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 Abstract
Abstract A retrospective study of the
functional outcome of 17 patients with tarsometatarsal dislocations and
fracture-dislocations treated at our
institution with open reduction and
internal fixation in the period
2000-2003. There were 14 males and 3
females. 6 patients were type A (total),
7 patients type B (partial), and 4
patients type C (divergent) according to
Hardcastle's classification. The mean
follow up was 19 months (8-34 months).
Patients were evaluated for pain and
change of occupation or lifestyle. The
X-Rays were evaluated for residual
derangement and presence of
osteoarthritic changes.
9 patients
reported no or minimal pain and one
patient underwent fusion of the tarsometatarsal joint. 6 X-Rays showed
early osteoarthritic changes, and one
Sudeck's dystrophy was reported. There
was no correlation between the timing of
surgery and outcome, but early surgical
intervention is to be recommended.
Different methods of treatment are
discussed. Recent studies emphasize the
need for precise anatomic reduction and
rigid fixation.
Introduction
Lisfranc's fracture-dislocation used to be considered a rare
injury(1,8,13,14). The overall incidence
appears to be more common than
previously suggested, due to increased
awareness of this injury, improved
diagnostic evaluation, and the increase
in road traffic and industrial
accidents.
The tarsometatarsal joint is
made up of the five metatarsals, the
three cuneiforms, and the cuboid bone.
The bony configuration, with the
recessed position of the second
metatarsal between the first and third
cuneiform, and the dorsal, plantar and
interosseous ligaments provide intrinsic
joint stability. It is difficult to
reconstruct the exact mechanism of the
injury, due to the complexity of this
joint. Direct and indirect injuries were
distinguished(1,8). Forced forefoot
pronation and rotational forces applied
to the forefoot were considered as the
main mechanism of injury(14).
More
commonly, axial loading of the plantar
flexed and fixed foot transferred
through the foot or applied to the heel
was implicated. Theses axial forces
usually have torque or rotational
components, leading to different types
of injury(2,3). Lisfranc injuries are
classified according to Hardcastle (13)
into three types: total, partial and
divergent (Fig 1).
|
Figure 1:A-C. Classification
of Lisfranc's
fracture-dislocation . (A)
Type A total. (B) Tvde B
Dartial . (C) Tvde C
divergent . |
In 1986, Myerson
suggested a new classification, based on
the three columns principle. Subtle
injuries of the Lisfranc's joint are
injuries between the medial and middle
column, characterized
by an increase in the distance between
the first cuneiform and the base of the
second metatarsal. These injuries should
be differentiated from simple sprain,
and stress views or views with weight
bearing are of value (Fig. 2).
|
Figure 2:Subtle injury of
the Lisfranc's joint. |
Due to
its location and unique characteristics,
up to 20% of Lisfranc's injuries are
overlooked or misdiagnosed (7,12).
Previously, conservative treatment of
these injuries was recommended, because
the patient's functional outcome was not
considered to be related to the degree
of displacement and accuracy of
reduction (1,8,14). Later studies showed
that the functional results are better
in patients who had anatomical
reduction, and when the reduction is
maintained by internal fixation. It is
now clear that early recognition,
anatomical reduction, and maintenance of
this alignment are essential for good
results (3,6,7,9,10,15).
Material
and Methods
Between January
2000 and December 2003, 34 patients were
admitted to our hospital with
dislocation or fracture-dislocation of
the tarsometatarsal joint. 5 patients
had severe crush injury of the foot with
extensive soft tissue damage, 3 had
additional injuries, which affected the
treatment or postoperative treatment
decisions regarding the Lisfranc injury.
9 patients had insufficient follow up
for inclusion in this study. The
remaining 17 patients fulfill the
criteria to be included in this
evaluation.
There were 3 female and 14
male patients, with a mean age of
32years (14-54 years). In 6 patients the
cause of trauma was a fall, in 2 a heavy
object fell on the foot (direct trauma),
and in 9 a road traffic accident, either
as a passenger or driver 4, pedestrian
hit by a car 1, motorcycle accident 1,
or car ran over the foot 3. The left
foot was affected in11 patients, and the
right side in 6 patients.
