are a spectrum of injuries to the tarsometatarsal joint complex of the midfoot. These range from subtle ligamentous sprains, often seen in athletes, to fracture dislocations seen in high-energy injuries. Accurate and early diagnosis is important to optimise treatment and minimise long-term disability, but unfortunately, this is a frequently missed injury. Undisplaced injuries have excellent outcomes with non-operative treatment. Displaced injuries have worse outcomes and require anatomical reduction and internal fixation for the best outcome. Although evidence to date supports the use of screw fixation, plate fixation may avoid further articular joint damage and may have benefits. Recent evidence supports the use of limited arthrodesis in more complex injuries.

The use of locking plates in complex midfoot fractures

INTRODUCTION

Complex fracture dislocations of the midfoot are uncommon. Improved outcomes have been demonstrated where it has been possible to restore and maintain the length and alignment of the medial column as well as the congruity of the articular surfaces. We present our experience with the use of angle-stable locking plates in the stabilisation of complex midfoot fracture dislocations.

METHODS

Twelve patients were identified on a prospective trauma database between 2003 and 2009. All fractures involved the medial column with four associated fracture subluxations of the lateral column also. Patients underwent open reduction internal fixation (ORIF) with restoration of the medial column axis, reduction of the articular surface congruity and stabilisation with angle-stable locking plates.

RESULTS

There were no post-operative infections or neurological injuries. Ten of the twelve patients required metalwork removal. There were no implant failures prior to removal of the metalwork. At a mean follow-up of 12.4 months (range: 4-32 months), 11 patients had minimal symptoms of swelling, discomfort or stiffness in the midfoot. This did not restrict their daily activities. One patient developed post-traumatic arthritis and collapse of the medial longitudinal arch. Two patients declined removal of the metalwork.

CONCLUSIONS

Angle-stable locking plates provide satisfactory stabilisation following ORIF of complex midfoot fracture dislocations. Most patients will require removal of the metalwork. Following removal of metalwork, the majority of patients will maintain the length, alignment and stability of the midfoot.

Primary internal fixation and soft-tissue reconstruction in the treatment for an open Lisfranc fracture-dislocation

The importance of anatomical reduction for improved outcome has been recognised in the management of Lisfranc injuries. Operative fixation is indicated in case of dislocation or unstable ligamentous injury, because discongruity of the Lisfranc joint can lead to deleterious functional outcome. Screws are the recommended method of fixation of the medial en middle column, and K-wires are used for stabilisation of the unstable lateral column. Primary arthrodesis can provide advantages in pure ligamentous injury. In the management of complex open Lisfranc fractures, external fixation with K-wires can be used, but often results in a high percentage of arc deformities and functional limitations. In recent years, there is a progressive change from external to internal fixation in primary stabilisation of open fractures. This case report describes the treatment for a grade III open Lisfranc fracture-dislocation by use of primary internal fixation and soft-tissue reconstruction.

Long-term outcome of high-energy open Lisfranc injuries: a retrospective study

BACKGROUND

The outcome of open Lisfranc injuries has been reported infrequently. Should these injuries be managed as closed injuries and is their outcome different?

METHODS

We undertook a retrospective study of high-energy, open Lisfranc injuries treated between 1999 and 2005. The types of dislocation, the associated injuries to the same foot, the radiologic and functional outcome, and the complications were studied. There were 22 patients. Five patients died. One had amputation. Of the remaining 16 patients, 13 men were followed up at a mean of 56 months (range, 29-88 months). The average age was 36 years (range, 7-55 years).

RESULTS

According to the modified Hardcastle classification, type B2 injury was the commonest. Ten patients had additional forefoot or midfoot injury. All patients were treated with debridement, open reduction, and multiple Kirschner (K) wire fixation. All injuries were Gustilo Anderson type IIIa or IIIb. Nine patients had split skin graft for soft tissue cover. Mean time taken for wound healing was 16 days (range, 10-30 days). Ten patients (77%) had fracture comminution. Eight patients had anatomic reduction, whereas five had nonanatomic reduction. Ten of 13 (77%) patients had at least one spontaneous tarsometatarsal joint fusion. The mean American Orthopaedic Foot and Ankle Society score was 82 (range, 59-100). Nonanatomic reduction, osteomyelitis, deformity of toes, planus foot, and mild discomfort on prolonged walking were the unfavorable outcomes present.