The injuries
were classified according to Hardcastle's classification: Type A
(total) 6 patients. Type B (partial) 7
patients. Type C (divergent) 4 patients.
All the 17 patients were treated with
open reduction and internal fixation.
The timing for surgery was less than 12
hours from trauma in 6 patients, less
than 24 hours in 5 patients. The
remaining surgical interventions were
performed between 2 and 30 days. The
type of internal fixation varied
according to the preference of the
surgeon from all K-wire fixation to all
screw fixation. In 4 patients a
combination of screws and K-wires was
used. A screw fixing the medial
cuneiform to the base of the second
metatarsal was used in 3 patients.
The
postoperative treatment protocol varied
slightly. All patients received below
knee plaster for an average period of 10
weeks (6-15 weeks). 10 patients did not
put any weight on the affected foot till
the K-wires or screws were removed. One
patient started weight bearing contrary
to instructions from the second
postoperative week. 6 patients remained nonweight bearing initially, and stared
weight bearing after 6 weeks (5-8 weeks)
postoperatively.
Pain was rated
according to a modified pain intensity
rating scale (5)
0 No pain at all.
1
Mild pain with long distance walking or
standing for more than one hour.
2 Pain
after standing or walking for 15-30
minutes.
3 Continuous pain with variable
intensity. The postoperative X-Rays were
evaluated as either good or fair. Good
if the gap between the first cuneiform
and the base of the second metatarsal is
less than 2 mm and the metatarsal bones
were aligned properly to the cuneiforms
and cuboid. The hardware was kept for a
period
of 6- 20 weeks (13 weeks). The mean
follow up was 19 months (8-34 months).
Results
The results of the 17 patients are summarized in table 1.
|
Table 1 : Patient's data and
results |
Only 2
patients reported no pain, 7 patients
had grade 1 pain, 6 patients grade 2
pain, and 2 patients grade 3 pain. One
of the patients with grade 3 pain
underwent fusion of the tarsometatarsal
joint (Fig. 3),
|
Figure 3:A-B. (A)
Osteoarthritic change oh the
Lisfranc's joint. The
patient had grade 3 pain .
(B) Fusion of the Lisfranc's
joint. |
the other one was
offered fusion, but he did not agree to
surgery. The five patients with direct
trauma to the foot had grade 2 and 3
pain, whereas 6 patients who had a fall
as a cause for their injury had grade 1
pain (3 patients), and grade 2 pain (1
patient), one patient had no pain, and
one patient had grade 3 pain. This last
patient sustained his injury in an
epileptic attack, and complied poorly
with postoperative instructions.
Patients with type A (total) and type B
(partial) injuries had less pain than
patients with type C (divergent)
injuries.
One patient with type B injury
had grade 3 pain. This is the same
patient who sustained his injury in an
epileptic fit, and had poor compliance
postoperatively. There was a delay in
the diagnosis in 3 patients (18%). One
patient was diagnosed as foot sprain
elsewhere, and was referred to the
hospital after one month. The other two
patients were initially diagnosed as
simple metatarsal fracture, and there
was a delay of 14 and 20 days in
treatment. There was no clear
correlation between timing of surgery
and pain intensity. In the patient who
had his surgery performed one month
after the trauma, the pain intensity was
grade one. Early surgery facilitates the
open reduction, but may not influence
the outcome.
The hardware was removed after 6 weeks
in one patient. This patient had the
K-wires placed percutaneously after the
open reduction. This was the only case
where k-wires were placed percutaneously
after open reduction. The postoperative
X-Rays were rated either good or fair
according to the gap between the first
cuneiform and the base of the second
metatarsal, and the alignment of the
metatarsals to the cuneiforms and cuboid.
11 X-Rays were rated good, and 6 fair.
The latest X-Rays of all patients were
evaluated for the presence of
irregularities and/or osteoarthritis of
the tarsometatarsal joint. One patient
(no. 4) developed Sudeck's dystrophy,
and grade 2 pain. 6 patients X-Rays
showed irregularities and/or early
osteoarthritic changes localized to the
medial column in two patients, and
involving more than one column in the
remainder. These changes were evident in
one patient 9 months after the injury.
The pain score of these patients was
grade 1 in 2 patients, grade 2 in 2
patients, and grade 3 in 2 patients. The
development of osteoarthritic changes
can be seen even with accurate reduction
and rigid fixation, and may reflect the
extent of articular damage at the time
of injury.
Three complications were
reported; one patient required revision
of the fixation because of alignment
loss. In this patient the reduction was
maintained only by K-wires. The patient,
who started early weight bearing
presented with a broken screw, but no
intervention was necessary. The third
patient developed deep infection, and
was treated with debridement and
antibiotics, and when last seen still
had a sinus with minimal discharge. Nine
patients returned to their previous
occupation and lifestyle, 7 patients had
to change their occupation or leave
their previous job, and one patient
retired on medical grounds related to
this injury
Conclusion
Lisfranc's dislocations and fracture-dislocations are more common
than previously appreciated. Patients
with trauma to the midfoot should be
carefully assessed with a high index of
suspicion. Stress views under sedation
or general anesthesia are of value in
doubtful cases (3,7,15). Although there
is no clear correlation between timing
of surgery and clinical outcome, early
reduction and fixation is recommended,
whenever possible (3,7,15).
Patients
with indirect trauma to the foot, and
patients with type A and B injuries have
better functional outcome than patients
with direct trauma and patients with
type C injuries. We consider that the
degree of articular surface damage at
the time of injury is an important
factor in determining the functional
outcome.
Compared with other published
results of tarsometatarsal
fracture-dislocation (2,5,12,13) our
results are inferior. This may be due to
the fact that most of our patients had
high velocity trauma, all K-Wire
fixation was used for several patients,
the relatively short term follow up, and
most of the patients being laborers
engaged in heavy physical work. Closed
reduction and K-Wire fixation has no
place in the management of this injury.
Open reduction allows proper evaluation
of the joint injury, reduction or
removal of small articular or avulsed
bone pieces, and precise reduction of
all three columns (2,3,6,7,9,10,13,15).
Rigid fixation of the first metatarsal
to the first cuneiform, and closing the
space between the first cuneiform and
the base of the second metatarsal are
the key to achieving stability of Lisfranc injuries. The reduction can be
maintained with 3.5 mm cortical screws
or 4 mm cancellous screws. Cannulated
screws may facilitate placement. Short
threaded cancellous screws and lag
screws may also be used (2,15). There is
no support in the literature that
compression screws may cause damage to
the articular surfaces (2,15). K-Wires
should only be used, if placement of
screws is not possible "e.g. presence of
fracture" (Fig. 4).
|
Figure 4:A-C. (A)
Fracture-Dislocation of the
tarsometatrsal
joint,divergent type, there
i a comminuted fracture of
the base of the 1st
metatarsal bone, the joint
was medially, and a fracture
of the base of 2nd and 3rd
metatarsals.
The lateral metatarsals are
laterally dislocated (B)
postoperative film.
(C) X-Ray 28 month after
injury , the patient has
grade 1 pain. |
The 4th and 5th
metatarsals are preferably fixed with
K-Wires to the cuboid to allow retention
of inherent mobility 15 (Fig. 5).
|
Figure 5:A-D. (A & B)
Anteroposterior and obligue
views of dislocation of
lisfranc's join type A. (C
and D postoperative X-Rays:
the medial column is fixed
with a screw, another screw
is used to fix the medial
cuneiform to the base of the
2nd metatarsal bone, the
lateral column is fixed with
K-Wires . |
Internal fixation should be left for a
period of 12-16 weeks. Recent studies
recommend leaving it for a minimum of 16
weeks. Protected weight bearing can be
started after 6 weeks and the cast can
be removed after 12 weeks.
References
Other
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Stress Hormones .
Original Study # 2
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Substance Abuse in Major Trauma Admissions to
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Original Study # 3
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