CONCLUSION

In open Lisfranc injuries, multiple K wire fixation should be considered especially in the presence of comminution and soft tissue loss. Although anatomic reduction is always not obtained, the treatment principles should include adequate debridement, maintaining alignment with multiple K wires, and obtaining early soft tissue cover. There is a high incidence of fusion across tarsometatarsal joints.

Management of severe deformity using a combination of internal and external fixation

This review addresses severe foot and ankle deformities and describes techniques for internal and external fixation. A combination of internal and external fixation techniques is often necessary in severe foot and ankle deformities secondary to leg length discrepancies. This article includes a thorough literature review as well as an extensive description of these techniques.

Chopart joint injury: a study of outcome and morbidity

Injuries involving the Chopart joint complex are relatively rare and frequently missed or misdiagnosed, often leading to a poor functional outcome. This study was performed to determine the outcome and morbidity in patients with Chopart joint injuries, and to increase awareness of this severe injury. Patients with a Chopart dislocation or fracture-dislocation, treated between January 2004 and January 2010, were identified using the appropriate diagnosis code and reviewing all radiographs of patients diagnosed with hindfoot or midfoot injuries treated at our institution. Data on patient characteristics, trauma mechanism, delay, and treatment were collected using patient files, operation reports, and by reviewing radiographs. Outcome was determined using the American Orthopaedic Foot & Ankle Society midfoot score and a visual analog scale satisfaction score, in patients with a minimum follow-up of 6 months. Nine patients (1.5 per year) were identified, including 6 women. The mean patient age was 41.6 ± 25.1 years. The trauma mechanism was sprain or sports injury in 5 (55.6%), motor vehicle accident in 3 (33.33%), and a fall from height in 1 (11.11%) case. Seven patients with an average follow-up of 31.3 ± 19.2 months reported a mean American Orthopaedic Foot & Ankle Society midfoot score of 72 (range, 32-100) points and a mean visual analog scale score of 7.1 (range, 5-10). Four (57.14%) patients still experienced pain or had limitations in daily activities at the time of the final follow-up. This study supports the conclusion of previous studies, which stated that a higher level of awareness is needed to prevent permanent disability.

Reconstruction of massive midfoot bone and soft tissue loss as a result of blast injury

Lower extremity blast injuries represent a unique challenge to surgeons and often involve complex, limb-threatening wounds with extensive soft tissue and bone loss. Surgical treatment of these injuries can be difficult because of limited autogenous resources for reconstruction of the defect. In this article, we describe a technique for medial column reconstruction using iliac crest bone graft and soft tissue coverage with an abductor hallucis rotational flap combined with a split-thickness skin graft. This method addresses the extensive bone and soft tissue defects that frequently characterize blast injuries to the foot, and may be applicable in other situations where trauma or infection has caused extensive destruction of the medial column.

High-energy foot and ankle trauma: principles for formulating an individualized care plan

Care of the patient with high-energy foot and ankle trauma requires an individualized care plan. Staged treatment respecting the traumatized soft tissue envelope is often advisable. Wound care is a priority, and the vacuum-assisted closure dressing serves an integral role. Before definitive reconstruction, the surgeon needs to develop a treatment plan designed to match the unique personality of the patient and injury. Amputation is considered a rational treatment option for the patient with severe injury and poor host biology. Despite the most appropriate management, many severe foot and ankle injuries have a guarded prognosis.

Use of external fixation and primary wound closure in an open comminuted first metatarsal fracture: a case report

Management of open, comminuted fractures presents a challenge for the foot and ankle surgeon. Reconstructive surgery for such injuries has a high potential for the development of serious complications, and factors such as the extent of soft tissue injury, neurovascular status to the foot, and fracture stability must be taken into consideration before determining a surgical plan. This article describes the case of a patient who presented with an open, comminuted first metatarsal fracture as a result of a chainsaw injury. The patient was treated with a uniplanar mini-external fixator, demineralized bone matrix, primary wound closure, and external bone growth stimulation. At 1-year follow-up, the interview and examination revealed the patient to be pain free with a functional first ray. ACFAS Level of Clinical Evidence: 4.